BETTER Kidney Care Act

I 116TH CONGRESS 2D SESSION H. R. 8254 To establish a demonstration program to provide integrated care for Medicare beneficiaries with end-stage renal disease, and for other purposes. IN THE HOUSE OF REPRESENTATIVES SEPTEMBER 15, 2020 Mr. BLUMENAUER (for himself, Mr. SMITH of Missouri, Mr. CA´RDENAS, Mrs. RODGERS of Washington, Mr. BUTTERFIELD, Mr. WENSTRUP, and Ms. SHALALA) introduced the following bill; which was referred to the Com- mittee 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 jurisdiction of the committee concerned A BILL To establish a demonstration program to provide integrated care for Medicare beneficiaries with end-stage renal dis- ease, 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 ‘‘Bringing Enhanced 4 Treatments and Therapies to ESRD Recipients Kidney 5 Care Act’’ or the ‘‘BETTER Kidney Care Act’’. 6 VerDate Sep 11 2014 21:19 Sep 25, 2020 Jkt 099200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H8254.IH H8254 pamtmann on DSKBC07HB2PROD with BILLS 2 •HR 8254 IH SEC. 2. FINDINGS. 1 Congress finds the following: 2 (1) Although the relative rate of end-stage renal 3 disease (referred to in this section as ‘‘ESRD’’) 4 among the Nation’s minority populations has de- 5 clined, significant disparities remain. Compared to 6 Whites, Black Americans are 2.6 times more likely 7 to have kidney failure, while Native Americans and 8 Alaska Natives are 1.2 times more likely. Hispanics 9 are 1.3 times more likely to have kidney failure com- 10 pared to non-Hispanics. 11 (2) Disparities also exist with respect to treat- 12 ment modalities. Specifically, although home dialysis 13 can offer advantages, Black, Hispanic, and Native 14 American and Alaska Native ESRD patients are less 15 likely to initiate home treatment than White ESRD 16 patients. 17 (3) Numerous studies show that individuals 18 with low incomes and in low-income communities are 19 at greater risk for ESRD. 20 (4) In addition to their kidney disease, ESRD 21 patients across all races and ethnicities often suffer 22 from one or more comorbidities. Eighty-eight per- 23 cent of ESRD patients have a history of hyper- 24 tension, 42 percent have diabetes, and nearly 30 25 percent have congestive heart failure. 26 VerDate Sep 11 2014 21:19 Sep 25, 2020 Jkt 099200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H8254.IH H8254 pamtmann on DSKBC07HB2PROD with BILLS 3 •HR 8254 IH (5) Each month, ESRD patients see multiple 1 providers and take several medications to manage 2 their kidney disease and comorbid conditions. Of all 3 patients, those with ESRD stand to benefit greatly 4 from better coordinated care. 5 (6) The Executive Order on Advancing Amer- 6 ican Kidney Health recognizes the need to develop 7 and implement new ESRD care delivery models to 8 improve quality and value for ESRD patients and 9 the Medicare program. 10 (7) In alignment with that goal, it is imperative 11 that Medicare test new models that have at their 12 core an interdisciplinary care team, among other 13 structural requirements, to— 14 (A) help ESRD patients better navigate 15 the health care system; 16 (B) empower such patients to manage 17 their plan of care and medication regimen; 18 (C) support such patients in receiving the 19 treatment modality, including a kidney trans- 20 plant, as prescribed by their nephrologist; 21 (D) access services to meet the nonclinical 22 needs of such patients that can affect care out- 23 comes; and 24 VerDate Sep 11 2014 21:19 Sep 25, 2020 Jkt 099200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H8254.IH H8254 pamtmann on DSKBC07HB2PROD with BILLS 4 •HR 8254 IH (E) receive additional services, such as 1 transplant evaluation, palliative care, evaluation 2 for hospice eligibility, and vascular access care. 3 SEC. 3. DEMONSTRATION PROGRAM TO PROVIDE INTE- 4 GRATED CARE FOR MEDICARE BENE- 5 FICIARIES WITH END-STAGE RENAL DISEASE. 