Summary of H.R. 2376 Legislation Supporting WELShift

 

H.R. 2376:  A Bill to implement a comprehensive care coordination demonstration project for Medicare and Medicaid beneficiaries who reside in Continuing Care Retirement Communities.

 

Section 1.  Short Title: Medicare Residential Care Coordination Act of 2013

 

Section 2.  Medicare and Medicaid Residential Care Coordination Demonstration Project:

 

Establishment and Implementation:  Requires CMS to conduct the demonstration project over the next 10 years in partnership with states who agree to participate. The number of participants and facilities may be limited by the participating states. In the first year, CMS would publish operating rules and accept applicants. Up to 4 additional years would be allowed for the demo facilities to be built. The program would enroll beneficiaries after 5 years.

 

Budget Neutrality:  Aggregate expenditures are not to exceed those costs which would have been incurred for the resident population if the program had not been implemented.

 

Defines the Residential Care Coordination Programs (RCCP):
• accepts 1000-1500 participants at one time
• provides comprehensive coordinated health care services in the CCRC
• residents would enroll in the RCCP program at move-in, but could disenroll and return to traditional Medicare and CCRC program features if desired.

 

Eligible CCRC is:
• Provides onsite housing for residents, including senior apartments
• Has additional services to facilitate aging in place
• Purpose-built for the Demo
• Has negotiated a program agreement with CMS consistent with state and federal residential care requirements.

 

Eligible CCRC Resident is:
• Enrolled in Medicare Part A and B
• Resides in an eligible CCRC
• May be, but does not have to be, a dual-eligible (Medicare and Medicaid)

 

Expands the definition of “Dual Eligible” to allow coordination of Medicare and Medicaid services:  If an individual residing in an eligible CCRC meets the state standard for either (not both) financial or medical eligibility, they become eligible for state assistance under the RCCP program. This guarantees that all participating residents can continue to reside in their CCRC/home regardless of their ability to pay, and the state will not incur the expense of a Medicaid nursing home for these CCRC residents.

 

Payment Under Medicare:  The RCCP would receive a monthly Medicare payment for each enrolled individual equal to 90% of the standard capitated, risk-adjusted Medicare payment for each eligible individual enrolled in exchange for assuming full responsibility for the entire spectrum of care for the individual, including parts A, B and D (hospitals, doctors and drugs, and all other elements of care coordination). Standard Medicare Advantage cost-sharing (copays, coinsurance and deductibles) would apply for out-of-networks services, and standard balance billing prohibitions apply.

 

Payment Under Medicaid:  The RCCP would receive a monthly prospective payment from the State Medicaid Plan for each individual who is financially or medically eligible for Medicaid. The amount of the payment shall be sufficient to cover the monthly CCRC fee and a nominal personal allowance. (NOTE: WEL estimates this amount to be roughly 1/3 of the Medicaid nursing home payment which would otherwise apply.)

 

Secretarial Responsibility:  The HHS Secretary oversees the RCCP agreements and enforces rules for participation and termination, and makes appropriate rules governing their safety and quality, and enforces sanctions. RCCPs must agree to these rules to be participate in the demonstration project, and participate in annual reviews.

 

Scope of Benefits:
• 24 hour access to all necessary health care and transportation
• Access to wellness and healthy living programs
• through a multi-disciplinary team led by a primary care physician
• benefits not provided on site will be furnished by contract with hospitals and other providers.

 

Assessing the Demonstration Project:  The Secretary shall establish clinical and other outcomes measurements to assess the efficacy of the program in improving health status and outcomes, the quality of care delivered, and controlling overall costs of providing services.

 

Patient Safeguards:  The participation agreement shall provide written safeguards including a patients bill of rights and procedures for grievances and appeals similar to those of the federal PACE program.

 

Termination of Program:  10 years duration for the Demonstration project, which may be extended by the authority of the Secretary.

 

Report to Congress:  The Secretary will submit an interim report to Congress containing an interim evaluation after 3 years of experience, and a final report after 10 years.

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