What This Bill Does
This bill asks the Center for Medicare and Medicaid Innovation to test a new way of managing care for people with Alzheimer's disease or related dementia. The test will pay organizations to provide comprehensive care management services and measure whether these services improve patient health, care quality, patient experience, and reduce spending without lowering care quality.
Who It Affects
People on Medicare with Alzheimer's disease or related dementia (except those in nursing homes, on Medicare Advantage plans, or enrolled in PACE programs). Healthcare organizations like hospitals, physician groups, health systems, federally qualified health centers, and accountable care organizations that provide dementia care. Unpaid caregivers of eligible individuals.
Key Provisions
• Organizations participating in this program must have an interdisciplinary team that includes at least one physician, physician assistant, nurse practitioner, or advanced practice nurse who spends at least 25 percent of patient contact time treating patients with cognitive impairment (Sec. 2, subsection (h)(3)(C))
• Organizations must regularly assess and monitor patients' neuropsychiatric symptoms, comorbidities, financial resources, caregiver support needs, and home safety risks (Sec. 2, subsection (h)(2)(A))
• Organizations must develop and implement a personalized dementia care plan that includes patient goals and caregiver goals, with options for advance care planning (Sec. 2, subsection (h)(2)(B))
• Patients are divided into three care pathways based on their clinical status and available financial or caregiver resources, assessed within 60 days of enrollment and reassessed at least yearly (Sec. 2, subsection (h)(5))
• Payments to organizations will be based on a per-member, per-month capitated system that varies by patient pathway, with additional bonuses for quality performance (Sec. 2, subsection (h)(7)(B) and (C))
• Patients pay zero out-of-pocket costs for care management services under this program (Sec. 2, subsection (h)(7)(D))
• Organizations can waive certain Medicare rules to offer gift cards or rewards to participating patients, provide telehealth without geographic restrictions, and pay for non-medical community services like respite care and adult day care (Sec. 2, subsection (h)(8))
• Organizations must conduct public outreach to underrepresented minority populations to ensure diverse patient enrollment (Sec. 2, subsection (h)(10))
What Changes
Medicare will begin testing a new coordinated care model specifically designed for Alzheimer's and dementia patients. Organizations can either run this as a standalone program or blend it into existing Medicare care coordination models. The Secretary has authority to later expand this program to Medicaid using similar payment and service structures.
Important Definitions
**Comprehensive care management services**: The care and support provided by organizations, including continuous monitoring of symptoms and home safety, developing personalized care plans, teaching caregivers skills to manage the disease, reviewing and managing medications, treating related conditions like depression, and coordinating care across healthcare and community resources. Does not include palliative care or hospice care.
**Eligible entity**: Organizations such as hospitals, physician groups, health systems, federally qualified health centers, rural health clinics, or accountable care organizations that can directly or through partnerships provide comprehensive dementia care services. Must demonstrate they can manage care quality, hire qualified staff, work with culturally appropriate practices, engage families and caregivers, offer 24/7 access to providers, and partner with community organizations.
**Eligible individual**: A Medicare beneficiary (enrolled in Parts A and B but not in Medicare Advantage or PACE programs) who has been diagnosed with dementia, has not chosen hospice care, and does not live in a nursing home.
**Patient pathways**: Three care levels assigned based on hospitalization history and available caregiver or financial resources. Uncomplicated pathway for those with 0-1 hospitalizations. Enhanced care coordination pathway for those with 2+ hospitalizations and sufficient resources. Complex care needs pathway for those with 2+ hospitalizations and insufficient resources.