6 (a) IN GENERAL.—Title XVIII of the Social Security 7 Act is amended by inserting after section 1866F the fol- 8 lowing new section: 9 ‘‘DEMONSTRATION PROGRAM TO PROVIDE INTEGRATED 10 CARE FOR MEDICARE BENEFICIARIES WITH END- 11 STAGE RENAL DISEASE 12 ‘‘SEC. 1866G. (a) ESTABLISHMENT.— 13 ‘‘(1) IN GENERAL.—The Secretary shall con- 14 duct under this section the ESRD Fee-For-Service 15 Integrated Care Demonstration Program (in this 16 section referred to as the ‘Program’), which is vol- 17 untary for Program-eligible beneficiaries and eligible 18 participating providers, to assess the effects of alter- 19 native care delivery models and payment methodolo- 20 gies on patient care improvements under this title 21 for such beneficiaries. Under the Program— 22 ‘‘(A) Program-eligible beneficiaries shall be 23 considered original Medicare Fee-For-Service 24 beneficiaries (as defined in section 1899(h)(3)) 25 VerDate Sep 11 2014 22:29 Sep 29, 2020 Jkt 099200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H8254.IH H8254 pamtmann on DSKBC07HB2PROD with BILLS 5 •HR 8254 IH for the duration of the participation of such 1 beneficiaries under the Program; 2 ‘‘(B) eligible participating providers may 3 form an ESRD Fee-For-Service Integrated 4 Care Organization (in this section referred to as 5 an ‘Organization’); and 6 ‘‘(C) an Organization shall integrate care 7 under the original Medicare Fee-For-Service 8 program under parts A and B for Program-eli- 9 gible beneficiaries. 10 ‘‘(2) DEFINITIONS.—In this section: 11 ‘‘(A) ELIGIBLE PARTICIPATING PRO- 12 VIDER.—The term ‘eligible participating pro- 13 vider’ means any of the following: 14 ‘‘(i) A facility certified as a renal di- 15 alysis facility under this title. 16 ‘‘(ii) An entity that owns one or more 17 of such facilities described in clause (i). 18 ‘‘(iii) A nephrologist (including a pedi- 19 atric nephrologist) or nephrology practice. 20 ‘‘(iv) Any other physician or physician 21 group practice. 22 ‘‘(v) A nurse practitioner, physician 23 assistant, or clinical nurse specialist (as 24 such terms are defined in section 25 VerDate Sep 11 2014 22:29 Sep 29, 2020 Jkt 099200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H8254.IH H8254 pamtmann on DSKBC07HB2PROD with BILLS 6 •HR 8254 IH 1861(aa)(5)) or a clinical social worker (as 1 defined in section 1861(hh)(1)) working in 2 conjunction with such a nurse practitioner, 3 physician assistant, or clinical nurse spe- 4 cialist. 5 ‘‘(B) ELIGIBLE PARTICIPATING PART- 6 NER.—The term ‘eligible participating partner’ 7 means, with respect to an Organization, any of 8 the following: 9 ‘‘(i) A Medicare Advantage plan de- 10 scribed in section 1851(a)(2) or a Medi- 11 care Advantage organization offering such 12 a plan. 13 ‘‘(ii) A medicaid managed care organi- 14 zation (as defined in section 1903(m)). 15 ‘‘(iii) A hospital or an academic med- 16 ical center experienced in the care of pa- 17 tients receiving dialysis. 18 ‘‘(iv) Any other entity determined ap- 19 propriate by the Secretary. 20 ‘‘(C) PROGRAM-ELIGIBLE BENEFICIARY.— 21 ‘‘(i) IN GENERAL.