[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[S. 1871 Placed on Calendar Senate (PCS)]
Calendar No. 280
113th CONGRESS
1st Session
S. 1871
To amend title XVIII of the Social Security Act to repeal the Medicare
sustainable growth rate formula and to improve beneficiary access under
the Medicare program, and for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
December 19, 2013
Mr. Baucus, from the Committee on Finance, reported the following
original bill; which was read twice and placed on the calendar
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to repeal the Medicare
sustainable growth rate formula and to improve beneficiary access under
the Medicare program, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``SGR Repeal and
Medicare Beneficiary Access Act of 2013''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--MEDICARE PAYMENT FOR PHYSICIANS' SERVICES
Sec. 101. Repealing the sustainable growth rate (SGR) and improving
Medicare payment for physicians' services.
Sec. 102. Priorities and funding for quality measure development.
Sec. 103. Encouraging care management for individuals with chronic care
needs.
Sec. 104. Ensuring accurate valuation of services under the physician
fee schedule.
Sec. 105. Promoting evidence-based care.
Sec. 106. Empowering beneficiary choices through access to information
on physicians' services.
Sec. 107. Expanding claims data availability to improve care.
TITLE II--EXTENSIONS AND OTHER PROVISIONS
Subtitle A--Medicare Extensions
Sec. 201. Work geographic adjustment.
Sec. 202. Medicare payment for therapy services.
Sec. 203. Medicare ambulance services.
Sec. 204. Revision of the Medicare-dependent hospital (MDH) program.
Sec. 205. Revision of Medicare inpatient hospital payment adjustment
for low-volume hospitals.
Sec. 206. Specialized Medicare Advantage plans for special needs
individuals.
Sec. 207. Reasonable cost reimbursement contracts.
Sec. 208. Quality measure endorsement and selection.
Sec. 209. Permanent extension of funding outreach and assistance for
low-income programs.
Subtitle B--Medicaid and Other Extensions
Sec. 211. Qualifying individual program.
Sec. 212. Transitional Medical Assistance.
Sec. 213. Express lane eligibility.
Sec. 214. Pediatric quality measures.
Sec. 215. Special diabetes programs.
Subtitle C--Human Services Extensions
Sec. 221. Abstinence education grants.
Sec. 222. Personal responsibility education program.
Sec. 223. Family-to-family health information centers.
Sec. 224. Health workforce demonstration project for low-income
individuals.
Subtitle D--Program Integrity
Sec. 231. Reducing improper Medicare payments.
Sec. 232. Authority for Medicaid fraud control units to investigate and
prosecute complaints of abuse and neglect
of Medicaid patients in home and community-
based settings.
Sec. 233. Improved use of funds received by the HHS Inspector General
from oversight and investigative
activities.
Sec. 234. Preventing and reducing improper Medicare and Medicaid
expenditures.
Subtitle E--Other Provisions
Sec. 241. Commission on Improving Patient Directed Health Care.
Sec. 242. Expansion of the definition of inpatient hospital services
for certain cancer hospitals.
Sec. 243. Quality measures for certain post-acute care providers
relating to notice and transfer of patient
health information and patient care
preferences.
Sec. 244. Criteria for medically necessary, short inpatient hospital
stays.
Sec. 245. Transparency of reasons for excluding additional procedures
from the Medicare ambulatory surgical
center (ASC) approved list.
Sec. 246. Supervision in critical access hospitals.
Sec. 247. Requiring State licensure of bidding entities under the
competitive acquisition program for certain
durable medical equipment, prosthetics,
orthotics, and supplies (DMEPOS).
Sec. 248. Recognition of attending physician assistants as attending
physicians to serve hospice patients.
Sec. 249. Remote patient monitoring pilot projects.
Sec. 250. Community-Based Institutional Special Needs Plan
Demonstration Program.
Sec. 251. Applying CMMI waiver authority to PACE in order to foster
innovations.
Sec. 252. Improve and modernize Medicaid data systems and reporting.
Sec. 253. Fairness in Medicaid supplemental needs trusts.
Sec. 254. Helping Ensure Life- and Limb-Saving Access to Podiatric
Physicians.
Sec. 255. Demonstration program to improve community mental health
services.
Sec. 256. Annual Medicaid DSH report.
Sec. 257. Implementation.
TITLE I--MEDICARE PAYMENT FOR PHYSICIANS' SERVICES
SEC. 101. REPEALING THE SUSTAINABLE GROWTH RATE (SGR) AND IMPROVING
MEDICARE PAYMENT FOR PHYSICIANS' SERVICES.
(a) Stabilizing Fee Updates.--
(1) Repeal of sgr payment methodology.--Section 1848 of the
Social Security Act (42 U.S.C. 1395w-4) is amended--
(A) in subsection (d)--
(i) in paragraph (1)(A), by inserting ``or
a subsequent paragraph'' after ``paragraph
(4)''; and
(ii) in paragraph (4)--
(I) in the heading, by inserting
``and ending with 2013'' after ``years
beginning with 2001''; and
(II) in subparagraph (A), by
inserting ``and ending with 2013''
after ``a year beginning with 2001'';
and
(B) in subsection (f)--
(i) in paragraph (1)(B), by inserting
``through 2013'' after ``of each succeeding
year''; and
(ii) in paragraph (2), by inserting ``and
ending with 2013'' after ``beginning with
2000''.
(2) Update of rates for 2014 and subsequent years.--
Subsection (d) of section 1848 of the Social Security Act (42
U.S.C. 1395w-4) is amended by adding at the end the following
new paragraphs:
``(15) Update for 2014 through 2023.--The update to the
single conversion factor established in paragraph (1)(C) for
each of 2014 through 2023 shall be zero percent.
