F:\P11\NHI\TRICOMM\AAHCA09_001.

XML

457
1 into agreements under the pilot program with addi-
2 tional qualifying ACOs to further test and refine
3 payment incentive models with respect to qualifying
4 ACOs.
5 ‘‘(2) EXPANDING USE OF SUCCESSFUL MODELS

6 TO PROGRAM IMPLEMENTATION.—

7 ‘‘(A) IN GENERAL.—Subject to subpara-

8 graph (B), the Secretary may issue regulations
9 to implement, on a permanent basis, 1 or more
10 models if, and to the extent that, such models
11 are beneficial to the program under this title, as
12 determined by the Secretary.
13 ‘‘(B) CERTIFICATION.—The Chief Actuary
14 of the Centers for Medicare & Medicaid Serv-
15 ices shall certify that 1 or more of such models
16 described in subparagraph (A) would result in
17 estimated spending that would be less than
18 what spending would otherwise be estimated to
19 be in the absence of such expansion.
20 ‘‘(i) TREATMENT OF PHYSICIAN GROUP PRACTICE
21 DEMONSTRATION.—
22 ‘‘(1) EXTENSION.—The Secretary may enter in
23 to an agreement with a qualifying ACO under the
24 demonstration under section 1866A, subject to re-
25 basing and other modifications deemed appropriate

f:\VHLC\071409\071409.140.xml (444390|2)
July 14, 2009 (12:51 p.m.)
VerDate Nov 24 2008 12:51 Jul 14, 2009 Jkt 000000 PO 00000 Frm 00457 Fmt 6652 Sfmt 6201 C:\TEMP\AAHCA0~1.XML HOLCPC
 F:\P11\NHI\TRICOMM\AAHCA09_001.XML

458
1 by the Secretary, until the pilot program under this
2 section is operational.
3 ‘‘(2) TRANSITION.—For purposes of extension
4 of an agreement with a qualifying ACO under sub-
5 section (g)(2), the Secretary shall treat receipt of an
6 incentive payment for a year by an organization
7 under the physician group practice demonstration
8 pursuant to section 1866A as a year for which an
9 incentive payment is made under such subsection, as
10 long as such practice group practice organization
11 meets the criteria under subsection (b)(2).
12 ‘‘(j) ADDITIONAL PROVISIONS.—
13 ‘‘(1) AUTHORITY FOR SEPARATE INCENTIVE

14 ARRANGEMENTS.—The Secretary may create sepa-

15 rate incentive arrangements (including using mul-
16 tiple years of data, varying thresholds, varying
17 shared savings amounts, and varying shared savings
18 limits) for different categories of qualifying ACOs to
19 reflect natural variations in data availability, vari-
20 ation in average annual attributable expenditures,
21 program integrity, and other matters the Secretary
22 deems appropriate.
23 ‘‘(2) ENCOURAGEMENT OF PARTICIPATION OF

24 SMALLER ORGANIZATIONS.—In order to encourage

25 the participation of smaller accountable care organi-

f:\VHLC\071409\071409.140.xml (444390|2)
July 14, 2009 (12:51 p.m.)
VerDate Nov 24 2008 12:51 Jul 14, 2009 Jkt 000000 PO 00000 Frm 00458 Fmt 6652 Sfmt 6201 C:\TEMP\AAHCA0~1.XML HOLCPC
 F:\P11\NHI\TRICOMM\AAHCA09_001.XML

459
1 zations under the pilot program, the Secretary may
2 limit a qualifying ACO’s exposure to high cost pa-
3 tients under the program.
4 ‘‘(3) INVOLVEMENT IN PRIVATE PAYER AR-

5 RANGEMENTS.—Nothing in this section shall be con-

6 strued as preventing qualifying ACOs participating
7 in the pilot program from negotiating similar con-
8 tracts with private payers.
9 ‘‘(4) ANTIDISCRIMINATION LIMITATION.—The

