2011 US Code
Title 42 - The Public Health and Welfare
Chapter 7 - SOCIAL SECURITY (§§ 301 - 1397mm)
Subchapter XVIII - HEALTH INSURANCE FOR AGED AND DISABLED (§§ 1395 - 1395kkk-1)
Section 1395b-8 - Chronic care improvement
View MetadataPublication Title | United States Code, 2006 Edition, Supplement 5, Title 42 - THE PUBLIC HEALTH AND WELFARE |
Category | Bills and Statutes |
Collection | United States Code |
SuDoc Class Number | Y 1.2/5: |
Contained Within | Title 42 - THE PUBLIC HEALTH AND WELFARE CHAPTER 7 - SOCIAL SECURITY SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED Sec. 1395b-8 - Chronic care improvement |
Contains | section 1395b-8 |
Date | 2011 |
Laws in Effect as of Date | January 3, 2012 |
Positive Law | No |
Disposition | standard |
Source Credit | Aug. 14, 1935, ch. 531, title XVIII, §1807, as added Pub. L. 108-173, title VII, §721(a), Dec. 8, 2003, 117 Stat. 2341. |
Statutes at Large References | 117 Stat. 2341, 2327, 2346, 2348 |
Public Law References | Public Law 108-173 |
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The Secretary shall provide for the phased-in development, testing, evaluation, and implementation of chronic care improvement programs in accordance with this section. Each such program shall be designed to improve clinical quality and beneficiary satisfaction and achieve spending targets with respect to expenditures under this subchapter for targeted beneficiaries with one or more threshold conditions.
(2) DefinitionsFor purposes of this section:
(A) Chronic care improvement programThe term “chronic care improvement program” means a program described in paragraph (1) that is offered under an agreement under subsection (b) or (c) of this section.
(B) Chronic care improvement organizationThe term “chronic care improvement organization” means an entity that has entered into an agreement under subsection (b) or (c) of this section to provide, directly or through contracts with subcontractors, a chronic care improvement program under this section. Such an entity may be a disease management organization, health insurer, integrated delivery system, physician group practice, a consortium of such entities, or any other legal entity that the Secretary determines appropriate to carry out a chronic care improvement program under this section.
(C) Care management planThe term “care management plan” means a plan established under subsection (d) of this section for a participant in a chronic care improvement program.
(D) Threshold conditionThe term “threshold condition” means a chronic condition, such as congestive heart failure, diabetes, chronic obstructive pulmonary disease (COPD), or other diseases or conditions, as selected by the Secretary as appropriate for the establishment of a chronic care improvement program.
(E) Targeted beneficiaryThe term “targeted beneficiary” means, with respect to a chronic care improvement program, an individual who—
(i) is entitled to benefits under part A of this subchapter and enrolled under part B of this subchapter, but not enrolled in a plan under part C of this subchapter;
(ii) has one or more threshold conditions covered under such program; and
(iii) has been identified under subsection (d)(1) of this section as a potential participant in such program.
(3) ConstructionNothing in this section shall be construed as—
(A) expanding the amount, duration, or scope of benefits under this subchapter;
(B) providing an entitlement to participate in a chronic care improvement program under this section;
(C) providing for any hearing or appeal rights under section 1395ff, 1395oo of this title, or otherwise, with respect to a chronic care improvement program under this section; or
(D) providing benefits under a chronic care improvement program for which a claim may be submitted to the Secretary by any provider of services or supplier (as defined in section 1395x(d) of this title).
(b) Developmental phase (Phase I) (1) In generalIn carrying out this section, the Secretary shall enter into agreements consistent with subsection (f) of this section with chronic care improvement organizations for the development, testing, and evaluation of chronic care improvement programs using randomized controlled trials. The first such agreement shall be entered into not later than 12 months after December 8, 2003.
(2) Agreement periodThe period of an agreement under this subsection shall be for 3 years.
