[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 626 Introduced in Senate (IS)]
<DOC>
118th CONGRESS
1st Session
S. 626
To recommend that the Center for Medicare and Medicaid Innovation test
the effect of a dementia care management model, and for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
March 2, 2023
Ms. Stabenow (for herself and Mrs. Capito) introduced the following
bill; which was read twice and referred to the Committee on Finance
_______________________________________________________________________
A BILL
To recommend that the Center for Medicare and Medicaid Innovation test
the effect of a dementia care management model, 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 ``Comprehensive Care for Alzheimer's
Act''.
SEC. 2. CMI TESTING OF DEMENTIA CARE MANAGEMENT.
Section 1115A of the Social Security Act (42 U.S.C. 1315a) is
amended--
(1) in subsection (b)(2)(B), by adding at the end the
following new clause:
``(xxviii) Furnishing comprehensive care
management services to eligible individuals
with Alzheimer's disease or a related dementia
through a Dementia Care Management Model, as
described in subsection (h).''; and
(2) by adding at the end the following new subsection:
``(h) Dementia Care Management Model.--
``(1) Description of model and requirements.--
``(A) In general.--The Dementia Care Management
Model described in this subsection is a model under
which payments are made under title XVIII to eligible
entities that furnish comprehensive care management
services to eligible individuals with Alzheimer's
disease or a related dementia, in order to test the
effectiveness of comprehensive care management services
on patient health, care quality, and care experience,
as well as on unpaid caregivers, and on reducing
spending under title XVIII without reducing the quality
of care.
``(B) Voluntary participation.--Participation under
the Dementia Care Management Model shall be voluntary
with respect to both eligible individuals and eligible
entities.
``(C) Implementation of dementia care management
model.--
``(i) In general.--The Secretary shall--
``(I) implement the Dementia Care
Management Model as a stand-alone
model;
``(II) incorporate the Dementia
Care Management Model into the Primary
Care First Model; or
``(III) incorporate the Dementia
Care Management Model into--
``(aa) the Primary Care
First Model; and
``(bb) the Direct
Contracting Model.
``(ii) Additional authority.--In addition
to the models described in subclauses (I)
through (III) of clause (i), the Secretary may
incorporate the Dementia Care Management Model
into other existing coordinated care models
established under title XVIII or under this
section, including accountable care
organizations, value-based purchasing
arrangements, and such other coordinated care
models as the Secretary determines to be
appropriate.
``(2) Comprehensive care management services defined.--In
this subsection, the term `comprehensive care management
services' means the following services furnished by an eligible
entity with respect to an eligible individual:
``(A) Continuous monitoring and assessment.--An
eligible entity shall regularly assess and continuously
monitor the following:
``(i) Neuropsychiatric symptoms, including
behavior, physical safety, and function of an
eligible individual.
``(ii) Comorbidities.
``(iii) Financial resources and needs.
``(iv) Caregiver supports and resources,
including caregiver education, training, and
support.
``(v) The well-being of unpaid caregivers
of the eligible individual.
``(vi) Potential risks and harms of the
eligible individual's home and environment and
the need for support for activities of daily
living.
``(B) Ongoing dementia care plan.--An eligible
entity shall develop and implement an Alzheimer's
disease or related dementia care plan, including
advance care planning as appropriate, for an eligible
individual. The care plan shall include patient-
centered goals for the eligible individual as well as
goals for unpaid caregivers of the eligible individual.
Such care plan shall be continuously evaluated and
modified as appropriate.
``(C) Psychosocial interventions.--An eligible
entity may implement psychosocial interventions
designed to prevent or reduce the burden of cognitive,
functional, behavioral, and psychological challenges as
well as the associated stress on unpaid caregivers of
the eligible individual.
``(D) Self-management tools.--An eligible entity
shall provide self-management tools to enhance the
skills of the unpaid caregiver of the eligible
individual to manage the Alzheimer's disease or related
dementia of the eligible individual and to navigate the
health care system. Such tools shall include training
and support for unpaid caregivers in managing the
limitations of eligible individuals, including
education, problem solving strategies, care navigation
support, support after discharge from a hospital or
nursing home, and decision-making support.
``(E) Medication management.--An eligible entity
shall furnish evidence-based medication review and
management services to an eligible individual,
including polypharmacy management, using a planned
process to reduce or stop medications that may no
longer be of benefit or may be having adverse cognitive
effects, prescribing approved medications, and
enhancing adherence to appropriate medications.
``(F) Treatment of related conditions.--An eligible
entity shall provide interventions to prevent or treat
conditions related to the Alzheimer's disease or
related dementia of the eligible individual, such as
depression and delirium.
``(G) Care coordination.--An eligible entity shall
provide ongoing care management services and shall
coordinate services and supports among providers of
services and suppliers, as well as social and community
resources. Such services shall include necessary
assistance for referrals to social and community-based
organizations, collaboration with primary care
providers and the interdisciplinary team of the
eligible individual, and support for care transitions
and continuity of care.