Effective Date
Not specified in bill text
I
118TH CONGRESS
1ST SESSION H. R. 1637
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 HOUSE OF REPRESENTATIVES
MARCH 17, 2023
Mr. LAHOOD (for himself, Mr. COLE, Mr. TONKO, and Mr. HIGGINS of New
York) introduced the following bill; which was referred to the Committee
on Energy and Commerce, and in addition to the Committee on Ways
and Means, for a period to be subsequently determined by the Speaker,
in each case for consideration of such provisions as fall within the juris-
diction of the committee concerned
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
VerDate Sep 11 2014
22:52 Mar 29, 2023
Jkt 039200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H1637.IH
H1637
kjohnson on DSK79L0C42PROD with BILLS
2
•HR 1637 IH
(1) in subsection (b)(2)(B), by adding at the
1
end the following new clause:
2
‘‘(xxviii)
Furnishing
comprehensive
3
care management services to eligible indi-
4
viduals with Alzheimer’s disease or a re-
5
lated dementia through a Dementia Care
6
Management Model, as described in sub-
7
section (h).’’; and
8
(2) by adding at the end the following new sub-
9
section:
10
‘‘(h) DEMENTIA CARE MANAGEMENT MODEL.—
11
‘‘(1) DESCRIPTION OF MODEL AND REQUIRE-
12
MENTS.—
13
‘‘(A) IN
GENERAL.—The Dementia Care
14
Management Model described in this subsection
15
is a model under which payments are made
16
under title XVIII to eligible entities that fur-
17
nish comprehensive care management services
18
to eligible individuals with Alzheimer’s disease
19
or a related dementia, in order to test the effec-
20
tiveness of comprehensive care management
21
services on patient health, care quality, and
22
care experience, as well as on unpaid caregivers,
23
and on reducing spending under title XVIII
24
without reducing the quality of care.
25
VerDate Sep 11 2014
22:52 Mar 29, 2023
Jkt 039200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6201
E:\BILLS\H1637.IH
H1637
kjohnson on DSK79L0C42PROD with BILLS
3
•HR 1637 IH
‘‘(B) VOLUNTARY
PARTICIPATION.—Par-
1
ticipation under the Dementia Care Manage-
2
ment Model shall be voluntary with respect to
3
both eligible individuals and eligible entities.
4
‘‘(C) IMPLEMENTATION
OF
DEMENTIA
5
CARE MANAGEMENT MODEL.—
6
‘‘(i) IN
GENERAL.—The Secretary
7
shall—
8
‘‘(I) implement the Dementia
9
Care Management Model as a stand-
10
alone model;
11
‘‘(II) incorporate the Dementia
12
Care Management Model into the Pri-
13
mary Care First Model; or
14
‘‘(III) incorporate the Dementia
15
Care Management Model into—
16
‘‘(aa)
the
Primary
Care
17
First Model; and
18
‘‘(bb) the Direct Contracting
19
Model.
20
‘‘(ii)
ADDITIONAL
AUTHORITY.—In
21
addition to the models described in sub-
22
clauses (I) through (III) of clause (i), the
23
Secretary may incorporate the Dementia
24
Care Management Model into other exist-
25
VerDate Sep 11 2014
22:52 Mar 29, 2023
Jkt 039200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H1637.IH
H1637
kjohnson on DSK79L0C42PROD with BILLS
4
•HR 1637 IH
ing coordinated care models established
1
under title XVIII or under this section, in-
2
cluding accountable care organizations,
3
value-based purchasing arrangements, and
4
such other coordinated care models as the
5
Secretary determines to be appropriate.
6
‘‘(2)
COMPREHENSIVE
CARE
MANAGEMENT
7
SERVICES DEFINED.—In this subsection, the term
8
‘comprehensive care management services’ means
9
the following services furnished by an eligible entity
10
with respect to an eligible individual:
11
‘‘(A) CONTINUOUS MONITORING AND AS-
12
SESSMENT.—An eligible entity shall regularly
13
assess and continuously monitor the following:
14
‘‘(i) Neuropsychiatric symptoms, in-
15
cluding behavior, physical safety, and func-
16
tion of an eligible individual.
17
‘‘(ii) Comorbidities.
18
‘‘(iii) Financial resources and needs.