``(16) Update for 2024 and subsequent years.--The update to
the single conversion factor established in paragraph (1)(C)
for 2024 and each subsequent year shall be--
``(A) for items and services furnished by a
qualifying APM participant (as defined in section
1833(z)(2)) for such year, 2 percent; and
``(B) for other items and services, 1 percent.''.
(3) MedPAC reports.--
(A) Initial report.--Not later than July 1, 2016,
the Medicare Payment Advisory Commission shall submit
to Congress a report on the relationship between--
(i) physician and other health professional
utilization and expenditures (and the rate of
increase of such utilization and expenditures)
of items and services for which payment is made
under section 1848 of the Social Security Act
(42 U.S.C. 1395w-4); and
(ii) total utilization and expenditures
(and the rate of increase of such utilization
and expenditures) under parts A, B, and D of
title XVIII of such Act.
Such report shall include a methodology to describe
such relationship and the impact of changes in such
physician and other health professional practice and
service ordering patterns on total utilization and
expenditures under parts A, B, and D of such title.
(B) Final report.--Not later than July 1, 2020, the
Medicare Payment Advisory Commission shall submit to
Congress a report on the relationship described in
subparagraph (A), including the results determined from
applying the methodology included in the report
submitted under such subparagraph.
(b) Consolidation of Certain Current Law Performance Programs With
New Value-based Performance Incentive Program.--
(1) EHR meaningful use incentive program.--
(A) Sunsetting separate meaningful use payment
adjustments.--Section 1848(a)(7)(A) of the Social
Security Act (42 U.S.C. 1395w-4(a)(7)(A)) is amended--
(i) in clause (i), by striking ``or any
subsequent payment year'' and inserting ``or
2016'';
(ii) in clause (ii)--
(I) in the matter preceding
subclause (I), by striking ``Subject to
clause (iii), for'' and inserting
``For'';
(II) in subclause (I), by adding at
the end ``and'';
(III) in subclause (II), by
striking ``; and'' and inserting a
period; and
(IV) by striking subclause (III);
and
(iii) by striking clause (iii).
(B) Continuation of meaningful use determinations
for vbp program.--Section 1848(o)(2) of the Social
Security Act (42 U.S.C. 1395w-4(o)(2)) is amended--
(i) in subparagraph (A), in the matter
preceding clause (i)--
(I) by striking ``For purposes of
paragraph (1), an'' and inserting
``An''; and
(II) by inserting ``, or pursuant
to subparagraph (D) for purposes of
subsection (q), for a performance
period under such subsection for a
year'' after ``under such subsection
for a year''; and
(ii) by adding at the end the following new
subparagraph:
``(D) Continued application for purposes of vbp
program.--With respect to 2017 and each subsequent
payment year, the Secretary shall, for purposes of
subsection (q) and in accordance with paragraph (1)(F)
of such subsection, determine whether an eligible
professional who is a VBP eligible professional (as
defined in subsection (q)(1)(C)) for such year is a
meaningful EHR user under this paragraph for the
performance period under subsection (q) for such
year.''.
(2) Quality reporting.--
(A) Sunsetting separate quality reporting
incentives.--Section 1848(a)(8)(A) of the Social
Security Act (42 U.S.C. 1395w-4(a)(8)(A)) is amended--
(i) in clause (i), by striking ``or any
subsequent year'' and inserting ``or 2016'';
and
(ii) in clause (ii)(II), by striking ``and
each subsequent year''.
(B) Continuation of quality measures and processes
for vbp program.--Section 1848 of the Social Security
Act (42 U.S.C. 1395w-4) is amended--
(i) in subsection (k), by adding at the end
the following new paragraph:
``(9) Continued application for purposes of vbp program.--
The Secretary shall, in accordance with subsection (q)(1)(F),
carry out the provisions of this subsection for purposes of
subsection (q).''; and
(ii) in subsection (m)--
(I) by redesignating the paragraph
(7) added by section 10327(a) of Public
Law 111-148 as paragraph (8); and
(II) by adding at the end the
following new paragraph:
``(9) Continued application for purposes of vbp program.--
The Secretary shall, in accordance with subsection (q)(1)(F),
carry out the processes under this subsection for purposes of
subsection (q).''.
(3) Value-based payments.--
(A) Sunsetting separate value-based payments.--
Clause (iii) of section 1848(p)(4)(B) of the Social
Security Act (42 U.S.C. 1395w-4(p)(4)(B)) is amended to
read as follows:
``(iii) Application.--The Secretary shall
apply the payment modifier established under
this subsection for items and services
furnished on or after January 1, 2015, but
before January 1, 2017, with respect to
specific physicians and groups of physicians
the Secretary determines appropriate. Such
payment modifier shall not be applied for items
and services furnished on or after January 1,
2017.''.
(B) Continuation of value-based payment modifier
measures for vbp program.--Section 1848(p) of the
Social Security Act (42 U.S.C. 1395w-4(p)) is amended--
(i) in paragraph (2), by adding at the end
the following new subparagraph:
``(C) Continued application for purposes of vbp
program.--The Secretary shall, in accordance with
subsection (q)(1)(F), carry out subparagraph (B) for
purposes of subsection (q).''; and
(ii) in paragraph (3), by adding at the end
the following: ``With respect to 2017 and each
subsequent year, the Secretary shall, in
accordance with subsection (q)(1)(F), carry out
this paragraph for purposes of subsection
(q).''.
