PACE Plus Act

II 117TH CONGRESS 1ST SESSION S. 1162 To improve access to the Program of All-Inclusive Care for the Elderly, and for other purposes. IN THE SENATE OF THE UNITED STATES APRIL 15, 2021 Mr. CASEY introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To improve access to the Program of All-Inclusive Care for the Elderly, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘Program of All-Inclu- 4 sive Care for the Elderly Plus Act’’ or the ‘‘PACE Plus 5 Act’’. 6 SEC. 2. PACE EXPANSION GRANT PROGRAM. 7 (a) DEFINITIONS.—In this section: 8 (1) AREA AGENCY ON AGING.—The term ‘‘area 9 agency on aging’’ has the meaning given that term 10 VerDate Sep 11 2014 04:05 Apr 28, 2021 Jkt 019200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S1162.IS S1162 kjohnson on DSK79L0C42PROD with BILLS 2 •S 1162 IS in section 102 of the Older Americans Act of 1965 1 (42 U.S.C. 3002). 2 (2) CMS.—The term ‘‘CMS’’ means the Cen- 3 ters for Medicare & Medicaid Services. 4 (3) FOR-PROFIT PACE PROVIDER.—The term 5 ‘‘for-profit PACE provider’’ means a PACE provider 6 that is operated by an entity that is not a public en- 7 tity or a private, nonprofit entity organized for char- 8 itable purposes under section 501(c)(3) of the Inter- 9 nal Revenue Code of 1986. 10 (4) PACE PILOT SITE.—The term ‘‘PACE pilot 11 site’’ means a PACE provider that— 12 (A) has been approved to provide services 13 in a geographic service area that is, in whole or 14 in part, a rural area or an underserved urban 15 area; and 16 (B) has received a grant under subsection 17 (b). 18 (5) PACE PROGRAM.—The term ‘‘PACE pro- 19 gram’’ has the meaning given that term in sections 20 1894(a)(2) and 1934(a)(2) of the Social Security 21 Act (42 U.S.C. 1395eee(a)(2); 1396u–4(a)(2)). 22 (6) PACE PROVIDER.—The term ‘‘PACE pro- 23 vider’’ has the meaning given that term in section 24 VerDate Sep 11 2014 00:20 Apr 29, 2021 Jkt 019200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S1162.IS S1162 kjohnson on DSK79L0C42PROD with BILLS 3 •S 1162 IS 1894(a)(3) or 1934(a)(3) of the Social Security Act 1 (42 U.S.C. 1395eee(a)(3); 1396u–4(a)(3)). 2 (7) RURAL AREA.—The term ‘‘rural area’’ has 3 the meaning given that term in section 4 1886(d)(2)(D) of the Social Security Act (42 U.S.C. 5 1395ww(d)(2)(D)). 6 (8) SECRETARY.—The term ‘‘Secretary’’ means 7 the Secretary of Health and Human Services. 8 (9) UNDERSERVED URBAN AREA.—The term 9 ‘‘underserved urban area’’ means an urban health 10 professional shortage area (as such term is defined 11 in section 332 of the Public Health Service Act (42 12 U.S.C. 254e)). 13 (b) SITE DEVELOPMENT ASSISTANCE PROGRAM.— 14 (1) SITE DEVELOPMENT ASSISTANCE.— 15 (A) IN GENERAL.—The Secretary shall es- 16 tablish a process and criteria to award grants 17 to qualified PACE providers that have been ap- 18 proved to serve a rural area or an underserved 19 urban area. 20 (B) REQUIREMENTS FOR PARTICIPATING 21 PACE PROVIDERS.—To be eligible for a grant 22 under subparagraph (A), a PACE provider shall 23 demonstrate to the Secretary that the provider 24 has a plan to partner with— 25 VerDate Sep 11 2014 04:05 Apr 28, 2021 Jkt 019200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S1162.IS S1162 kjohnson on DSK79L0C42PROD with BILLS 4 •S 1162 IS (i) each area agency on aging serving 1 the area that the provider is approved to 2 serve; or 3 (ii) if there is no area agency on aging 4 serving such area, the applicable State 5 Unit on Aging. 6 (C) AMOUNT PER AWARD.—A grant 7 awarded under subparagraph (A) to any indi- 8 vidual PACE pilot site shall not exceed 9 $1,000,000. 10 (D) NUMBER OF AWARDS.—Not more than 11 30 PACE pilot sites shall be awarded a grant 12 under subparagraph (A). 