19
‘‘(iv) Caregiver supports and re-
20
sources, including caregiver education,
21
training, and support.
22
‘‘(v) The well-being of unpaid care-
23
givers of the eligible individual.
24
VerDate Sep 11 2014
22:52 Mar 29, 2023
Jkt 039200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H1637.IH
H1637
kjohnson on DSK79L0C42PROD with BILLS
5
•HR 1637 IH
‘‘(vi) Potential risks and harms of the
1
eligible individual’s home and environment
2
and the need for support for activities of
3
daily living.
4
‘‘(B) ONGOING DEMENTIA CARE PLAN.—
5
An eligible entity shall develop and implement
6
an Alzheimer’s disease or related dementia care
7
plan, including advance care planning as appro-
8
priate, for an eligible individual. The care plan
9
shall include patient-centered goals for the eligi-
10
ble individual as well as goals for unpaid care-
11
givers of the eligible individual. Such care plan
12
shall be continuously evaluated and modified as
13
appropriate.
14
‘‘(C) PSYCHOSOCIAL INTERVENTIONS.—An
15
eligible entity may implement psychosocial
16
interventions designed to prevent or reduce the
17
burden of cognitive, functional, behavioral, and
18
psychological challenges as well as the associ-
19
ated stress on unpaid caregivers of the eligible
20
individual.
21
‘‘(D) SELF-MANAGEMENT TOOLS.—An eli-
22
gible entity shall provide self-management tools
23
to enhance the skills of the unpaid caregiver of
24
the eligible individual to manage the Alz-
25
VerDate Sep 11 2014
22:52 Mar 29, 2023
Jkt 039200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H1637.IH
H1637
kjohnson on DSK79L0C42PROD with BILLS
6
•HR 1637 IH
heimer’s disease or related dementia of the eli-
1
gible individual and to navigate the health care
2
system. Such tools shall include training and
3
support for unpaid caregivers in managing the
4
limitations of eligible individuals, including edu-
5
cation, problem solving strategies, care naviga-
6
tion support, support after discharge from a
7
hospital or nursing home, and decision-making
8
support.
9
‘‘(E) MEDICATION MANAGEMENT.—An eli-
10
gible entity shall furnish evidence-based medica-
11
tion review and management services to an eli-
12
gible individual, including polypharmacy man-
13
agement, using a planned process to reduce or
14
stop medications that may no longer be of ben-
15
efit or may be having adverse cognitive effects,
16
prescribing approved medications, and enhanc-
17
ing adherence to appropriate medications.
18
‘‘(F) TREATMENT
OF
RELATED
CONDI-
19
TIONS.—An eligible entity shall provide inter-
20
ventions to prevent or treat conditions related
21
to the Alzheimer’s disease or related dementia
22
of the eligible individual, such as depression
23
and delirium.
24
VerDate Sep 11 2014
22:52 Mar 29, 2023
Jkt 039200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H1637.IH
H1637
kjohnson on DSK79L0C42PROD with BILLS
7
•HR 1637 IH
‘‘(G) CARE
COORDINATION.—An eligible
1
entity shall provide ongoing care management
2
services and shall coordinate services and sup-
3
ports among providers of services and suppliers,
4
as well as social and community resources.
5
Such services shall include necessary assistance
6
for referrals to social and community-based or-
7
ganizations, collaboration with primary care
8
providers and the interdisciplinary team of the
9
eligible individual, and support for care transi-
10
tions and continuity of care.
11
‘‘(H) EXCLUSION
OF
PALLIATIVE
CARE
12
AND HOSPICE CARE.—Comprehensive care man-
13
agement services shall not include palliative
14
care or hospice care.
15
‘‘(I) OTHER
SERVICES.—The Secretary
16
may require or permit other services, as appro-
17
priate.