(c) Value-based Performance Incentive Program.--
(1) In general.--Section 1848 of the Social Security Act
(42 U.S.C. 1395w-4) is amended by adding at the end the
following new subsection:
``(q) Value-based Performance Incentive Program.--
``(1) Establishment.--
``(A) In general.--Subject to the succeeding
provisions of this subsection, the Secretary shall
establish an eligible professional value-based
performance incentive program (in this subsection
referred to as the `VBP program') under which the
Secretary shall--
``(i) develop a methodology for assessing
the total performance of each VBP eligible
professional according to performance standards
under paragraph (3) for a performance period
(as established under paragraph (4)) for a
year;
``(ii) using such methodology, provide for
a composite performance score in accordance
with paragraph (5) for each such professional
for each performance period; and
``(iii) use such composite performance
score of the VBP eligible professional for a
performance period for a year to make VBP
program incentive payments under paragraph (7)
to the professional for the year.
``(B) Program implementation.--The VBP program
shall apply to payments for items and services
furnished on or after January 1, 2017.
``(C) VBP eligible professional defined.--
``(i) In general.--For purposes of this
subsection, subject to clauses (ii) and (iv),
the term `VBP eligible professional' means--
``(I) for the first and second
years for which the VBP program applies
to payments (and for the performance
period for such first and second year),
a physician (as defined in section
1861(r)), a physician assistant, nurse
practitioner, and clinical nurse
specialist (as such terms are defined
in section 1861(aa)(5)), and a
certified registered nurse anesthetist
(as defined in section 1861(bb)(2));
and
``(II) for the third year for which
the VBP program applies to payments
(and for the performance period for
such third year) and for each
succeeding year (and for the
performance period for each such year),
the professionals described in
subclause (I) and such other eligible
professionals (as defined in subsection
(k)(3)(B)) as specified by the
Secretary.
``(ii) Exclusions.--For purposes of clause
(i), the term `VBP eligible professional' does
not include, with respect to a year, an
eligible professional (as defined in subsection
(k)(3)(B))--
``(I) who is a qualifying APM
participant (as defined in section
1833(z)(2));
``(II) who, subject to clause
(vii), is a partial qualifying APM
participant (as defined in clause
(iii)) for the most recent period for
which data are available and who, for
the performance period with respect to
such year, does not report on
applicable measures and activities
described in paragraph (2)(B) that are
required to be reported by such a
professional under the VBP program; or
``(III) who, for the performance
period with respect to such year, does
not exceed the low-volume threshold
measurement selected under clause (iv).
``(iii) Partial qualifying apm
participant.--For purposes of this
subparagraph, the term `partial qualifying APM
participant' means, with respect to a year, an
eligible professional for whom the Secretary
determines the minimum payment percentage (or
percentages), as applicable, described in
paragraph (2) of section 1833(z) for such year
have not been satisfied, but who would be
considered a qualifying APM participant (as
defined in such paragraph) for such year if--
``(I) with respect to 2017 and
2018, the reference in subparagraph (A)
of such paragraph to 25 percent was
instead a reference to 20 percent;
``(II) with respect to 2019 and
2020--
``(aa) the reference in
subparagraph (B)(i) of such
paragraph to 50 percent was
instead a reference to 40
percent; and
``(bb) the references in
subparagraph (B)(ii) of such
paragraph to 50 percent and 25
percent of such paragraph were
instead references to 40
percent and 20 percent,
respectively; and
``(III) with respect to 2021 and
subsequent years--
``(aa) the reference in
subparagraph (C)(i) of such
paragraph to 75 percent was
instead a reference to 50
percent; and
``(bb) the references in
subparagraph (C)(ii) of such
paragraph to 75 percent and 25
percent of such paragraph were
instead references to 50
percent and 20 percent,
respectively.
``(iv) Selection of low-volume threshold
measurement.--The Secretary shall select one of
the following low-volume threshold measurements
to apply for purposes of clause (ii)(III):
``(I) The minimum number (as
determined by the Secretary) of
individuals enrolled under this part
who are treated by the VBP eligible
professional for the performance period
involved.
``(II) The minimum number (as
determined by the Secretary) of items
and services furnished to individuals
enrolled under this part by such
professional for such performance
period.
``(III) The minimum amount (as
determined by the Secretary) of allowed
charges billed by such professional
under this part for such performance
period.
``(v) Treatment of new medicare enrolled
eligible professionals.--In the case of a
professional who first becomes a Medicare
enrolled eligible professional during the
performance period for a year (and had not
previously submitted claims under this title
such as a person, an entity, or a part of a
physician group or under a different billing
number or tax identifier), such professional
shall not be treated under this subsection as a
VBP eligible professional until the subsequent
year and performance period for such subsequent
year.
``(vi) Clarification.--In the case of items
and services furnished during a year by an
individual who is not a VBP eligible
professional (including pursuant to clauses
(ii) and (v)) with respect to a year, in no
case shall a reduction under paragraph (6) or a
VBP program incentive payment under paragraph
(7) apply to such individual for such year.
``(vii) Partial qualifying apm participant
clarification.--In the case of an eligible
professional who is a partial qualifying APM
participant, with respect to a year, and who
for the performance period for such year
reports on applicable measures and activities
described in paragraph (2)(B) that are required
to be reported by such a professional under the
VBP program, such eligible professional is
considered to be a VBP eligible professional
with respect to such year.
``(D) Application to group practices.--
``(i) In general.--Under the VBP program:
``(I) Quality performance
category.--The Secretary shall
establish and apply a process that
includes features of the provisions of
subsection (m)(3)(C) for VBP eligible
professionals in a group practice with
respect to assessing performance of
such group with respect to the
performance category described in
clause (i) of paragraph (2)(A).
``(II) Other performance
categories.--The Secretary may
establish and apply a process that
includes features of the provisions of
subsection (m)(3)(C) for VBP eligible
professionals in a group practice with
respect to assessing the performance of
such group with respect to the
performance categories described in
clauses (ii) through (iv) of such
paragraph.