13 (E) USE OF FUNDS.—Funds made avail- 14 able under a grant awarded under subpara- 15 graph (A) may be used for the following ex- 16 penses only to the extent such expenses are in- 17 curred in relation to establishing or delivering 18 PACE program services in a rural area or un- 19 derserved urban area: 20 (i) Feasibility analysis and planning. 21 (ii) Interdisciplinary team develop- 22 ment. 23 (iii) Development of a provider net- 24 work, including contract development. 25 VerDate Sep 11 2014 04:05 Apr 28, 2021 Jkt 019200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1162.IS S1162 kjohnson on DSK79L0C42PROD with BILLS 5 •S 1162 IS (iv) Development or adaptation of 1 claims processing systems. 2 (v) Preparation of special education 3 and outreach efforts required for the 4 PACE program. 5 (vi) Development of any special qual- 6 ity of care or patient satisfaction data col- 7 lection efforts. 8 (vii) Purchase or lease of a building. 9 (viii) Modifications to a building. 10 (ix) To cover the cost of reinsurance 11 during the grant period. 12 (x) Establishment of a working capital 13 fund to sustain fixed administrative, facil- 14 ity, or other fixed costs until the provider 15 reaches sufficient enrollment size. 16 (xi) Startup and development costs in- 17 curred prior to the approval of the PACE 18 pilot site’s PACE provider application, new 19 center application, or service area expan- 20 sion application by CMS. 21 (xii) Any other efforts determined by 22 the PACE pilot site to be critical to its 23 successful startup, as approved by the Sec- 24 retary. 25 VerDate Sep 11 2014 04:05 Apr 28, 2021 Jkt 019200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S1162.IS S1162 kjohnson on DSK79L0C42PROD with BILLS 6 •S 1162 IS (F) SITE DEVELOPMENT GRANT ELIGI- 1 BILITY.— 2 (i) GRANT ELIGIBILITY.—A PACE 3 provider shall only be eligible to receive a 4 grant under this subsection if the provider 5 is not a for-profit PACE provider. 6 (ii) LIMITATION ON ELIGIBILITY TO 7 PROVIDERS IN 3-WAY PACE PROGRAM 8 AGREEMENTS.—A PACE provider shall 9 not be eligible for a grant under this sub- 10 section unless the provider has entered into 11 an agreement, consistent with sections 12 1894 and 1934 of the Social Security Act 13 (42 U.S.C. 1395eee, 1396u–4), and regula- 14 tions promulgated to carry out such sec- 15 tions, among the PACE provider, the Sec- 16 retary, and a State administering agency 17 for the operation of a PACE program by 18 the provider under such sections. 19 (2) TECHNICAL ASSISTANCE PROGRAM.—The 20 Secretary shall establish a technical assistance pro- 21 gram to provide— 22 (A) outreach and education to State agen- 23 cies and provider organizations interested in es- 24 VerDate Sep 11 2014 04:05 Apr 28, 2021 Jkt 019200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S1162.IS S1162 kjohnson on DSK79L0C42PROD with BILLS 7 •S 1162 IS tablishing and expanding PACE programs in 1 rural areas or underserved urban areas; and 2 (B) technical assistance necessary to sup- 3 port PACE pilot sites. 4 (3) APPROPRIATION.—There is appropriated to 5 the Secretary $30,000,000 to carry out this sub- 6 section, to remain available until expended. 7 (c) EVALUATION OF PACE PROVIDERS SERVING 8 RURAL OR UNDERSERVED URBAN SERVICE AREAS.—Not 9 later than 60 months after the date of enactment of this 10 Act, the Secretary shall submit a report to Congress, in- 11 cluding the Special Committee on Aging of the Senate and 12 the Committee on Finance of the Senate, containing an 13 evaluation of the experience of PACE pilot sites in rural 14 areas and underserved urban areas. 