18
‘‘(3) ELIGIBLE ENTITY DEFINED.—In this sub-
19
section, the term ‘eligible entity’ means an entity,
20
such as a health system, hospital, physician or non-
21
physician group practice, multiple physician prac-
22
tices, a Federally qualified health center, a rural
23
health clinic, or an accountable care organization,
24
that—
25
VerDate Sep 11 2014
22:52 Mar 29, 2023
Jkt 039200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H1637.IH
H1637
kjohnson on DSK79L0C42PROD with BILLS
8
•HR 1637 IH
‘‘(A) is qualified to furnish comprehensive
1
care management services to an eligible indi-
2
vidual, and any unpaid caregiver of such eligible
3
individual, under the Dementia Care Manage-
4
ment Model either directly or through arrange-
5
ments with Medicare participating providers of
6
services and suppliers as well as social and com-
7
munity-based organizations;
8
‘‘(B) is accountable for the quality of com-
9
prehensive care management services furnished
10
to an eligible individual under the model;
11
‘‘(C) furnishes comprehensive care man-
12
agement services through an interdisciplinary
13
team that has at least 1 physician, physician
14
assistant, nurse practitioner, or advanced prac-
15
tice nurse who devotes 25 percent or more of
16
patient contact time to the evaluation and care
17
of patients with acquired cognitive impairment;
18
‘‘(D) furnishes comprehensive care man-
19
agement services in a culturally appropriate
20
manner;
21
‘‘(E) utilizes a comprehensive, person-cen-
22
tered care management approach;
23
VerDate Sep 11 2014
22:52 Mar 29, 2023
Jkt 039200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H1637.IH
H1637
kjohnson on DSK79L0C42PROD with BILLS
9
•HR 1637 IH
‘‘(F) furnishes wellness and healthcare
1
planning, including medication review and man-
2
agement;
3
‘‘(G) supports family and caregiver engage-
4
ment;
5
‘‘(H) provides access to a primary care
6
provider or a member of the interdisciplinary
7
team 24 hours a day 7 days a week;
8
‘‘(I) has relationships with medical and
9
nonmedical community-based organizations that
10
support patients with Alzheimer’s disease or a
11
related dementia and their caregivers; and
12
‘‘(J) meets such other requirements as the
13
Secretary may determine to be appropriate.
14
‘‘(4) ELIGIBLE INDIVIDUAL DEFINED.—In this
15
subsection, the term ‘eligible individual’ means an
16
individual—
17
‘‘(A) who—
18
‘‘(i) is entitled to, or enrolled for, ben-
19
efits under part A of title XVIII and en-
20
rolled under part B of such title (including
21
such an individual who is a dual eligible in-
22
dividual
described
in
subsection
23
(a)(4)(A)(iii)); and
24
VerDate Sep 11 2014
22:52 Mar 29, 2023
Jkt 039200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H1637.IH
H1637
kjohnson on DSK79L0C42PROD with BILLS
10
•HR 1637 IH
‘‘(ii) is not enrolled under part C of
1
such title or under a PACE program under
2
section 1894;
3
‘‘(B) who has been diagnosed with a form
4
of dementia;
5
‘‘(C) who has not made an election to re-
6
ceive hospice care; and
7
‘‘(D) who is not a resident of a nursing
8
home.
9
‘‘(5) PATIENT PATHWAYS.—
10
‘‘(A) INITIAL PLACEMENT.—
11
‘‘(i) PLACEMENT OF PATIENTS INTO
12
CARE PATHWAYS.—An eligible entity shall
13
assign an eligible individual to an appro-
14
priate pathway (as described in clauses
15
(ii), (iii), and (iv)) based on an assessment
16
of the clinical and financial status of the
17
eligible individual that is conducted not
18
later than 60 days after the eligible indi-
19
vidual is enrolled in the model.