``(ii) Ensuring comprehensiveness of group
practice assessment.--The process established
under clause (i) shall to the extent
practicable reflect the full range of items and
services furnished by the VBP eligible
professionals in the group practice involved.
``(iii) Clarification.--VBP eligible
professionals electing to be a virtual group
under paragraph (5)(J) shall not be considered
VBP eligible professionals in a group practice
for purposes of applying this subparagraph.
``(E) Use of registries.--Under the VBP program,
the Secretary shall encourage the use of qualified
clinical data registries pursuant to subsection
(m)(3)(E) in carrying out this subsection.
``(F) Application of certain provisions.--In
applying a provision of subsection (k), (m), (o), or
(p) for purposes of this subsection, the Secretary
shall--
``(i) adjust the application of such
provision to ensure the provision is consistent
with the provisions of this subsection; and
``(ii) not apply such provision to the
extent that the provision is duplicative with a
provision of this subsection.
``(2) Measures and activities under performance
categories.--
``(A) Performance categories.--Under the VBP
program, the Secretary shall use the following
performance categories (each of which is referred to in
this subsection as a performance category) in
determining the composite performance score under
paragraph (5):
``(i) Quality.
``(ii) Resource use.
``(iii) Clinical practice improvement
activities.
``(iv) Meaningful use of certified EHR
technology.
``(B) Measures and activities specified for each
category.--For purposes of paragraph (3)(A) and subject
to subparagraph (C), measures and activities specified
for a performance period (as established under
paragraph (4)) for a year are as follows:
``(i) Quality.--For the performance
category described in subparagraph (A)(i), the
quality measures established for such period
under subsections (k) and (m), including under
subsection (m)(3)(E), and the measures of
quality of care established for such period
under subsection (p)(2).
``(ii) Resource use.--For the performance
category described in subparagraph (A)(ii), the
measurement of resource use for such period
under subsection (p)(3), using the methodology
under subsection (r), as appropriate, and, as
feasible and applicable, accounting for the
cost of covered part D drugs.
``(iii) Clinical practice improvement
activities.--For the performance category
described in subparagraph (A)(iii), clinical
practice improvement activities under
subcategories specified by the Secretary for
such period, which shall include at least the
following:
``(I) The subcategory of expanded
practice access, which shall include
activities such as same day
appointments for urgent needs and after
hours access to clinician advice.
``(II) The subcategory of
population management, which shall
include activities such as monitoring
health conditions of individuals to
provide timely health care
interventions or participation in a
qualified clinical data registry.
``(III) The subcategory of care
coordination, which shall include
activities such as timely communication
of test results, timely exchange of
clinical information to patients and
other providers, and use of remote
monitoring or telehealth.
``(IV) The subcategory of
beneficiary engagement, which shall
include activities such as the
establishment of care plans for
individuals with complex care needs,
beneficiary self-management training,
and using shared decision-making
mechanisms.
``(V) The subcategory of patient
safety and practice assessment, such as
through use of clinical or surgical
checklists and practice assessments
related to maintaining certification.
``(VI) The subcategory of
participation in an alternative payment
model (as defined in section
1833(z)(3)(C)).
In establishing activities under this clause,
the Secretary shall give consideration to the
circumstances of small practices (consisting of
10 or fewer professionals) and practices
located in rural areas and in health
professional shortage areas (as designated
under section 332(a)(1)(A) of the Public Health
Service Act).
``(iv) Meaningful ehr use.--For the
performance category described in subparagraph
(A)(iv), the requirements established for such
period under subsection (o)(2) for determining
whether an eligible professional is a
meaningful EHR user.
``(C) Additional provisions.--
``(i) Emphasizing outcome measures under
quality performance category.--In applying
subparagraph (B)(i), the Secretary shall, as
feasible, emphasize the application of outcome
measures.
``(ii) Application of additional system
measures.--The Secretary may use measures used
for a payment system other than for physicians
for purposes of the performance category
described in subparagraph (A)(i).
``(iii) Global and population-based
measures.--The Secretary may use global
measures, such as global outcome measures, and
population-based measures for purposes of the
performance category described in subparagraph
(A)(i).
``(iv) Request for information for clinical
practice improvement activities.--In initially
applying subparagraph (B)(iii), the Secretary
shall use a request for information to solicit
recommendations from stakeholders for
identifying activities described in such
subparagraph and specifying criteria for such
activities.
``(v) Contract authority for clinical
practice improvement activities performance
category.--In applying subparagraph (B)(iii),
the Secretary may contract with entities to
assist the Secretary in--
``(I) identifying activities
described in subparagraph (B)(iii);
``(II) specifying criteria for such
activities; and
``(III) determining whether a VBP
eligible professional meets such
criteria.
``(3) Performance standards.--
``(A) Establishment.--Under the VBP program, the
Secretary shall establish performance standards with
respect to measures and activities specified under
paragraph (2)(B) for a performance period (as
established under paragraph (4)) for a year.
``(B) Considerations in establishing standards.--In
establishing such performance standards with respect to
measures and activities specified under paragraph
(2)(B), the Secretary shall take into account the
following:
``(i) Historical performance standards.
``(ii) Improvement rates.
``(iii) The opportunity for continued
improvement.
``(4) Performance period.--The Secretary shall establish a
performance period (or periods) for a year (beginning with the
year described in paragraph (1)(B)). Such performance period
(or periods) shall begin and end prior to the beginning of such
year and be as close as possible to such year. In this
subsection, such performance period (or periods) for a year
shall be referred to as the performance period for the year.