15 (d) STATE EXPANSION GRANTS.— 16 (1) IN GENERAL.—The Secretary shall establish 17 a process and criteria to award State expansion 18 grants to qualified State agencies in States that do 19 not currently have PACE providers. 20 (2) AMOUNT PER AWARD.—A State expansion 21 grant awarded under subparagraph (A) to any State 22 agency shall not exceed $100,000. 23 (3) USE OF FUNDS.—Funds made available 24 under a State expansion grant awarded under para- 25 VerDate Sep 11 2014 04:05 Apr 28, 2021 Jkt 019200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1162.IS S1162 kjohnson on DSK79L0C42PROD with BILLS 8 •S 1162 IS graph (1) may be used for the following expenses 1 only to the extent such expenses are incurred in re- 2 lation to establishing a PACE program in the State: 3 (A) Expenditures related to the develop- 4 ment of a capitated payment rate model, includ- 5 ing appropriate risk adjustment, for making 6 payments to PACE providers under a PACE 7 program agreement. 8 (B) Expenditures on any other efforts de- 9 termined by the State Medicaid agency to be 10 critical to the successful implementation of a 11 PACE program in the State, as approved by 12 the Secretary. 13 (4) APPROPRIATION.—There are appropriated 14 to the Secretary $2,000,000 to carry out this sub- 15 section, to remain available until expended. 16 (e) AMOUNTS IN ADDITION TO PAYMENTS UNDER 17 SOCIAL SECURITY ACT.—Any amounts paid under the au- 18 thority of this section to a PACE provider shall be in addi- 19 tion to payments made to the provider under section 1894 20 or 1934 of the Social Security Act (42 U.S.C. 1395eee; 21 1396u–4). 22 SEC. 3. TWO-WAY PACE PROGRAM AGREEMENTS. 23 (a) MEDICARE.—Section 1894(a)(4) of the Social Se- 24 curity Act (42 U.S.C. 1395eee(a)(4)) is amended by add- 25 VerDate Sep 11 2014 04:05 Apr 28, 2021 Jkt 019200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S1162.IS S1162 kjohnson on DSK79L0C42PROD with BILLS 9 •S 1162 IS ing at the end the following new sentence: ‘‘Beginning 1 January 1, 2022, with respect to a PACE provider oper- 2 ating in a State that has not entered into an agreement 3 described in the previous sentence as of such date, such 4 term shall include an agreement, consistent with this sec- 5 tion and regulations promulgated to carry out this section, 6 between such a PACE provider and the Secretary for the 7 operation of a PACE program in such State by the pro- 8 vider under this section alone.’’. 9 (b) MEDICAID.—Section 1934 of the Social Security 10 Act (42 U.S.C. 1396u–4) is amended— 11 (1) in subsection (a)(4), by adding at the end 12 the following new sentence: ‘‘Beginning January 1, 13 2022, with respect to a PACE provider operating in 14 a State that has not entered into an agreement de- 15 scribed in the previous sentence as of such date, 16 such term shall include an agreement, consistent 17 with section 1894 and regulations promulgated to 18 carry out such section, between such a PACE pro- 19 vider and the Secretary for the operation of a PACE 20 program in such State by the provider under such 21 section 1894 alone.’’; and 22 (2) by adding at the end the following new sub- 23 section: 24 VerDate Sep 11 2014 04:05 Apr 28, 2021 Jkt 019200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S1162.IS S1162 kjohnson on DSK79L0C42PROD with BILLS 10 •S 1162 IS ‘‘(k) APPLICATION TO PACE PROVIDERS IN 2-WAY 1 PACE PROGRAM AGREEMENT STATES.— 2 ‘‘(1) IN GENERAL.—In the case of a State de- 3 scribed in the second sentence of subsection (a)(4), 4 the Secretary shall administer the preceding provi- 5 sions of this section with respect to PACE programs 6 offered by PACE providers under PACE program 7 agreements described in such sentence to PACE pro- 8 gram eligible individuals who are eligible for benefits 9 under part A, or enrolled under part B, of title 10 XVIII. 