—The term ‘Pro- 22 gram-eligible beneficiary’ means, with re- 23 spect to an Organization offering an 24 ESRD Fee-For-Service Integrated Care 25 VerDate Sep 11 2014 21:19 Sep 25, 2020 Jkt 099200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H8254.IH H8254 pamtmann on DSKBC07HB2PROD with BILLS 7 •HR 8254 IH Model, an individual entitled to benefits 1 under part A and enrolled under part B 2 (including such an individual entitled to 3 medical assistance under a State plan 4 under title XIX) who— 5 ‘‘(I) is identified by the Secretary 6 as having end-stage renal disease and 7 who is receiving renal dialysis services 8 under the original Medicare Fee-For- 9 Service program under parts A and B, 10 and is not enrolled in a Medicare Ad- 11 vantage plan under part C or group 12 health insurance coverage or indi- 13 vidual health insurance coverage (as 14 defined in section 2791(b) of the Pub- 15 lic Health Service Act (42 U.S.C. 16 300gg–91(b))) that is primary to cov- 17 erage under this title; 18 ‘‘(II) receives renal dialysis serv- 19 ices primarily from an eligible partici- 20 pating provider of such Organization, 21 including such renal dialysis services 22 received after being identified as a 23 suitable candidate for transplantation; 24 and 25 VerDate Sep 11 2014 22:29 Sep 29, 2020 Jkt 099200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H8254.IH H8254 pamtmann on DSKBC07HB2PROD with BILLS 8 •HR 8254 IH ‘‘(III) has attained the age of 18 1 years. 2 ‘‘(ii) AFFIRMATION OF PROGRAM ELI- 3 GIBILITY UPON HOSPICE ELECTION OR 4 KIDNEY TRANSPLANT.—A Program-eligible 5 beneficiary who was assigned to or elected 6 an ESRD Fee-For-Service Integrated Care 7 Model offered by an Organization and 8 who— 9 ‘‘(I) elects to receive hospice ben- 10 efits under section 1852(d)(1); or 11 ‘‘(II) receives a kidney transplant 12 as covered under this title and main- 13 tains entitlement to benefits under 14 part A and enrollment in part B on 15 the basis of end stage renal disease, 16 shall continue to meet the definition of 17 Program-eligible beneficiary established 18 under this subparagraph. 19 ‘‘(b) ESRD FEE-FOR-SERVICE INTEGRATED CARE 20 ORGANIZATION ELIGIBILITY REQUIREMENTS.— 21 ‘‘(1) ORGANIZATIONS.— 22 ‘‘(A) IN GENERAL.—One or more eligible 23 participating providers may establish an Orga- 24 nization and may enter into, subject to sub- 25 VerDate Sep 11 2014 22:29 Sep 29, 2020 Jkt 099200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H8254.IH H8254 pamtmann on DSKBC07HB2PROD with BILLS 9 •HR 8254 IH paragraph (B), one or more partnership, owner- 1 ship, or co-ownership agreements with one or 2 more eligible participating partners to establish 3 an Organization or to offer one or more ESRD 4 Fee-For-Service Integrated Care Models in ac- 5 cordance with paragraph (2). 6 ‘‘(B) LIMITATION ON NUMBER OF AGREE- 7 MENTS.—The Secretary may specify a limita- 8 tion on the number of Organizations in which 9 an eligible participating partner may participate 10 for purposes of offering one or more ESRD 11 Fee-For-Service Integrated Care Models under 12 partnership, ownership, or co-ownership agree- 13 ments described in subparagraph (A). 14 ‘‘(C) MINIMUM PROGRAM ELIGIBLE BENE- 15 FICIARY PARTICIPATION REQUIREMENT.— 16 ‘‘(i) IN GENERAL.—Subject to clause 17 (ii), the Secretary may not enter into or 18 continue an agreement with an Organiza- 19 tion unless the Organization has at least 20 350 Program-eligible beneficiaries, or at 21 least 60 percent of Program-eligible bene- 22 ficiaries receiving care from the Organiza- 23 tion’s facilities, who are assigned to or 24 elect an ESRD Fee-For-Service Integrated 25 VerDate Sep 11 2014 22:29 Sep 29, 2020 Jkt 099200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H8254.IH H8254 pamtmann on DSKBC07HB2PROD with BILLS 10 •HR 8254 IH Model offered by the Organization and who 1 continue their assignment to or election of 2 the Organization. 