``(5) Composite performance score.--
``(A) In general.--Subject to the succeeding
provisions of this paragraph, the Secretary shall
develop a methodology for assessing the total
performance of each VBP eligible professional according
to performance standards under paragraph (3) with
respect to applicable measures and activities specified
in paragraph (2)(B) with respect to each performance
category applicable to such professional for a
performance period (as established under paragraph (4))
for a year. Using such methodology, the Secretary shall
provide for a composite assessment (in this subsection
referred to as the `composite performance score') for
each such professional for each performance period.
``(B) Weighting performance categories, measures,
and activities.--Under the methodology under
subparagraph (A), the Secretary--
``(i) may assign different scoring weights
(including a weight of 0) for--
``(I) each performance category
based on the extent to which the
category is applicable to the type of
eligible professional involved; and
``(II) each measure and activity
specified under paragraph (2)(B) with
respect to each such category based on
the extent to which the measure or
activity is applicable to the type of
eligible professional involved; and
``(ii) with respect to the performance
category described in paragraph (2)(A)(i)--
``(I) shall assign a higher scoring
weight to outcomes measures than to
other measures and increase the scoring
weight for outcome measures over time;
and
``(II) may assign a higher scoring
weight to patient experience measures.
``(C) Incentive to report; encouraging use of
certified ehr technology for reporting quality
measures.--
``(i) Incentive to report.--Under the
methodology established under subparagraph (A),
the Secretary shall provide that in the case of
a VBP eligible professional who fails to report
on an applicable measure or activity that is
required to be reported by the professional,
the professional shall be treated as achieving
the lowest potential score applicable to such
measure or activity.
``(ii) Encouraging use of certified ehr
technology for reporting quality measures.--
Under the methodology established under
subparagraph (A), the Secretary shall--
``(I) encourage VBP eligible
professionals to report on applicable
measures with respect to the
performance category described in
paragraph (2)(A)(i) through the use of
certified EHR technology; and
``(II) with respect to a
performance period, with respect to a
year, for which a VBP eligible
professional reports such measures
through the use of such EHR technology,
treat such professional as satisfying
the clinical quality measures reporting
requirement described in subsection
(o)(2)(A)(iii) for such year.
``(D) Clinical practice improvement activities
performance score.--
``(i) Rule for accreditation.--A VBP
eligible professional who is in a practice that
is certified as a patient-centered medical home
or comparable specialty practice pursuant to
subsection (b)(8)(B)(i) with respect to a
performance period shall be given the highest
potential score for the performance category
described in paragraph (2)(A)(iii) for such
period.
``(ii) APM participation.--Participation by
a VBP eligible professional in an alternative
payment model (as defined in section
1833(z)(3)(C)) with respect to a performance
period shall earn such eligible professional
one-half of the highest potential score for the
performance category described in paragraph
(2)(A)(iii) for such performance period.
Nothing in the previous sentence shall prevent
such professional from earning more than one-
half of such highest potential score for such
performance period by performing additional
activities with respect to such performance
category.
``(iii) Subcategories.--A VBP eligible
professional shall not be required to perform
activities in each subcategory under paragraph
(2)(B)(iii) to achieve the highest potential
score for the performance category described in
paragraph (2)(A)(iii).
``(E) Distribution.--The Secretary shall ensure
that the application of the methodology developed under
subparagraph (A) results in a continuous distribution
of performance scores, which shall result in
differential payments under paragraph (7).
``(F) Achievement and improvement.--
``(i) Taking into account improvement.--
Beginning with the second year to which the VBP
program applies, in addition to the achievement
score of a VBP eligible professional, the
methodology developed under subparagraph (A)--
``(I) in the case of the
performance score for the performance
category described in clauses (i) and
(ii) of paragraph (2)(A), shall take
into account the improvement of the
professional; and
``(II) in the case of performance
scores for other performance
categories, may take into account the
improvement of the professional.
``(ii) Assigning higher weight for
achievement.--Beginning with the fourth year to
which the VBP program applies, under the
methodology developed under subparagraph (A),
the Secretary shall assign a higher scoring
weight under subparagraph (B) with respect to
the achievement score of a VBP eligible
professional with respect to a measure or
activity specified under paragraph (2)(B) (or
with respect to such a measure or activity and
with respect to categories described in
paragraph (2)(A)) than to any improvement score
applied under clause (i) with respect to such
measure or activity (or such measure or
activity and categories).
``(G) Weights for the performance categories.--
``(i) In general.--Under the methodology
developed under subparagraph (A), subject to
clauses (ii) and (iii), the composite
performance score shall be determined as
follows:
``(I) Quality.--Thirty percent of
such score shall be based on
performance with respect to the
category described in clause (i) of
paragraph (2)(A).
``(II) Resource use.--Thirty
percent of such score shall be based on
performance with respect to the
category described in clause (ii) of
paragraph (2)(A).
``(III) Clinical practice
improvement activities.--Fifteen
percent of such score shall be based on
performance with respect to the
category described in clause (iii) of
paragraph (2)(A).
``(IV) Meaningful use of certified
ehr technology.--Twenty-five percent of
such score shall be based on
performance with respect to the
category described in clause (iv) of
paragraph (2)(A).
``(ii) Authority to adjust percentages in
case of high ehr meaningful use adoption.--In
any year in which the Secretary estimates that
the proportion of eligible professionals (as
defined in subsection (o)(5)) who are
meaningful EHR users (as determined under
subsection (o)(2)) is 75 percent or greater,
the Secretary may reduce the percent applicable
under clause (i)(IV), but not below 15 percent.
If the Secretary makes such reduction for a
year, the percentages applicable under one or
more of subclauses (I), (II), and (III) of
clause (i) for such year shall be increased in
a manner such that the total percentage points
of the increase under this clause for such year
equals the total number of percentage points
reduced under the preceding sentence for such
year.
