What This Bill Does
This bill asks the Center for Medicare and Medicaid Innovation to test a new care model for people with Alzheimer's disease and other forms of dementia. The model provides comprehensive care management services to eligible patients through health care organizations. The goal is to test whether this model improves patient health, care quality and experience while also reducing Medicare spending without lowering the quality of care. (Sec. 2)
Who It Affects
Medicare beneficiaries diagnosed with Alzheimer's disease or related dementia who are not enrolled in Medicare Advantage plans and do not live in nursing homes. Health systems, hospitals, physician groups, federally qualified health centers, rural health clinics and accountable care organizations that choose to participate in the model. Unpaid caregivers of eligible individuals.
Key Provisions
* Eligible entities must establish an interdisciplinary team with at least one physician, physician assistant, nurse practitioner or advanced practice nurse who devotes 25 percent or more of patient contact time to patients with dementia. The team must provide care management services 24 hours a day, 7 days a week. (Sec. 2(h)(3)(C) and (H))
* Eligible entities must provide comprehensive care management services including continuous monitoring of neuropsychiatric symptoms and caregiver well-being, development of dementia care plans with advance care planning, medication management, and coordination of services among providers and community organizations. (Sec. 2(h)(2))
* Patients are assigned to one of three care pathways based on their clinical status and available financial and caregiver resources within 60 days of enrollment, with reassessment at least once per year. (Sec. 2(h)(5))
* Payments to eligible entities are made on a per-member, per-month capitated basis and vary based on the patient's assigned pathway. Payments include start-up costs and quality bonuses based on provider performance. (Sec. 2(h)(7))
* Eligible individuals pay no deductibles, coinsurance or copayments for care management services under this model. (Sec. 2(h)(7)(D))
* The Secretary may waive certain Medicare rules to allow eligible entities to provide gift cards or other rewards for patients, supports for caregivers, telehealth services without geographic limits and payments for nonmedical services from community organizations like adult day care and respite care. (Sec. 2(h)(8))
What Changes
The bill adds a new dementia care management model to the Center for Medicare and Medicaid Innovation's authority. Participation is voluntary for both patients and health care organizations. The Secretary of Health and Human Services can implement this model as a standalone program or incorporate it into the Primary Care First Model, Direct Contracting Model or other coordinated care models under Medicare. The Secretary may also design a similar model under Medicaid for eligible individuals with dementia. (Sec. 2(h)(1) and (11))
Important Definitions
Comprehensive care management services: Services including continuous monitoring of patient symptoms and caregiver well-being, ongoing dementia care plans, psychological interventions, self-management tools for caregivers, medication management, treatment of related conditions like depression, and coordination of care among providers and community resources. Excludes palliative and hospice care. (Sec. 2(h)(2))
Eligible entity: A health system, hospital, physician group practice, federally qualified health center, rural health clinic or accountable care organization that is qualified to provide dementia care management services through an interdisciplinary team, is accountable for care quality, provides culturally appropriate services, supports family and caregiver engagement and maintains relationships with community organizations supporting dementia patients. (Sec. 2(h)(3))
Eligible individual: A Medicare beneficiary entitled to or enrolled for Part A benefits and enrolled for Part B benefits who is not enrolled in Medicare Advantage or a Program of All-Inclusive Care for the Elderly, has been diagnosed with dementia, has not elected hospice care and is not a nursing home resident. (Sec. 2(h)(4))
II
118TH CONGRESS
1ST SESSION
S. 626
To recommend that the Center for Medicare and Medicaid Innovation test
the effect of a dementia care management model, and for other purposes.
IN THE SENATE OF THE UNITED STATES
MARCH 2, 2023
Ms. STABENOW (for herself and Mrs. CAPITO) introduced the following bill;
which was read twice and referred to the Committee on Finance
A BILL
To recommend that the Center for Medicare and Medicaid
Innovation test the effect of a dementia care manage-
ment model, 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 ‘‘Comprehensive Care
4
for Alzheimer’s Act’’.
5
SEC. 2. CMI TESTING OF DEMENTIA CARE MANAGEMENT.
6
Section 1115A of the Social Security Act (42 U.S.C.