20
‘‘(ii) PATHWAY FOR UNCOMPLICATED
21
DEMENTIA
DIAGNOSIS.—During the pre-
22
ceding 12-month period, the eligible indi-
23
vidual has not more than 1 unplanned in-
24
VerDate Sep 11 2014
22:52 Mar 29, 2023
Jkt 039200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H1637.IH
H1637
kjohnson on DSK79L0C42PROD with BILLS
11
•HR 1637 IH
patient hospitalization or visit to a hospital
1
emergency department.
2
‘‘(iii) PATHWAY FOR DEMENTIA DIAG-
3
NOSIS WITH ENHANCED CARE COORDINA-
4
TION NEEDS.—During the preceding 12-
5
month period, the eligible individual—
6
‘‘(I)(aa) has 2 or more un-
7
planned inpatient hospitalizations or
8
visits to a hospital emergency depart-
9
ment; or
10
‘‘(bb) has a psychiatric hos-
11
pitalization; and
12
‘‘(II) has sufficient financial or
13
caregiver resources (as determined by
14
the Secretary).
15
‘‘(iv) PATHWAY FOR DEMENTIA DIAG-
16
NOSIS WITH COMPLEX CARE NEEDS.—Dur-
17
ing the preceding 12-month period, the eli-
18
gible individual—
19
‘‘(I)(aa) has 2 or more un-
20
planned inpatient hospitalizations or
21
visits to a hospital emergency depart-
22
ment; or
23
‘‘(bb) has a psychiatric hos-
24
pitalization; and
25
VerDate Sep 11 2014
22:52 Mar 29, 2023
Jkt 039200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H1637.IH
H1637
kjohnson on DSK79L0C42PROD with BILLS
12
•HR 1637 IH
‘‘(II) has insufficient financial or
1
caregiver resources (as determined by
2
the Secretary).
3
‘‘(B) REGULAR
PATIENT
ASSESSMENTS
4
FOR APPROPRIATE PATHWAY.—
5
‘‘(i) IN GENERAL.—After determina-
6
tion of the initial pathway, at a frequency
7
to be determined by the Secretary, but not
8
less than once per year, an eligible entity
9
shall reassess the pathway determination
10
of each eligible individual enrolled under
11
the model.
12
‘‘(ii) INCREASED ADL LIMITATIONS.—
13
Each eligible individual enrolled in the
14
pathway for uncomplicated dementia diag-
15
nosis
(as
described
in
subparagraph
16
(A)(ii)) who has had increased limitations
17
in performing activities of daily living since
18
the prior assessment shall be assigned to
19
the pathway for dementia diagnosis with
20
enhanced care coordination needs (as de-
21
scribed in subparagraph (A)(iii)) or the
22
pathway for dementia diagnosis with com-
23
plex care needs (as described in subpara-
24
graph (A)(iv)), depending on the eligible
25
VerDate Sep 11 2014
22:52 Mar 29, 2023
Jkt 039200
PO 00000
Frm 00012
Fmt 6652
Sfmt 6201
E:\BILLS\H1637.IH
H1637
kjohnson on DSK79L0C42PROD with BILLS
13
•HR 1637 IH
individual’s financial and caregiver re-
1
sources applicable to each pathway.
2
‘‘(iii) ENHANCED OR COMPLEX CARE
3
NEEDS.—Each eligible individual enrolled
4
in the pathway for dementia diagnosis with
5
enhanced care coordination needs (as de-
6
scribed in subparagraph (A)(iii)) or the
7
pathway for dementia diagnosis with com-
8
plex care needs (as described in subpara-
9
graph (A)(iv)) shall be assigned to 1 of the
10
2 pathways based on the eligible individ-
11
ual’s financial and caregiver resources ap-
12
plicable to each pathway.
13
‘‘(6) QUALITY ASSESSMENT.—
14
‘‘(A) IN
GENERAL.—The Secretary shall
15
specify appropriate measures to assess the qual-
16
ity of care furnished by an eligible entity under
17
the Dement
[Text truncated for display. Full text available on Congress.gov.]