Sec. 5. PACE pilot
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Section 1115A(b)(2) of the Social Security Act ( 42 U.S.C. 1315a(b)(2) ) is amended— in subparagraph (B), by adding at the end the following new clause: National testing of a model for expanded eligibility for the Program of All-Inclusive Care for the Elderly as described in subparagraph (D). ; and by adding at the end the following new subparagraph: 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: 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. 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. 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— 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; 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; 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 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. In order to participate in the model, a PACE provider must— conduct a survey or needs assessment of their service area to determine the most appropriate population with which to expand their services; receive prior approval from the applicable State Medicaid agency to submit an application to participate in the model; and 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. A PACE provider’s application to participate in this model shall include the following information: 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. The types of services that the expanded population will require and the PACE provider's plan to implement these services. 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. How the expanded population’s participation in the PACE program is intended to improve quality of care and health outcomes under the model. Certification that the applicable State Medicaid agency has approved the PACE provider's application to participate in the model. Plans to coordinate with the State Medicaid agency to develop an initial capitated rate with appropriate risk adjustment. Plans for the PACE provider and the State Medicaid agency to review and adjust the Medicaid capitated rate on a biennial basis, as needed. Any other information required by the Secretary. The Secretary shall provide, or designate an entity to provide, technical assistance to participating PACE providers as they apply for and implement the model. 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. 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— annually monitor outcomes under the model, which may include financial, quality, access, and utilization outcomes; annually monitor the health outcomes of the PACE provider’s expanded population; and any other outcomes as determined by the Secretary. 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. 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. .
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