Sec. 303. Providing individuals with kidney failure access to managed care and coordinated care programs
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Section 1851(a)(3) of the Social Security Act (42 U.S.C. 1395w–21(a)(3)) is amended— by striking subparagraph (B); and by striking and all that follows through eligible individual.— In this title and inserting . eligible individual.— In this title Section 1852(b)(1) of the Social Security Act (42 U.S.C. 1395w–22(b)(1)) is amended— by striking subparagraph (B); and by striking and all that follows through Beneficiaries.— A Medicare+Choice organization and inserting . Beneficiaries.— A Medicare Advantage organization The amendments made by this paragraph shall apply with respect to plan years beginning on or after January 1, 2015.
Section 1851(d)(2)(A)(iii) of the Social Security Act (42 U.S.C. 1395w–21(d)(2)(A)(iii)) is amended by inserting before the period at the end the following , including any additional information that individuals determined to have end stage renal disease may need to make informed decisions with respect to such an election . Section 1852(e)(3)(A) of the Social Security Act (42 U.S.C. 1395w–22(e)(3)(A)) is amended by adding at the end the following new clause: In addition to the data required to be collected, analyzed, and reported under clause
(i)and notwithstanding the limitations under subparagraph (B), as part of the quality improvement program under paragraph (1), each MA organization shall provide for the collection, analysis, and reporting of data, determined in consultation with the kidney care community, that permits the measurement of health outcomes and other indices of quality with respect to individuals determined to have end stage renal disease. . Section 1859(f)(1) of the Social Security Act (42 U.S.C. 1395w–28(f)(1)) is amended by inserting , in the case of a specialized MA plan for special needs individuals who have not been determined to have end stage renal disease, before for periods before January 1, 2017 . Section 1881(b) of the Social Security Act (42 U.S.C. 1395rr(b)) is amended by adding at the end the following new paragraph: Not later than January 1, 2016, the Secretary shall, in accordance with this paragraph, establish an ESRD Care Coordination gainsharing program for nephrologists, renal dialysis facilities, and providers of services that develop coordinated care organizations to provide a full range of clinical and supportive services (as described in subparagraph (D)) to individuals determined to have end stage renal disease. Under such program, subject to subparagraph (C), the payment amounts renal dialysis facilities and providers of services described in subparagraph
(A)would otherwise receive under paragraph
(14)and nephrologists described in subparagraph
(A)would otherwise receive under section 1848 with respect to dialysis services furnished by such a facility, provider, or nephrologist during a year, shall be increased by a portion of the amount (as determined by the Secretary) of actual reductions in expenditure under this title attributable to the coordinated care organization developed by such facility, provider, or nephrologist involved, taking into account non-dialysis expenditures under parts A and B, during the preceding calendar year. The payment amount under this subparagraph shall be provided to a nephrologist, renal dialysis facility, and provider of services that developed the coordinated care organization no later than March 31 of the year after the year during which such services are provided by such nephrologist, facility, or provider. The aggregate incentive payment amounts provided under such program for a year may not exceed the amount equal to 2 percent less than the estimated total amount of non-dialysis expenditures under parts A and B for 2016 for items and services that are not related to dialysis or transplant services. For purposes of subparagraph (A), the full range of clinical and supportive services includes at least the following: Primary care and other preventative services. Specialty care for co-morbidities or non-renal acute conditions, including at least podiatry, cardiology, and orthopedics. Vascular access. Laboratory testing and diagnostic imaging. Pharmacy care management. Patient, family, and caregiver education. Psychiatric, behavioral therapy, and counseling services. In providing payment incentive amounts under such program, the Secretary shall apply a risk adjustment methodology that— uses risk adjuster factors applied under part C; and adjusts such payments to exclude the top 2 percent of outliers. In establishing such program, the Secretary shall ensure that each of the following is satisfied: The program allows for all types and sizes of renal dialysis facilities and providers of services described in subparagraph (A), including profit and not-for-profit, urban and rural, as well as all other types and sizes of such facilities and providers, to participate. The program rewards high quality, efficient facilities and providers through gain-sharing. For purposes of determining the actual reductions in expenditures under this title attributable to a coordinated care organization described in subparagraph (A), the program includes a market-based benchmark system that will not be rebased against which such expenditures shall be compared. The program results in reductions of expenditures under parts A and B for services that are not dialysis-related services. The program allows new applicants to participate in the program after the initial implementation period. The program establishes clear quality metrics in consultation with the kidney care community. The program provides for waivers of Federal laws or requirements, in consultation with interested stakeholders. Under such program the Secretary attributes individuals described in subparagraph
(A)who receive treatment through a care coordination organization described in such subparagraph to such organization rather than to any other payment model that requires beneficiary attribution. Under such program the Secretary provides quarterly Medicare parts A and B claims data to facilities and providers described in subparagraph
(A)participating in such program. Not later than three years after the date of the implementation of the ESRD Care Coordination gainsharing program, the Secretary shall submit to the Congress a report on the waivers granted under subparagraph (F)(vii) and the effectiveness of such waivers in allowing the coordination of care. . Section 1881(b) of the Social Security Act (42 U.S.C. 1395rr(b)) is amended— in each of paragraphs (12)(A) and (13)(A), by striking paragraph
(14)and inserting paragraphs
(14)and
(15); and in paragraph (14)(A)(i), by inserting and paragraph
(15)after Subject to subparagraph
(E). Section 1848 of the Social Security Act (42 U.S.C. 1395w–4) is amended by adding at the end the following new subsection: For provisions related to incentive payment amounts to nephrologists under the ESRD Care Coordination gainsharing program, see section 1881(b)(15). . The Secretary of Health and Human Services shall require hospitals that furnish items and services to individuals entitled to benefits under part A of title XVIII of the Social Security Act or eligible for benefits under part B of such title and who subsequently receive dialysis services at a renal dialysis facility (as defined in section 1881 of such Act (42 U.S.C. 1395rr)) to provide to such facility health information with respect to such individual, including a discharge summary and co-morbidity information, upon request of the facility, not later than 7 days after notification by the hospital of the provision of such services to such individual or of the determination that such individual has end stage renal disease, as applicable.
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- 42 USC 1395w–21(a)(3)
- 42 USC 1395w–22(b)(1)
- 42 USC 1395w–21(d)(2)(A)(iii)
- 42 USC 1395w–22(e)(3)(A)
- 42 USC 1395w–28(f)(1)
- 42 USC 1395w–4
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Sec. 303
Providing individuals with kidney failure access to managed care and coordinated care programs
Cite42 USC 1395w–21(a)(3)
Cite42 USC 1395w–22(b)(1)
Cite42 USC 1395w–21(d)(2)(A)(iii)
Cite42 USC 1395w–22(e)(3)(A)
Cite42 USC 1395w–28(f)(1)
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