IN THE SENATE OF THE UNITED STATES
March 11, 2015
Mr. Grassley (for himself and Mr. Cardin) introduced the following bill; which was read twice and referred to the Committee on Finance
To establish a Community-Based Institutional Special Needs Plan demonstration program to target home and community-based care to eligible Medicare beneficiaries.
This Act may be cited as the
Community Based Independence for Seniors Act.
Congress makes the following findings:
Community-based services play an essential role in keeping individuals healthy.
Without community-based long-term services and supports, which are not typically covered by Medicare, seniors frequently experience negative health outcomes and lose their ability to live independently.
Seniors who deplete their resources often have no option but to turn to Medicaid for coverage of long-term care expenses.
Targeting community-based services and supports to at-risk seniors can help these individuals avoid depleting their assets and becoming Medicaid dependent.
Community-based institutional special needs plan demonstration
The Secretary of Health and Human Services (in this section referred to as the
Secretary) shall establish a Community-Based Institutional Special Needs Plan demonstration program (in this section referred to as the
CBI-SNP demonstration program) to target home and community-based care to eligible Medicare beneficiaries.
The Secretary shall enter into agreements with up to 5 Medicare Advantage plans to conduct the CBI-SNP demonstration program. Each such MA plan may enroll up to 1,000 eligible Medicare beneficiaries (including new enrollees) in such program.
Under the CBI-SNP demonstration program, eligible Medicare beneficiaries shall receive benefits, in addition to those under part C of title XVIII of the Social Security Act (including benefits under section 1852(a)(3) of such Act (42 U.S.C. 1395w22(a)(3))) and notwithstanding any waivers under section 1915(c) (42 U.S.C. 1396n(c)), including long-term care services and supports, that the Secretary determines appropriate for the purposes of the CBI-SNP demonstration program, such as—
home delivered meals;
adult day care services; and
non-Medicare-covered safety and other equipment.
The Secretary shall establish a benchmark payment amount for reimbursing Medicare Advantage plans participating in the CBI-SNP demonstration program for benefits provided to eligible beneficiaries under such program. Such payments shall be in addition to payments made to such plans under part C of title XVIII of the Social Security Act.
To be eligible to participate in the CBI-SNP demonstration program, a Medicare Advantage plan must—
have experience in offering special needs plans for nursing home-eligible, non-institutionalized Medicare beneficiaries who live in the community;
have experience working with low income seniors groups;
be located in a State that the Secretary has determined will participate in the CBI-SNP demonstration program by agreeing to make available data necessary for purposes of conducting the independent evaluation required under subsection (h); and
meet such other criteria as the Secretary may require.
Eligible Medicare beneficiary defined
In this section, the term eligible Medicare beneficiary means a Medicare beneficiary who—
is enrolled or eligible to enroll in a Medicare Advantage plan that has been selected to participate in the CBI-SNP demonstration program;
is a subsidy eligible individual (as defined in section 1860D–14(a)(3)(A) of the Social Security Act (42 U.S.C. 1395w114(a)(3)(A)));
is not eligible to receive benefits under title XIX of the Social Security Act;
is unable to perform 2 or more activities of daily living (as defined in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986); and
is age 65 or older.
Special election period
Notwithstanding sections 1852(e)(2)(C) and 1860D–1(b)(1)(B)(iii) of the Social Security Act (42 U.S.C. 1395w–21(e)(2)(C); 1395w–101(b)(1)(B)(iii)), an eligible Medicare beneficiary may, other than during the annual, coordinated election periods under such sections—
discontinue enrollment in a Medicare Advantage plan not participating in the CBI-SNP demonstration program and enroll in a Medicare Advantage plan participating in such program; and
discontinue enrollment under the original medicare fee-for-service program under parts A and B of such title and the enrollment in a prescription drug plan under part D of such title and enroll in a Medicare Advantage plan participating in the CBI-SNP demonstration program.
The Secretary shall help to educate eligible Medicare beneficiaries on the availability of the CBI-SNP demonstration program through State Health Insurance Assistance Programs and other organizations dedicated to assisting seniors with Medicare benefits and enrollment.
The CBI-SNP demonstration program shall be implemented not later than January 1, 2017.
Subject to paragraph (3), the CBI-SNP demonstration program shall be conducted for a period of 5 years.
Extension or expansion
Taking into account the report under subsection (h)(2), the Secretary may, through rulemaking, expand (including implementation on a nationwide or permanent basis) the duration or the scope CBI-SNP demonstration program to the extent determined appropriate by the Secretary, unless the Secretary determines that such expansion is expected to—
increase expenditures under titles XVIII and XIX of the Social Security Act with respect to eligible Medicare beneficiaries participating in the CBI-SNP demonstration program; or
decrease the quality of health care services furnished to eligible Medicare beneficiaries participating in the CBI-SNP demonstration program.
Independent evaluation and reports
The Secretary shall provide for the evaluation of the CBI-SNP demonstration program by an independent third party. Such evaluation shall be completed using evaluation criteria that are clearly articulated prior to the implementation of such program. Such criteria shall include specific goals of such program, hypotheses being tested, clear data collection and reporting requirements, recognizing that definitions, benefits and program requirements for long-term care services and supports vary across States. Such evaluation shall determine whether the CBI-SNP demonstration program has—
improved patient care;
reduced hospitalizations or rehospitalizations;
reduced or delayed Medicaid nursing facility admissions and lengths of stay;
reduced spend down of income and assets for purposes of becoming eligible for Medicaid; and
improved quality of life for the demonstration population and beneficiary and caregiver satisfaction.
Not later than 4 years after the implementation of the CBI-SNP demonstration program, the Secretary shall submit to Congress a report containing the results of the evaluation conducted under paragraph (1), together with such recommendations for legislative or administrative action as the Secretary determines appropriate. In preparing such report, the Secretary shall use at least 3 years worth of data under the demonstration program.
By the end of the third year of the CBI-SNP demonstration program, the Secretary shall ensure that the aggregate payments made under titles XVIII and XIX of the Social Security Act, including under the demonstration program, for subsequent periods do not exceed the amount which the Secretary estimates would have been expended under such titles during such a period if the CBI-SNP demonstration program had not been implemented.
Paperwork reduction act
Chapter 35 of title 44, United States Code, shall not apply to the testing and evaluation of the CBI-SNP demonstration program.