10 Secretary shall not enter into an agreement with an

11 entity to provide health care items or services under
12 the pilot program, or with an entity to administer
13 the program, unless such entity guarantees that it
14 will not deny, limit, or condition the coverage or pro-
15 vision of benefits under the program, for individuals
16 eligible to be enrolled under such program, based on
17 any health status-related factor described in section
18 2702(a)(1) of the Public Health Service Act.
19 ‘‘(5) CONSTRUCTION.—Nothing in this section
20 shall be construed to compel or require an organiza-
21 tion to use an organization-specific target growth
22 rate for an accountable care organization under this
23 section for purposes of section 1848.
24 ‘‘(6) FUNDING.—For purposes of administering
25 and carrying out the pilot program, other than for

f:\VHLC\071409\071409.140.xml (444390|2)
July 14, 2009 (12:51 p.m.)
VerDate Nov 24 2008 12:51 Jul 14, 2009 Jkt 000000 PO 00000 Frm 00459 Fmt 6652 Sfmt 6201 C:\TEMP\AAHCA0~1.XML HOLCPC
 F:\P11\NHI\TRICOMM\AAHCA09_001.XML

460
1 payments for items and services furnished under this
2 title and incentive payments under subsection (c)(1),
3 in addition to funds otherwise appropriated, there
4 are appropriated to the Secretary for the Center for
5 Medicare & Medicaid Services Program Management
6 Account $25,000,000 for each of fiscal years 2010
7 through 2014 and $20,000,000 for fiscal year 2015.
8 Amounts appropriated under this paragraph for a
9 fiscal year shall be available until expended.’’.
10 SEC. 1302. MEDICAL HOME PILOT PROGRAM.

11 (a) IN GENERAL.—Title XVIII of the Social Security

12 Act is amended by inserting after section 1866D, as in-
13 serted by section 1301, the following new section:
14 ‘‘MEDICAL HOME PILOT PROGRAM

15 ‘‘SEC. 1866E. (a) ESTABLISHMENT AND MEDICAL

16 HOME MODELS.—
17 ‘‘(1) ESTABLISHMENT OF PILOT PROGRAM.—

18 The Secretary shall establish a medical home pilot

19 program (in this section referred to as the ‘pilot pro-
20 gram’) for the purpose of evaluating the feasibility
21 and advisability of reimbursing qualified patient-cen-
22 tered medical homes for furnishing medical home
23 services (as defined under subsection (b)(1)) to high
24 need beneficiaries (as defined in subsection
25 (d)(1)(C)) and to targeted high need beneficiaries
26 (as defined in subsection (c)(1)(C)).
f:\VHLC\071409\071409.140.xml (444390|2)
July 14, 2009 (12:51 p.m.)
VerDate Nov 24 2008 12:51 Jul 14, 2009 Jkt 000000 PO 00000 Frm 00460 Fmt 6652 Sfmt 6201 C:\TEMP\AAHCA0~1.XML HOLCPC
 F:\P11\NHI\TRICOMM\AAHCA09_001.XML

461
1 ‘‘(2) SCOPE.—Subject to subsection (g), the
2 pilot program shall include urban, rural, and under-
3 served areas.
4 ‘‘(3) MODELS OF MEDICAL HOMES IN THE

5 PILOT PROGRAM.—The pilot program shall evaluate

6 each of the following medical home models:
7 ‘‘(A) INDEPENDENT PATIENT-CENTERED

8 MEDICAL HOME MODEL.—Independent patient-

9 centered medical home model under subsection
10 (c).
11 ‘‘(B) COMMUNITY-BASED MEDICAL HOME

12 MODEL.—Community-based medical home

13 model under subsection (d).
14 ‘‘(4) PARTICIPATION OF NURSE PRACTITIONERS

15 AND PHYSICIAN ASSISTANTS.—

16 ‘‘(A) Nothing in this section shall be con-

17 strued as preventing a nurse practitioner from
18 leading a patient centered medical home so long
19 as—
20 ‘‘(i) all the requirements of this sec-
21 tion are met; and
22 ‘‘(ii) the nurse practitioner is acting
23 consistently with State law.
24 ‘‘(B) Nothing in this section shall be con-
25 strued as preventing a physician assistant from

f:\VHLC\071409\071409.140.xml (444390|2)
July 14, 2009 (12:51 p.m.)
VerDate Nov 24 2008 12:51 Jul 14, 2009 Jkt 000000 PO 00000 Frm 00461 Fmt 6652 Sfmt 6201 C:\TEMP\AAHCA0~1.XML HOLCPC
 F:\P11\NHI\TRICOMM\AAHCA09_001.XML