``(H) Exclusion of palliative care and hospice
care.--Comprehensive care management services shall not
include palliative care or hospice care.
``(I) Other services.--The Secretary may require or
permit other services, as appropriate.
``(3) Eligible entity defined.--In this subsection, the
term `eligible entity' means an entity, such as a health
system, hospital, physician or nonphysician group practice,
multiple physician practices, a Federally qualified health
center, a rural health clinic, or an accountable care
organization, that--
``(A) is qualified to furnish comprehensive care
management services to an eligible individual, and any
unpaid caregiver of such eligible individual, under the
Dementia Care Management Model either directly or
through arrangements with Medicare participating
providers of services and suppliers as well as social
and community-based organizations;
``(B) is accountable for the quality of
comprehensive care management services furnished to an
eligible individual under the model;
``(C) furnishes comprehensive care management
services through an interdisciplinary team that has at
least 1 physician, physician assistant, nurse
practitioner, or advanced practice nurse who devotes 25
percent or more of patient contact time to the
evaluation and care of patients with acquired cognitive
impairment;
``(D) furnishes comprehensive care management
services in a culturally appropriate manner;
``(E) utilizes a comprehensive, person-centered
care management approach;
``(F) furnishes wellness and healthcare planning,
including medication review and management;
``(G) supports family and caregiver engagement;
``(H) provides access to a primary care provider or
a member of the interdisciplinary team 24 hours a day 7
days a week;
``(I) has relationships with medical and nonmedical
community-based organizations that support patients
with Alzheimer's disease or a related dementia and
their caregivers; and
``(J) meets such other requirements as the
Secretary may determine to be appropriate.
``(4) Eligible individual defined.--In this subsection, the
term `eligible individual' means an individual--
``(A) who--
``(i) is entitled to, or enrolled for,
benefits under part A of title XVIII and
enrolled under part B of such title (including
such an individual who is a dual eligible
individual described in subsection
(a)(4)(A)(iii)); and
``(ii) is not enrolled under part C of such
title or under a PACE program under section
1894;
``(B) who has been diagnosed with a form of
dementia;
``(C) who has not made an election to receive
hospice care; and
``(D) who is not a resident of a nursing home.
``(5) Patient pathways.--
``(A) Initial placement.--
``(i) Placement of patients into care
pathways.--An eligible entity shall assign an
eligible individual to an appropriate pathway
(as described in clauses (ii), (iii), and (iv))
based on an assessment of the clinical and
financial status of the eligible individual
that is conducted not later than 60 days after
the eligible individual is enrolled in the
model.
``(ii) Pathway for uncomplicated dementia
diagnosis.--During the preceding 12-month
period, the eligible individual has not more
than 1 unplanned inpatient hospitalization or
visit to a hospital emergency department.
``(iii) Pathway for dementia diagnosis with
enhanced care coordination needs.--During the
preceding 12-month period, the eligible
individual--
``(I)(aa) has 2 or more unplanned
inpatient hospitalizations or visits to
a hospital emergency department; or
``(bb) has a psychiatric
hospitalization; and
``(II) has sufficient financial or
caregiver resources (as determined by
the Secretary).
``(iv) Pathway for dementia diagnosis with
complex care needs.--During the preceding 12-
month period, the eligible individual--
``(I)(aa) has 2 or more unplanned
inpatient hospitalizations or visits to
a hospital emergency department; or
``(bb) has a psychiatric
hospitalization; and
``(II) has insufficient financial
or caregiver resources (as determined
by the Secretary).
``(B) Regular patient assessments for appropriate
pathway.--
``(i) In general.--After determination of
the initial pathway, at a frequency to be
determined by the Secretary, but not less than
once per year, an eligible entity shall
reassess the pathway determination of each
eligible individual enrolled under the model.
``(ii) Increased adl limitations.--Each
eligible individual enrolled in the pathway for
uncomplicated dementia diagnosis (as described
in subparagraph (A)(ii)) who has had increased
limitations in performing activities of daily
living since the prior assessment shall be
assigned to the pathway for dementia diagnosis
with enhanced care coordination needs (as
described in subparagraph (A)(iii)) or the
pathway for dementia diagnosis with complex
care needs (as described in subparagraph
(A)(iv)), depending on the eligible
individual's financial and caregiver resources
applicable to each pathway.
``(iii) Enhanced or complex care needs.--
Each eligible individual enrolled in the
pathway for dementia diagnosis with enhanced
care coordination needs (as described in
subparagraph (A)(iii)) or the pathway for
dementia diagnosis with complex care needs (as
described in subparagraph (A)(iv)) shall be
assigned to 1 of the 2 pathways based on the
eligible individual's financial and caregiver
resources applicable to each pathway.
