Providing Innovative Care for Complex Cases Demonstration Act of 2015

Providing Innovative Care for Complex Cases Demonstration Act of 2015

This bill amends title XVIII (Medicare) of the Social Security Act to establish a pilot program to demonstrate improvements in patient care and cost savings for the highest-cost Medicare fee-for-service (FFS) beneficiaries through enrollment of such beneficiaries with participating organizations. The program shall be designed to provide comprehensive and integrated care management and services through a network of health care providers to meet the specialized needs of such beneficiaries. The Centers for Medicare & Medicaid Services (CMS) must design the program in such a manner as to preserve the operation of the Medicare prescription drug benefit.

A participating organization must meet the same requirements that apply to a Medicare Advantage (MA) organization. CMS must develop quality performance standards and, using an integrated care model, care management requirements for participating organizations.

For each individual enrolled under the program, CMS shall make a monthly capitated payment to the participating organization as would be made for an individual enrolled in an MA plan (excluding MA prescription drug plans), except that the amount of payment shall: (1) equal 98% of the projected cost under the Medicare FFS program for the highest-cost Medicare FFS beneficiaries; and (2) be adjusted to account for differences in costs among different geographic areas and among high-cost Medicare FFS beneficiaries, including outlier costs.

CMS must report to Congress on the performance of the program within two years of initial enrollment.