7
1315a) is amended—
8
(1) in subsection (b)(2)(B), by adding at the
9
end the following new clause:
10
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‘‘(xxviii)
Furnishing
comprehensive
1
care management services to eligible indi-
2
viduals with Alzheimer’s disease or a re-
3
lated dementia through a Dementia Care
4
Management Model, as described in sub-
5
section (h).’’; and
6
(2) by adding at the end the following new sub-
7
section:
8
‘‘(h) DEMENTIA CARE MANAGEMENT MODEL.—
9
‘‘(1) DESCRIPTION OF MODEL AND REQUIRE-
10
MENTS.—
11
‘‘(A) IN
GENERAL.—The Dementia Care
12
Management Model described in this subsection
13
is a model under which payments are made
14
under title XVIII to eligible entities that fur-
15
nish comprehensive care management services
16
to eligible individuals with Alzheimer’s disease
17
or a related dementia, in order to test the effec-
18
tiveness of comprehensive care management
19
services on patient health, care quality, and
20
care experience, as well as on unpaid caregivers,
21
and on reducing spending under title XVIII
22
without reducing the quality of care.
23
‘‘(B) VOLUNTARY
PARTICIPATION.—Par-
24
ticipation under the Dementia Care Manage-
25
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ment Model shall be voluntary with respect to
1
both eligible individuals and eligible entities.
2
‘‘(C) IMPLEMENTATION
OF
DEMENTIA
3
CARE MANAGEMENT MODEL.—
4
‘‘(i) IN
GENERAL.—The Secretary
5
shall—
6
‘‘(I) implement the Dementia
7
Care Management Model as a stand-
8
alone model;
9
‘‘(II) incorporate the Dementia
10
Care Management Model into the Pri-
11
mary Care First Model; or
12
‘‘(III) incorporate the Dementia
13
Care Management Model into—
14
‘‘(aa)
the
Primary
Care
15
First Model; and
16
‘‘(bb) the Direct Contracting
17
Model.
18
‘‘(ii)
ADDITIONAL
AUTHORITY.—In
19
addition to the models described in sub-
20
clauses (I) through (III) of clause (i), the
21
Secretary may incorporate the Dementia
22
Care Management Model into other exist-
23
ing coordinated care models established
24
under title XVIII or under this section, in-
25
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cluding accountable care organizations,
1
value-based purchasing arrangements, and
2
such other coordinated care models as the
3
Secretary determines to be appropriate.
4
‘‘(2)
COMPREHENSIVE
CARE
MANAGEMENT
5
SERVICES DEFINED.—In this subsection, the term
6
‘comprehensive care management services’ means
7
the following services furnished by an eligible entity
8
with respect to an eligible individual:
9
‘‘(A) CONTINUOUS MONITORING AND AS-
10
SESSMENT.—An eligible entity shall regularly
11
assess and continuously monitor the following:
12
‘‘(i) Neuropsychiatric symptoms, in-
13
cluding behavior, physical safety, and func-
14
tion of an eligible individual.
15
‘‘(ii) Comorbidities.
16
‘‘(iii) Financial resources and needs.
17
‘‘(iv) Caregiver supports and re-
18
sources, including caregiver education,
19
training, and support.
20
‘‘(v) The well-being of unpaid care-
21
givers of the eligible individual.
22
‘‘(vi) Potential risks and harms of the
23
eligible individual’s home and environment
24
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and the need for support for activities of
1
daily living.
2
‘‘(B) ONGOING DEMENTIA CARE PLAN.—
3
An eligible entity shall develop and implement
4
an Alzheimer’s disease or related dementia care
5
plan, including advance care planning as appro-
6
priate, for an eligible individual. The care plan
7
shall include patient-centered goals for the eligi-
8
ble individual as well as goals for unpaid care-
9
givers of the eligible individual. Such care plan
10
shall be continuously evaluated and modified as
11
appropriate.
12
‘‘(C) PSYCHOSOCIAL INTERVENTIONS.—An
13
eligible entity may implement psychosocial
14
interventions designed to prevent or reduce the
15
burden of cognitive, functional, behavioral, and
16
psychological challenges as well as the associ-
17
ated stress on unpaid caregivers of the eligible
18
individual.