11 ‘‘(2) ASSESSMENT OF NEED OF NURSING HOME 12 LEVEL OF CARE.— 13 ‘‘(A) IN GENERAL.—For purposes of the 14 administration of this section pursuant to this 15 subsection, the determination under subsection 16 (a)(5)(B) of whether an individual requires the 17 level of care required under the State plan for 18 coverage of nursing facility services shall be 19 made by an independent entity based on a level 20 of care assessment tool used by the State to de- 21 termine whether an individual requires such 22 level of care. 23 ‘‘(B) INDEPENDENT ENTITY DEFINED.— 24 In this subsection, the term ‘independent entity’ 25 VerDate Sep 11 2014 04:05 Apr 28, 2021 Jkt 019200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S1162.IS S1162 kjohnson on DSK79L0C42PROD with BILLS 11 •S 1162 IS means an entity with demonstrated professional 1 knowledge to identify institutional level of care 2 needs that— 3 ‘‘(i) is not the PACE provider oper- 4 ating the PACE program involved; 5 ‘‘(ii) is not owned or controlled by, or 6 an employee of, such PACE provider; 7 ‘‘(iii) does not receive any differential 8 payment (such as a bonus) for identifying 9 individuals who are PACE program eligible 10 individuals under the PACE program 11 agreement involved; and 12 ‘‘(iv) is free of any other conflict of 13 interest (as defined by the Secretary) be- 14 tween the entity and the PACE provider 15 operating the PACE program involved.’’. 16 SEC. 4. ANYTIME ENROLLMENT IN PACE. 17 (a) IN GENERAL.— 18 (1) ANY TIME ENROLLMENT AND EFFECTIVE 19 DATE.—Section 1894(c)(5) of the Social Security 20 Act (42 U.S.C. 1395eee(c)(5)) is amended by adding 21 at the end the following new subparagraph: 22 ‘‘(C) ANY TIME ENROLLMENT AND EFFEC- 23 TIVE DATE OF ENROLLMENT.— 24 VerDate Sep 11 2014 04:05 Apr 28, 2021 Jkt 019200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S1162.IS S1162 kjohnson on DSK79L0C42PROD with BILLS 12 •S 1162 IS ‘‘(i) ANY TIME ENROLLMENT.—A 1 PACE program eligible individual may en- 2 roll in a PACE program at any time dur- 3 ing a month. 4 ‘‘(ii) EFFECTIVE DATE.—Subject to 5 clause (iii), the enrollment of a PACE pro- 6 gram eligible individual in a PACE pro- 7 gram shall be effective on the date the 8 PACE provider operating the PACE pro- 9 gram receives an enrollment agreement 10 signed by such PACE program eligible in- 11 dividual with respect to such PACE pro- 12 gram. 13 ‘‘(iii) SPECIAL RULE IN THE CASE OF 14 DUAL ELIGIBLE BENEFICIARIES.—In the 15 case of a PACE program eligible individual 16 who is eligible for benefits under this title 17 and title XIX, clause (i) shall only apply if 18 the State in which such individual resides 19 has made an election under section 20 1934(c)(5)(C) to permit PACE program 21 eligible individuals enroll in a PACE pro- 22 gram at any time during a month in such 23 State.’’. 24 VerDate Sep 11 2014 04:05 Apr 28, 2021 Jkt 019200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\S1162.IS S1162 kjohnson on DSK79L0C42PROD with BILLS 13 •S 1162 IS (2) PRORATED PAYMENTS.—Section 1894(d) of 1 the Social Security Act (42 U.S.C. 1395eee(d)) is 2 amended by adding at the end the following new 3 paragraph: 4 ‘‘(4) PRORATED PAYMENTS.—In the case of a 5 PACE program eligible individual enrolled in a 6 PACE program operated by a PACE provider with 7 an enrollment effective date that is not the first day 8 of a month, the capitation amount that would other- 9 wis [Text truncated for display. 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