``(6) Quality assessment.--
``(A) In general.--The Secretary shall specify
appropriate measures to assess the quality of care
furnished by an eligible entity under the Dementia Care
Management Model. Such measures shall include, as
appropriate, measures for clinical processes and
outcomes, patient and caregiver experience of care, and
utilization of services for which payment is made under
the original medicare fee-for-service program under
title XVIII, including measures for--
``(i) emergency department utilization;
``(ii) inpatient hospital utilization;
``(iii) documented advanced care plan;
``(iv) medication review;
``(v) screening for future fall risk;
``(vi) depression screening for caregivers;
``(vii) caregiver stress assessment; and
``(viii) caregiver assessment of outcomes.
``(B) Reporting.--An eligible entity shall submit
data in a form and manner determined by the Secretary
on measures specified by the Secretary.
``(C) Performance assessment.--In order to assess
the quality of care furnished by an eligible entity
under the model, the Secretary shall establish--
``(i) quality performance standards; and
``(ii) methodologies for quality
performance scoring and related payment
adjustments.
``(D) Stakeholder input.--The Secretary shall seek
input from eligible entities on final measure
specifications, including appropriate adjustment for
patient preferences.
``(7) Payments.--
``(A) In general.--Under the Dementia Care
Management Model, the Secretary shall establish payment
amounts for care management services furnished to
eligible individuals, including initial investment
costs. Such amounts shall reflect start-up costs and
initial investments incurred by an eligible entity in
establishing the Dementia Care Management Model.
``(B) Capitated basis.--Payments under the Dementia
Care Management Model shall be made on a capitated
basis, such as a per-member, per-month payment, or such
other similar payment mechanisms that the Secretary
determines to be appropriate. Payments shall vary based
on the assigned pathway of each patient as described in
paragraph (5).
``(C) Quality bonus.--Under the Dementia Care
Management Model, additional payments shall be made to
any eligible entity for quality bonuses based on the
performance of the eligible entity in providing quality
care (as determined under paragraph (6)).
``(D) Zero cost-sharing.--An eligible individual
shall not be liable for any cost-sharing, including
deductibles, coinsurance, or copayments, for care
management services for dementia care furnished to such
eligible individual under the model.
``(E) Supplemental to payments for covered
services.--Payments made under the model shall be in
addition to any payments for items or services not
provided under the model for which payment may be made
under title XVIII for services furnished to such
eligible individuals.
``(F) Nonduplication.--Payments for care management
services furnished to eligible individuals under the
Dementia Care Management Model may not duplicate
payments for services furnished to such eligible
individuals for which payments are made under the
original medicare fee-for-service program under title
XVIII.
``(8) Waivers.--The Secretary shall waive provisions of
this title, and title XVIII, to permit an eligible entity
operating a Dementia Care Management Model to provide the
following:
``(A) Beneficiary rewards.--Gift cards or other
rewards for patients who successfully participate in
the program (as determined by the Secretary).
``(B) Caregivers.--Supports for caregivers.
``(C) Telehealth.--Telehealth services without
regard to geographic or other originating site
limitations under section 1834(m).
``(D) Services from community organizations.--
Payments, cost-sharing support, or both, for nonmedical
services furnished by community-based organizations,
such as limited caregiving services, respite care,
adult day care counseling services, and such other
services as the Secretary determines to be appropriate.
``(9) Modifications for application in the primary care
first and direct contracting models.--
``(A) In general.--Except as provided under
subparagraph (B), if the Secretary elects to
incorporate the Dementia Care Management Model into the
Primary Care First Model, the Direct Contracting Model,
or both, as provided for under paragraph (1)(C)(i), the
Secretary shall maintain the requirements of this
subsection.
``(B) Permissible modifications.--The Secretary may
adjust the requirements of this subsection to the
extent necessary to ensure consistency of the Dementia
Care Management Model with the Primary Care First
Model, the Direct Contracting Model, or both, with
respect to--
``(i) any eligible entity, including
beneficiary alignment thresholds;
``(ii) any eligible individual;
``(iii) capitated payments; and
``(iv) quality-bonus payments.
``(C) Consultation with stakeholders.--Prior to
making any adjustment under subparagraph (B), the
Secretary shall consult with appropriate stakeholders
and patient advocacy organizations.
``(10) Outreach to underrepresented minority populations.--
An eligible entity shall carry out public outreach and
education efforts, including the dissemination of information,
for members of underrepresented minority populations regarding
participation in the Dementia Care Management Model to ensure
diversity in the patient population of such model.
``(11) Option to expand to medicaid.--The Secretary may
design a model under which payments are made under title XIX,
in a similar manner to the manner in which payments are made
under title XVIII under the Dementia Care Management Model
described in this subsection, to eligible entities that furnish
comprehensive care management services to individuals who are
eligible for medical assistance under a State plan under title
XIX (or a waiver of such a plan) with Alzheimer's disease or a
related dementia, in order to test the effectiveness of
comprehensive care management services on patient health, care
quality, and care experience, as well as on unpaid caregivers,
and on reducing spending under title XIX without reducing the
quality of care.''.
<all>