(3) Minimum participation (A) In generalThe Secretary shall enter into agreements under this subsection in a manner so that chronic care improvement programs offered under this section are offered in geographic areas that, in the aggregate, consist of areas in which at least 10 percent of the aggregate number of medicare beneficiaries reside.
(B) Medicare beneficiary definedIn this paragraph, the term “medicare beneficiary” means an individual who is entitled to benefits under part A of this subchapter, enrolled under part B of this subchapter, or both, and who resides in the United States.
(4) Site selectionIn selecting geographic areas in which agreements are entered into under this subsection, the Secretary shall ensure that each chronic care improvement program is conducted in a geographic area in which at least 10,000 targeted beneficiaries reside among other individuals entitled to benefits under part A of this subchapter, enrolled under part B of this subchapter, or both to serve as a control population.
(5) Independent evaluations of Phase I programsThe Secretary shall contract for an independent evaluation of the programs conducted under this subsection. Such evaluation shall be done by a contractor with knowledge of chronic care management programs and demonstrated experience in the evaluation of such programs. Each evaluation shall include an assessment of the following factors of the programs:
(A) Quality improvement measures, such as adherence to evidence-based guidelines and rehospitalization rates.
(B) Beneficiary and provider satisfaction.
(C) Health outcomes.
(D) Financial outcomes, including any cost savings to the program under this subchapter.
(c) Expanded implementation phase (Phase II) (1) In generalWith respect to chronic care improvement programs conducted under subsection (b) of this section, if the Secretary finds that the results of the independent evaluation conducted under subsection (b)(6) of this section indicate that the conditions specified in paragraph (2) have been met by a program (or components of such program), the Secretary shall enter into agreements consistent with subsection (f) of this section to expand the implementation of the program (or components) to additional geographic areas not covered under the program as conducted under subsection (b) of this section, which may include the implementation of the program on a national basis. Such expansion shall begin not earlier than 2 years after the program is implemented under subsection (b) of this section and not later than 6 months after the date of completion of such program.
(2) Conditions for expansion of programsThe conditions specified in this paragraph are, with respect to a chronic care improvement program conducted under subsection (b) of this section for a threshold condition, that the program is expected to—
(A) improve the clinical quality of care;
(B) improve beneficiary satisfaction; and
(C) achieve targets for savings to the program under this subchapter specified by the Secretary in the agreement within a range determined to be appropriate by the Secretary, subject to the application of budget neutrality with respect to the program and not taking into account any payments by the organization under the agreement under the program for risk under subsection (f)(3)(B) of this section.
(3) Independent evaluations of Phase II programsThe Secretary shall carry out evaluations of programs expanded under this subsection as the Secretary determines appropriate. Such evaluations shall be carried out in the similar manner as is provided under subsection (b)(5) of this section.
(d) Identification and enrollment of prospective program participants (1) Identification of prospective program participantsThe Secretary shall establish a method for identifying targeted beneficiaries who may benefit from participation in a chronic care improvement program.
(2) Initial contact by SecretaryThe Secretary shall communicate with each targeted beneficiary concerning participation in a chronic care improvement program. Such communication may be made by the Secretary and shall include information on the following:
(A) A description of the advantages to the beneficiary in participating in a program.
(B) Notification that the organization offering a program may contact the beneficiary directly concerning such participation.
(C) Notification that participation in a program is voluntary.
(D) A description of the method for the beneficiary to participate or for declining to participate and the method for obtaining additional information concerning such participation.
(3) Voluntary participationA targeted beneficiary may participate in a chronic care improvement program on a voluntary basis and may terminate participation at any time.
(e) Chronic care improvement programs (1) In generalEach chronic care improvement program shall—
(A) have a process to screen each targeted beneficiary for conditions other than threshold conditions, such as impaired cognitive ability and co-morbidities, for the purposes of developing an individualized, goal-oriented care management plan under paragraph (2);
(B) provide each targeted beneficiary participating in the program with such plan; and
(C) carry out such plan and other chronic care improvement activities in accordance with paragraph (3).