``(iii) Authority to adjust percentages for
quality and resource use.--
``(I) In general.--Subject to
subclause (II), the percentages
described in subclauses (I) and (II) of
clause (i), including after application
of clause (ii), shall be equal.
``(II) Exception.--For the first 2
years for which the VBP program
applies, after application of clause
(ii), the Secretary may increase the
percentage applicable under subclause
(I) or (II) of clause (i) as long as
the Secretary decreases the percentage
applicable under the other subclause by
an equal number of percentage points
and the number of percentage points
applicable under each of subclauses (I)
and (II) is not less than 15.
``(H) Resource use.--Analysis of the performance
category described in paragraph (2)(A)(ii) shall
include results from the methodology described in
subsection (r)(5), as appropriate.
``(I) Inclusion of quality measure data from
multiple payers.--In applying subsections (k), (m), and
(p) with respect to measures described in paragraph
(2)(B)(i), analysis of the performance category
described in paragraph (2)(A)(i) may include data
submitted by VBP eligible professionals with respect to
multiple payers.
``(J) Use of voluntary virtual groups for certain
assessment purposes.--
``(i) In general.--In the case of VBP
eligible professionals electing to be a virtual
group under clause (ii) with respect to a
performance period for a year, for purposes of
applying the methodology under subparagraph
(A)--
``(I) the assessment of performance
provided under such methodology with
respect to the performance categories
described in clauses (i) and (ii) of
paragraph (2)(A) that is to be applied
to each such professional in such group
for such performance period shall be
with respect to the combined
performance of all such professionals
in such group for such period; and
``(II) the composite score provided
under this paragraph for such
performance period with respect to each
such performance category for each such
VBP eligible professional in such
virtual group shall be based on the
assessment of the combined performance
under subclause (I) for the performance
category and performance period.
``(ii) Election of practices to be a
virtual group.--The Secretary shall, in
accordance with clause (iii), establish and
have in place a process to allow an individual
VBP eligible professional or a group practice
consisting of not more than 10 VBP eligible
professionals to elect, with respect to a
performance period for a year, for such
individual VBP eligible professional or all
such VBP eligible professionals in such group
practice, respectively, to be a virtual group
under this subparagraph with at least one other
such individual VBP eligible professional or
group practice making such an election.
``(iii) Requirements.--The process under
clause (ii) shall provide that--
``(I) an election under such
clause, with respect to a performance
period, shall be made before the
beginning of such performance period
and may not be changed during such
performance period; and
``(II) a practice described in such
clause, and each VBP eligible
professional in such practice, may
elect to be in no more than one virtual
group for a performance period.
``(6) Funding for vbp program incentive payments.--
``(A) Total amount for incentive payments.--The
total amount for VBP program incentive payments under
paragraph (7) for all VBP eligible professionals for a
year shall be equal to the total amount of the
performance funding pool for all VBP eligible
professionals under subparagraph (B) for such year, as
estimated by the Secretary.
``(B) Performance funding pool.--
``(i) In general.--In the case of items and
services furnished by a VBP eligible
professional during a year (beginning with
2017), the otherwise applicable fee schedule
amount (as defined in clause (iii)) with
respect to such items and services and eligible
professional for such year shall be reduced by
the applicable percent under clause (ii). The
total amount of such reductions for a year
shall be referred to in this subsection as the
`performance funding pool' for such year.
``(ii) Applicable percent defined.--For
purposes of clause (i), the term `applicable
percent' means--
``(I) for 2017, 4 percent;
``(II) for 2018, 6 percent;
``(III) for 2019, 8 percent;
``(IV) for 2020, 10 percent; and
``(V) for 2021 and subsequent
years, a percent specified by the
Secretary (but in no case less than 10
percent or more than 12 percent).
``(iii) Otherwise applicable fee schedule
amount.--For purposes of this subparagraph and
paragraph (7), the term `otherwise applicable
fee schedule amount' means, with respect to
items and services furnished by a VBP eligible
professional during a year, the fee schedule
amount for such items and services and year
that would otherwise apply (without application
of this subparagraph or paragraph (7)) with
respect to such eligible professional under
subsection (b), after application of subsection
(a)(3), or under another fee schedule under
this part.
``(7) VBP program incentive payments.--
``(A) VBP program incentive payment adjustment
factor.--The Secretary shall specify a VBP program
incentive payment adjustment factor for each VBP
eligible professional for a year. Such VBP program
incentive payment adjustment factor for a VBP eligible
professional for a year shall be determined--
``(i) by the composite performance score of
the eligible professional for such year;
``(ii) in a manner such that the adjustment
factors specified under this subparagraph for a
year results in differential payments under
this paragraph reflecting the full range of the
distribution of composite performance scores of
VBP eligible professionals determined under
paragraph (5)(E) for such year, with such
professionals having higher composite
performance scores receiving higher payment;
and
``(iii) in a manner such that the
adjustment factors specified under this
subparagraph for a year--
``(I) do not result in a payment
reduction for such year by an amount
that exceeds the applicable percent
described in paragraph (6)(B)(ii) for
such year; and
``(II) do not result in a payment
increase for such year by an amount
that exceeds the applicable percent
described in paragraph (6)(B)(ii) for
such year.
``(B) Calculation of vbp program incentive payment
amounts.--The VBP program incentive payment amount with
respect to items and services furnished by a VBP
eligible professional during a year shall be equal to
the difference between--
``(i) the product of--
``(I) the VBP program incentive
payment adjustment factor determined
under subparagraph (A) for such VBP
eligible professional for such year;
and
``(II) the otherwise applicable fee
schedule amount (as defined in
paragraph (6)(B)(iii)) with respect to
such items and services and eligible
professional for such year; and
``(ii) the otherwise applicable fee
schedule amount, as reduced under paragraph
(6)(B), with respect to such items and
services, eligible professional, and year.