19
‘‘(D) SELF-MANAGEMENT TOOLS.—An eli-
20
gible entity shall provide self-management tools
21
to enhance the skills of the unpaid caregiver of
22
the eligible individual to manage the Alz-
23
heimer’s disease or related dementia of the eli-
24
gible individual and to navigate the health care
25
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system. Such tools shall include training and
1
support for unpaid caregivers in managing the
2
limitations of eligible individuals, including edu-
3
cation, problem solving strategies, care naviga-
4
tion support, support after discharge from a
5
hospital or nursing home, and decision-making
6
support.
7
‘‘(E) MEDICATION MANAGEMENT.—An eli-
8
gible entity shall furnish evidence-based medica-
9
tion review and management services to an eli-
10
gible individual, including polypharmacy man-
11
agement, using a planned process to reduce or
12
stop medications that may no longer be of ben-
13
efit or may be having adverse cognitive effects,
14
prescribing approved medications, and enhanc-
15
ing adherence to appropriate medications.
16
‘‘(F) TREATMENT
OF
RELATED
CONDI-
17
TIONS.—An eligible entity shall provide inter-
18
ventions to prevent or treat conditions related
19
to the Alzheimer’s disease or related dementia
20
of the eligible individual, such as depression
21
and delirium.
22
‘‘(G) CARE
COORDINATION.—An eligible
23
entity shall provide ongoing care management
24
services and shall coordinate services and sup-
25
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ports among providers of services and suppliers,
1
as well as social and community resources.
2
Such services shall include necessary assistance
3
for referrals to social and community-based or-
4
ganizations, collaboration with primary care
5
providers and the interdisciplinary team of the
6
eligible individual, and support for care transi-
7
tions and continuity of care.
8
‘‘(H) EXCLUSION
OF
PALLIATIVE
CARE
9
AND HOSPICE CARE.—Comprehensive care man-
10
agement services shall not include palliative
11
care or hospice care.
12
‘‘(I) OTHER
SERVICES.—The Secretary
13
may require or permit other services, as appro-
14
priate.
15
‘‘(3) ELIGIBLE ENTITY DEFINED.—In this sub-
16
section, the term ‘eligible entity’ means an entity,
17
such as a health system, hospital, physician or non-
18
physician group practice, multiple physician prac-
19
tices, a Federally qualified health center, a rural
20
health clinic, or an accountable care organization,
21
that—
22
‘‘(A) is qualified to furnish comprehensive
23
care management services to an eligible indi-
24
vidual, and any unpaid caregiver of such eligible
25
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individual, under the Dementia Care Manage-
1
ment Model either directly or through arrange-
2
ments with Medicare participating providers of
3
services and suppliers as well as social and com-
4
munity-based organizations;
5
‘‘(B) is accountable for the quality of com-
6
prehensive care management services furnished
7
to an eligible individual under the model;
8
‘‘(C) furnishes comprehensive care man-
9
agement services through an interdisciplinary
10
team that has at least 1 physician, physician
11
assistant, nurse practitioner, or advanced prac-
12
tice nurse who devotes 25 percent or more of
13
patient contact time to the evaluation and care
14
of patients with acquired cognitive impairment;
15
‘‘(D) furnishes comprehensive care man-
16
agement services in a culturally appropriate
17
manner;
18
‘‘(E) utilizes a comprehensive, person-cen-
19
tered care management approach;
20
‘‘(F) furnishes wellness and healthcare
21
planning, including medication review and man-
22
agement;
23
‘‘(G) supports family and caregiver engage-
24
ment;
25
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‘‘(H) provides access to a primary care
1
provider or a member of the interdisciplinary
2
team 24 hours a day 7 days a week;
3
‘‘(I) has relationships with medical and
4
nonmedical community-based organizations that
5
support patients with Alzheimer’s disease or a
6
related dementia and their caregivers; and
7
‘‘(J) meets such other requirements as the
8
Secretary may determine to be appropriate.
9
‘‘(4) ELIGIBLE INDIVIDUAL DEFINED.—In this
10
subsection, the term ‘eligible individual’ means an
11
individual—
12
‘‘(A) who—
13
‘‘(i) is entitled to, or enrolled for, ben-
14
efits under part A of title XVIII and en-
15
rolled under part B of such title (including
16
such an individual who is a dual eligible in-
17
dividual
described
in
subsection
18
(a)(4)(A)(iii)); and
19
‘‘(ii) is not enrolled under part C of
20
such title or under a PACE program under
21
section 1894;
22
‘‘(B) who has been diagnosed with a form
23
of dementia;
24
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‘‘(C) who has not made an election to re-
1
ceive hospice care; and
2
‘‘(D) who is not a resident of a nursing
3
home.