(2) Elements of care management plansA care management plan for a targeted beneficiary shall be developed with the beneficiary and shall, to the extent appropriate, include the following:
(A) A designated point of contact responsible for communications with the beneficiary and for facilitating communications with other health care providers under the plan.
(B) Self-care education for the beneficiary (through approaches such as disease management or medical nutrition therapy) and education for primary caregivers and family members.
(C) Education for physicians and other providers and collaboration to enhance communication of relevant clinical information.
(D) The use of monitoring technologies that enable patient guidance through the exchange of pertinent clinical information, such as vital signs, symptomatic information, and health self-assessment.
(E) The provision of information about hospice care, pain and palliative care, and end-of-life care.
(3) Conduct of programsIn carrying out paragraph (1)(C) with respect to a participant, the chronic care improvement organization shall—
(A) guide the participant in managing the participant's health (including all co-morbidities, relevant health care services, and pharmaceutical needs) and in performing activities as specified under the elements of the care management plan of the participant;
(B) use decision-support tools such as evidence-based practice guidelines or other criteria as determined by the Secretary; and
(C) develop a clinical information database to track and monitor each participant across settings and to evaluate outcomes.
(4) Additional responsibilities (A) Outcomes reportEach chronic care improvement organization offering a chronic care improvement program shall monitor and report to the Secretary, in a manner specified by the Secretary, on health care quality, cost, and outcomes.
(B) Additional requirementsEach such organization and program shall comply with such additional requirements as the Secretary may specify.
(5) AccreditationThe Secretary may provide that chronic care improvement programs and chronic care improvement organizations that are accredited by qualified organizations (as defined by the Secretary) may be deemed to meet such requirements under this section as the Secretary may specify.
(f) Terms of agreements (1) Terms and conditions (A) In generalAn agreement under this section with a chronic care improvement organization shall contain such terms and conditions as the Secretary may specify consistent with this section.
(B) Clinical, quality improvement, and financial requirementsThe Secretary may not enter into an agreement with such an organization under this section for the operation of a chronic care improvement program unless—
(i) the program and organization meet the requirements of subsection (e) of this section and such clinical, quality improvement, financial, and other requirements as the Secretary deems to be appropriate for the targeted beneficiaries to be served; and
(ii) the organization demonstrates to the satisfaction of the Secretary that the organization is able to assume financial risk for performance under the agreement (as applied under paragraph (3)(B)) with respect to payments made to the organization under such agreement through available reserves, reinsurance, withholds, or such other means as the Secretary determines appropriate.
(2) Manner of paymentSubject to paragraph (3)(B), the payment under an agreement under—
(A) subsection (b) of this section shall be computed on a per-member per-month basis; or
(B) subsection (c) of this section may be on a per-member per-month basis or such other basis as the Secretary and organization may agree.
(3) Application of performance standards (A) Specification of performance standardsEach agreement under this section with a chronic care improvement organization shall specify performance standards for each of the factors specified in subsection (c)(2) of this section, including clinical quality and spending targets under this subchapter, against which the performance of the chronic care improvement organization under the agreement is measured.
(B) Adjustment of payment based on performance (i) In generalEach such agreement shall provide for adjustments in payment rates to an organization under the agreement insofar as the Secretary determines that the organization failed to meet the performance standards specified in the agreement under subparagraph (A).
(ii) Financial risk for performanceIn the case of an agreement under subsection (b) or (c) of this section, the agreement shall provide for a full recovery for any amount by which the fees paid to the organization under the agreement exceed the estimated savings to the programs under this subchapter attributable to implementation of such agreement.
(4) Budget neutral payment conditionUnder this section, the Secretary shall ensure that the aggregate sum of medicare program benefit expenditures for beneficiaries participating in chronic care improvement programs and funds paid to chronic care improvement organizations under this section, shall not exceed the medicare program benefit expenditures that the Secretary estimates would have been made for such targeted beneficiaries in the absence of such programs.