3 ‘‘(ii) ALLOWING TRANSITION.—The 4 Secretary may waive the requirement 5 under clause (i) for an Organization dur- 6 ing the first agreement year with respect 7 to the Organization. 8 ‘‘(D) FISCAL SOUNDNESS REQUIRE- 9 MENTS.— 10 ‘‘(i) IN GENERAL.—The Secretary 11 shall enter into appropriate agreements 12 under this section only with Organizations 13 that demonstrate sufficient capital re- 14 serves, measured as a percentage of 15 monthly prospective payments described in 16 subsection (e) and consistent with capital 17 reserve requirements established by each 18 State in which the Organization operates, 19 subject to clause (ii). 20 ‘‘(ii) ALTERNATIVE MECHANISM TO 21 DEMONSTRATE RISK-BEARING CAPACITY.— 22 An Organization shall be considered to 23 meet the requirement in clause (i) if the 24 Organization includes at least one eligible 25 VerDate Sep 11 2014 21:19 Sep 25, 2020 Jkt 099200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H8254.IH H8254 pamtmann on DSKBC07HB2PROD with BILLS 11 •HR 8254 IH participating provider or eligible partici- 1 pating partner that— 2 ‘‘(I)(aa) is licensed under State 3 law as a risk-bearing entity eligible to 4 offer health insurance or health bene- 5 fits coverage in each State in which 6 the Organization participates in the 7 demonstration under this section; or 8 ‘‘(bb) is otherwise authorized by 9 each state in which the Organization 10 participates in the demonstration 11 under this section to bear risk for of- 12 fering health insurance or health ben- 13 efits; 14 ‘‘(II) agrees to bear risk under 15 the Organization; and 16 ‘‘(III) has the capacity to bear 17 risk commensurate with the Organiza- 18 tion’s expected expenditures under an 19 agreement under this section. 20 ‘‘(iii) DISCLOSURE.—Each Organiza- 21 tion with an agreement under this section 22 shall, in accordance with current regula- 23 tions of the Secretary that govern similar 24 disclosures, report to the Secretary finan- 25 VerDate Sep 11 2014 21:19 Sep 25, 2020 Jkt 099200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H8254.IH H8254 pamtmann on DSKBC07HB2PROD with BILLS 12 •HR 8254 IH cial information consistent with such infor- 1 mation required to be reported by a Medi- 2 care Advantage organization under part C 3 to demonstrate that the Organization has 4 a fiscally sound operation. 5 ‘‘(E) GOVERNANCE REQUIREMENTS.— 6 Each Organization with an agreement under 7 this section shall establish a governing body 8 with oversight responsibility for the Organiza- 9 tion’s compliance with Program requirements 10 that includes— 11 ‘‘(i) representation from each eligible 12 participating provider of such Organiza- 13 tion; 14 ‘‘(ii) at least two nephrologists, one of 15 which may be affiliated with an eligible 16 participating provider; and 17 ‘‘(iii) at least one beneficiary advo- 18 cate. 19 ‘‘(2) ESRD FEE-FOR-SERVICE INTEGRATED 20 CARE MODEL.— 21 ‘‘(A) BENEFIT REQUIREMENTS.— 22 ‘‘(i) IN GENERAL.—Subject to clause 23 (iii), an Organization shall offer an ESRD 24 VerDate Sep 11 2014 21:19 Sep 25, 2020 Jkt 099200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\H8254.IH H8254 pamtmann on DSKBC07HB2PROD with BILLS 13 •HR 8254 IH Fee-For-Service Integrated Care Model 1 that shall— 2 ‘‘(I) cover all benefits under 3 parts A and B (subject to payment 4 rules regarding the treatment of and 5 payment for kidney organ acquisitions 6 and hospice described in subsections 7 (e)(3) and (4)); and 8 ‘‘(II) include services for transi- 9 tion (particularly including education) 10 into tran [Text truncated for display. 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