4
‘‘(5) PATIENT PATHWAYS.—
5
‘‘(A) INITIAL PLACEMENT.—
6
‘‘(i) PLACEMENT OF PATIENTS INTO
7
CARE PATHWAYS.—An eligible entity shall
8
assign an eligible individual to an appro-
9
priate pathway (as described in clauses
10
(ii), (iii), and (iv)) based on an assessment
11
of the clinical and financial status of the
12
eligible individual that is conducted not
13
later than 60 days after the eligible indi-
14
vidual is enrolled in the model.
15
‘‘(ii) PATHWAY FOR UNCOMPLICATED
16
DEMENTIA
DIAGNOSIS.—During the pre-
17
ceding 12-month period, the eligible indi-
18
vidual has not more than 1 unplanned in-
19
patient hospitalization or visit to a hospital
20
emergency department.
21
‘‘(iii) PATHWAY FOR DEMENTIA DIAG-
22
NOSIS WITH ENHANCED CARE COORDINA-
23
TION NEEDS.—During the preceding 12-
24
month period, the eligible individual—
25
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‘‘(I)(aa) has 2 or more un-
1
planned inpatient hospitalizations or
2
visits to a hospital emergency depart-
3
ment; or
4
‘‘(bb) has a psychiatric hos-
5
pitalization; and
6
‘‘(II) has sufficient financial or
7
caregiver resources (as determined by
8
the Secretary).
9
‘‘(iv) PATHWAY FOR DEMENTIA DIAG-
10
NOSIS WITH COMPLEX CARE NEEDS.—Dur-
11
ing the preceding 12-month period, the eli-
12
gible individual—
13
‘‘(I)(aa) has 2 or more un-
14
planned inpatient hospitalizations or
15
visits to a hospital emergency depart-
16
ment; or
17
‘‘(bb) has a psychiatric hos-
18
pitalization; and
19
‘‘(II) has insufficient financial or
20
caregiver resources (as determined by
21
the Secretary).
22
‘‘(B) REGULAR
PATIENT
ASSESSMENTS
23
FOR APPROPRIATE PATHWAY.—
24
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‘‘(i) IN GENERAL.—After determina-
1
tion of the initial pathway, at a frequency
2
to be determined by the Secretary, but not
3
less than once per year, an eligible entity
4
shall reassess the pathway determination
5
of each eligible individual enrolled under
6
the model.
7
‘‘(ii) INCREASED ADL LIMITATIONS.—
8
Each eligible individual enrolled in the
9
pathway for uncomplicated dementia diag-
10
nosis
(as
described
in
subparagraph
11
(A)(ii)) who has had increased limitations
12
in performing activities of daily living since
13
the prior assessment shall be assigned to
14
the pathway for dementia diagnosis with
15
enhanced care coordination needs (as de-
16
scribed in subparagraph (A)(iii)) or the
17
pathway for dementia diagnosis with com-
18
plex care needs (as described in subpara-
19
graph (A)(iv)), depending on the eligible
20
individual’s financial and caregiver re-
21
sources applicable to each pathway.
22
‘‘(iii) ENHANCED OR COMPLEX CARE
23
NEEDS.—Each eligible individual enrolled
24
in the pathway for dementia diagnosis with
25
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enhanced care coordination needs (as de-
1
scribed in subparagraph (A)(iii)) or the
2
pathway for dementia diagnosis with com-
3
plex care needs (as described in subpara-
4
graph (A)(iv)) shall be assigned to 1 of the
5
2 pathways based on the eligible individ-
6
ual’s financial and caregiver resources ap-
7
plicable to each pathway.
8
‘‘(6) QUALITY ASSESSMENT.—
9
‘‘(A) IN
GENERAL.—The Secretary shall
10
specify appropriate measures to assess the qual-
11
ity of care furnished by an eligible entity under
12
the Dementia Care Management Model. Such
13
measures shall include, as appropriate, meas-
14
ures for clinical processes and outcomes, patient
15
and caregiver experience of care, and utilization
16
of services for which payment is made under
17
the original medicare fee-for-service program
18
under title XV
[Text truncated for display. Full text available on Congress.gov.]