(g) Funding(1) Subject to paragraph (2), there are appropriated to the Secretary, in appropriate part from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund, such sums as may be necessary to provide for agreements with chronic care improvement programs under this section.
(2) In no case shall the funding under this section exceed $100,000,000 in aggregate increased expenditures under this subchapter (after taking into account any savings attributable to the operation of this section) over the 3-fiscal-year period beginning on October 1, 2003.
(Aug. 14, 1935, ch. 531, title XVIII, §1807, as added Pub. L. 108–173, title VII, §721(a), Dec. 8, 2003, 117 Stat. 2341.)
References in TextParts A, B, and C of this subchapter, referred to in subsecs. (a)(2)(E)(i) and (b)(3)(B), (4), are classified to sections 1395c et seq., 1395j et seq., and 1395w–21 et seq., respectively, of this title.
Demonstration Project for Consumer-Directed Chronic Outpatient ServicesPub. L. 108–173, title VI, §648, Dec. 8, 2003, 117 Stat. 2327, provided that:
“(a)
“(1)
“(2)
“(b)
“(1)
“(A)
“(B)
“(2)
“(c)
“(d)
“(e)
“(1)
“(2)
“(A) An analysis of the patient outcomes and costs of furnishing care to the individuals with chronic conditions participating in the projects as compared to such outcomes and costs to other individuals for the same health conditions.
“(B) Evaluation of patient satisfaction under the demonstration projects.
“(C) Such recommendations regarding the extension, expansion, or termination of the projects as the Secretary determines appropriate.
“(f)
“(g)
“(2) There are authorized to be appropriated from such Trust Fund such sums as may be necessary for the Secretary to enter into contracts with appropriate organizations for the deign [sic], implementation, and evaluation of the demonstration project.
“(3) In no case may expenditures under this section exceed the aggregate expenditures that would otherwise have been made for the provision of personal care services.”
ReportsPub. L. 108–173, title VII, §721(b), Dec. 8, 2003, 117 Stat. 2346, provided that: “The Secretary [of Health and Human Services] shall submit to Congress reports on the operation of section 1807 of the Social Security Act [this section], as added by subsection (a), as follows:
“(1) Not later than 2 years after the date of the implementation of such section, the Secretary shall submit to Congress an interim report on the scope of implementation of the programs under subsection (b) of such section, the design of the programs, and preliminary cost and quality findings with respect to those programs based on the following measures of the programs:
“(A) Quality improvement measures, such as adherence to evidence-based guidelines and rehospitalization rates.
“(B) Beneficiary and provider satisfaction.
“(C) Health outcomes.
“(D) Financial outcomes.
“(2) Not later than 3 years and 6 months after the date of the implementation of such section the Secretary shall submit to Congress an update to the report required under paragraph (1) on the results of such programs.
“(3) The Secretary shall submit to Congress 2 additional biennial reports on the chronic care improvement programs conducted under such section. The first such report shall be submitted not later than 2 years after the report is submitted under paragraph (2). Each such report shall include information on—
“(A) the scope of implementation (in terms of both regions and chronic conditions) of the chronic care improvement programs;
“(B) the design of the programs; and
“(C) the improvements in health outcomes and financial efficiencies that result from such implementation.”
Chronically Ill Medicare Beneficiary Research, Data, Demonstration StrategyPub. L. 108–173, title VII, §723, Dec. 8, 2003, 117 Stat. 2348, provided that:
“(a)
“(b)
“(1) integrate existing data sets including, the Medicare Current Beneficiary Survey (MCBS), Minimum Data Set (MDS), Outcome and Assessment Information Set (OASIS), data from Quality Improvement Organizations (QIO), and claims data;
“(2) identify any new data needs and a methodology to address new data needs;
“(3) plan for the collection of such data in a data warehouse; and
“(4) develop a research agenda using such data.
“(c)
“(d)
“(e)
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