The application of the preceding sentence may result in
the VBP program incentive payment amount being 0.0 with
respect to an item or service furnished by a VBP
eligible professional.
``(C) Application of vbp program incentive payment
amount.--In the case of items and services furnished by
a VBP eligible professional during a year (beginning
with 2017), the otherwise applicable fee schedule
amount, as reduced under paragraph (6)(B), with respect
to such items and services and eligible professional
for such year shall be increased, if applicable, by the
VBP program incentive payment amount determined under
subparagraph (B) with respect to such items and
services, professional, and year.
``(D) Budget neutrality.--In specifying the VBP
program incentive payment adjustment factor for each
VBP eligible professional for a year under subparagraph
(A), the Secretary shall ensure that the total amount
of VBP program incentive payment amounts under this
paragraph for all VBP eligible professionals in a year
shall be equal to the performance funding pool for such
year under paragraph (6), as estimated by the
Secretary.
``(8) Announcement of result of adjustments.--Under the VBP
program, the Secretary shall, not later than 60 days prior to
the year involved, make available to each VBP eligible
professional the VBP program incentive payment adjustment
factor under paragraph (7) and the payment reduction under
paragraph (6) applicable to the eligible professional for items
and services furnished by the professional in such year. The
Secretary may include such information in the confidential
feedback under paragraph (13).
``(9) No effect in subsequent years.--The VBP program
incentive payment under paragraph (7) and the payment reduction
under paragraph (6) shall each apply only with respect to the
year involved, and the Secretary shall not take into account
such VBP program incentive payment or payment reduction in
making payments to a VBP eligible professional under this part
in a subsequent year.
``(10) Public reporting.--
``(A) In general.--The Secretary shall, in an
easily understandable format, make available on the
Physician Compare Internet website under subsection (t)
the following:
``(i) Information regarding the performance
of VBP eligible professionals under the VBP
program, which--
``(I) shall include the composite
score for each such VBP eligible
professional and the performance of
each such VBP eligible professional
with respect to each performance
category; and
``(II) may include the performance
of each such VBP eligible professional
with respect to each measure or
activity specified in paragraph (2)(B).
``(ii) The names of eligible professionals
in eligible alternative payment models (as
defined in section 1833(z)(3)(D)) and, to the
extent feasible, the names of such eligible
alternative payment models and performance of
such models.
``(B) Opportunity to review and submit
corrections.--The Secretary shall provide for an
opportunity for a professional described in
subparagraph (A) to review, and submit corrections for,
the information to be made public with respect to the
professional under such subparagraph prior to such
information being made public.
``(C) Aggregate information.--The Secretary shall
periodically post on the Physician Compare Internet
website aggregate information on the VBP program,
including the range of composite scores for all VBP
eligible professionals and the range of the performance
of all VBP eligible professionals with respect to each
performance category.
``(11) Consultation.--The Secretary shall consult with
stakeholders in carrying out the VBP program, including for the
identification of measures and activities under paragraph
(2)(B) and the methodologies developed under paragraphs (5)(A)
and (7). Such consultation shall include the use of a request
for information or other mechanisms determined appropriate.
``(12) Technical assistance to small practices and
practices in health professional shortage areas.--
``(A) In general.--The Secretary shall enter into
contracts or agreements with appropriate entities (such
as quality improvement organizations, regional
extension centers (as described in section 3012(c) of
the Public Health Service Act), or regional health
collaboratives) to offer guidance and assistance to VBP
eligible professionals in practices of 10 or fewer
professionals (with priority given to such practices
located in rural areas, health professional shortage
areas (as designated in section 332(a)(1)(A) of the
Public Health Service Act), medically underserved
areas, or practices with low composite scores) with
respect to--
``(i) the performance categories described
in clauses (i) through (iv) of paragraph
(2)(A); or
``(ii) how to transition to the
implementation of and participation in an
alternative payment model as described in
section 1833(z)(3)(C).
``(B) Funding for implementation.--For purposes of
implementing subparagraph (A), the Secretary shall
provide for the transfer from the Federal Supplementary
Medical Insurance Trust Fund established under section
1841 to the Centers for Medicare & Medicaid Services
Program Management Account of $25,000,000 for each of
fiscal years 2014 through 2018. Of amounts transferred
under the preceding sentence, not less than $10,000,000
shall be available for technical assistance to small
practices (consisting of 10 or fewer professionals) in
health professional shortage areas (as so designated).
Amounts transferred under this subparagraph for a
fiscal year shall be available until expended.
``(13) Feedback and information to improve performance.--
``(A) Performance feedback.--
``(i) In general.--Beginning July 1, 2015,
the Secretary--
``(I) shall make available timely
(such as quarterly) confidential
feedback to each VBP eligible
professional on the performance of such
professional with respect to the
performance categories under clauses
(i) and (ii) of paragraph (2)(A); and
``(II) may make available
confidential feedback to each such
professional on the performance of such
professional with respect to the
performance categories under clauses
(iii) and (iv) of such paragraph.
``(ii) Mechanisms.--The Secretary may use
one or more mechanisms to make feedback
available under clause (i), which may include
use of a web-based portal or other mechanisms
determined appropriate by the Secretary. The
Secretary shall encourage provision of feedback
through qualified clinical data registries, as
described in subsection (m)(3)(E).
``(iii) Use of data.--For purposes of
clause (i), the Secretary may use data, with
respect to a VBP eligible professional, from
periods prior to the current performance period
and may use rolling periods in order to make
illustrative calculations about the performance
of such professional.