462
1 participating in a patient centered medical
2 home so long as—
3 ‘‘(i) all the requirements of this sec-
4 tion are met; and
5 ‘‘(ii) the physician assistant is acting
6 consistently with State law.
7 ‘‘(b) DEFINITIONS.—For purposes of this section:
8 ‘‘(1) PATIENT-CENTERED MEDICAL HOME

9 SERVICES.—The term ‘patient-centered medical

10 home services’ means services that—
11 ‘‘(A) provide beneficiaries with direct and
12 ongoing access to a primary care or principal
13 care by a physician or nurse practitioner who
14 accepts responsibility for providing first contact,
15 continuous and comprehensive care to such ben-
16 eficiary;
17 ‘‘(B) coordinate the care provided to a ben-
18 eficiary by a team of individuals at the practice
19 level across office, institutional and home set-
20 tings led by a primary care or principal care
21 physician or nurse practitioner, as needed and
22 appropriate;
23 ‘‘(C) provide for all the patient’s health
24 care needs or take responsibility for appro-

f:\VHLC\071409\071409.140.xml (444390|2)
July 14, 2009 (12:51 p.m.)
VerDate Nov 24 2008 12:51 Jul 14, 2009 Jkt 000000 PO 00000 Frm 00462 Fmt 6652 Sfmt 6201 C:\TEMP\AAHCA0~1.XML HOLCPC
 F:\P11\NHI\TRICOMM\AAHCA09_001.XML

463
1 priately arranging care with other qualified pro-
2 viders for all stages of life;
3 ‘‘(D) provide continuous access to care and
4 communication with participating beneficiaries;
5 ‘‘(E) provide support for patient self-man-
6 agement, proactive and regular patient moni-
7 toring, support for family caregivers, use pa-
8 tient-centered processes, and coordination with
9 community resources;
10 ‘‘(F) integrate readily accessible, clinically
11 useful information on participating patients
12 that enables the practice to treat such patients
13 comprehensively and systematically; and
14 ‘‘(G) implement evidence-based guidelines
15 and apply such guidelines to the identified
16 needs of beneficiaries over time and with the in-
17 tensity needed by such beneficiaries.
18 ‘‘(2) PRIMARY CARE.—The term ‘primary care’
19 means health care that is provided by a physician or
20 nurse practitioner who practices in the field of fam-
21 ily medicine, general internal medicine, geriatric
22 medicine, or pediatric medicine.
23 ‘‘(3) PRINCIPAL CARE.—The term ‘principal
24 care’ means integrated, accessible health care that is
25 provided by a physician who is a medical sub-

f:\VHLC\071409\071409.140.xml (444390|2)
July 14, 2009 (12:51 p.m.)
VerDate Nov 24 2008 12:51 Jul 14, 2009 Jkt 000000 PO 00000 Frm 00463 Fmt 6652 Sfmt 6201 C:\TEMP\AAHCA0~1.XML HOLCPC
 F:\P11\NHI\TRICOMM\AAHCA09_001.XML

464
1 specialist that addresses the majority of the personal
2 health care needs of patients with chronic conditions
3 requiring the subspecialist’s expertise, and for whom
4 the subspecialist assumes care management.
5 ‘‘(c) INDEPENDENT PATIENT-CENTERED MEDICAL
6 HOME MODEL.—
7 ‘‘(1) IN GENERAL.—

8 ‘‘(A) PAYMENT AUTHORITY.—Under the

9 independent patient-centered medical home
10 model under this subsection, the Secretary shall
11 make payments for medical home services fur-
12 nished by an independent patient-centered med-
13 ical home (as defined in subparagraph (B))
14 pursuant to paragraph (3)(B) for a targeted
15 high need beneficiaries (as defined in subpara-
16 graph (C)).
17 ‘‘(B) INDEPENDENT PATIENT-CENTERED

18 MEDICAL HOME DEFINED.—In this section, the

19 term ‘independent patient-centered medical
20 home’ means a physician-directed or nurse-
21 practitioner-directed practice that is qualified
22 under paragraph (2) as—
23 ‘‘(i) providing beneficiaries with pa-
24 tient-centered medical home services; and

f:\VHLC\071409\071409.140.xml (444390|2)
July 14, 2009 (12:51 p.m.)
VerDate Nov 24 2008 12:51 Jul 14, 2009 Jkt 000000 PO 00000 Frm 00464 Fmt 6652 Sfmt 6201 C:\TEMP\AAHCA0~1.XML HOLCPC