``(iv) Disclosure exemption.--Feedback made
available under this subparagraph shall be
exempt from disclosure under section 552 of
title 5, United States Code.
``(v) Receipt of information.--The
Secretary may use the mechanisms established
under clause (ii) to receive information from
professionals, such as information with respect
to this subsection.
``(B) Additional information.--
``(i) In general.--Beginning July 1, 2016,
the Secretary shall make available to each VBP
eligible professional information, with respect
to individuals who are patients of such VBP
eligible professional, about items and services
for which payment is made under this title that
are furnished to such individuals by other
suppliers and providers of services, which may
include information described in clause (ii).
Such information shall be made available under
the previous sentence to such VBP eligible
professionals by mechanisms determined
appropriate by the Secretary, which may include
use of a web-based portal. Such information
shall be made available in accordance with the
same or similar terms as data are made
available to accountable care organizations
under section 1899, including a beneficiary
opt-out.
``(ii) Type of information.--For purposes
of clause (i), the information described in
this clause, is the following:
``(I) With respect to selected
items and services (as determined
appropriate by the Secretary) for which
payment is made under this title and
that are furnished to individuals, who
are patients of a VBP eligible
professional, by another supplier or
provider of services during the most
recent period for which data are
available (such as the most recent
three-month period), the name of such
providers furnishing such items and
services to such patients during such
period, the types of such items and
services so furnished, and the dates
such items and services were so
furnished.
``(II) Historical averages (and
other measures of the distribution if
appropriate) of the total, and
components of, allowed charges (and
other figures as determined appropriate
by the Secretary) for care episodes for
such period.
``(14) Review.--
``(A) Targeted review.--The Secretary shall
establish a process under which a VBP eligible
professional may seek an informal review of the
calculation of the VBP program incentive payment
adjustment factor applicable to such eligible
professional under this subsection for a year. The
results of a review conducted pursuant to the previous
sentence shall not be taken into account for purposes
of paragraph (7) with respect to a year (other than
with respect to the calculation of such eligible
professional's VBP program incentive payment adjustment
factor for such year) after the factors determined in
subparagraph (A) of such paragraph have been determined
for such year.
``(B) Limitation.--Except as provided for in
subparagraph (A), there shall be no administrative or
judicial review under section 1869, section 1878, or
otherwise of the following:
``(i) The methodology used to determine the
amount of the VBP program incentive payment
adjustment factor under paragraph (7) and the
determination of such amount.
``(ii) The determination of the amount of
funding available for such VBP program
incentive payments under paragraph (6)(A) and
the payment reduction under paragraph
(6)(B)(i).
``(iii) The establishment of the
performance standards under paragraph (3) and
the performance period under paragraph (4).
``(iv) The identification of measures and
activities specified under paragraph (2)(B) and
information made public or posted on the
Physician Compare Internet website of the
Centers for Medicare & Medicaid Services under
paragraph (10).
``(v) The methodology developed under
paragraph (5) that is used to calculate
performance scores and the calculation of such
scores, including the weighting of measures and
activities under such methodology.''.
(2) GAO reports.--
(A) Evaluation of eligible professional vbp
program.--Not later than October 1, 2018, and October
1, 2021, the Comptroller General of the United States
shall submit to Congress a report evaluating the
eligible professional value-based performance incentive
program under subsection (q) of section 1848 of the
Social Security Act (42 U.S.C. 1395w-4), as added by
paragraph (1). Such report shall--
(i) examine the distribution of the
performance and incentive payments for VBP
eligible professionals (as defined in
subsection (q)(1)(C) of such section) under
such program, and patterns relating to such
performance and incentive payments, including
those based on type of provider, practice size,
geographic location, and patient mix;
(ii) provide recommendations for improving
such program;
(iii) evaluate the impact of technical
assistance funding under section 1848(q)(12) of
the Social Security Act, as added by paragraph
(1), on the ability of professionals to improve
within such program or successfully transition
to an alternative payment model (as defined in
section 1833(z)(3) of the Social Security Act,
as added by subsection (e)(1)), with priority
for such evaluation given to practices located
in rural areas, health professional shortage
areas (as designated in section 332(a)(1)(A) of
the Public Health Service Act), and medically
underserved areas; and
(iv) provide recommendations for optimizing
the use of such technical assistance funds.
(B) Study to examine alignment of quality measures
used in public and private programs.--
(i) In general.--Not later than 18 months
after the date of the enactment of this Act,
the Comptroller General of the United States
shall submit to Congress a report that--
(I) compares the similarities and
differences in the use of quality
measures under the original medicare
fee-for-service program under parts A
and B of title XVIII of the Social
Security Act, the Medicare Advantage
program under part C of such title,
selected State Medicaid programs under
title XIX of such Act, and private
payer arrangements; and
(II) makes recommendations on how
to reduce the administrative burden
involved in applying such quality
measures.
(ii) Requirements.--The report under clause
(i) shall--
(I) consider those measures
applicable to individuals entitled to,
or enrolled for, benefits under such
part A, or enrolled under such part B
and individuals under the age of 65;
and
(II) focus on those measures that
comprise the most significant component
of the quality performance category of
the eligible professional value-based
performance incentive program under
subsection (q) of section 1848 of the
Social Security Act (42 U.S.C. 1395w-
4), as added by paragraph (1).
(C) Study to examine rural and health professional
shortage area alternative payment models.--Not later
than October 1, 2019, and October 1, 2021, the
Comptroller General of the United States shall submit
to Congress a report that examines the transition of
professionals in rural areas, health professional
shortage areas (as designated in section 332(a)(1)(A)
of the Public Health Service Act), or medically
underserved areas to an alternative payment model (as
defined in section 1833(z)(3) of the Social Security
Act, as added by subsection (e)(1)). Such report shall
make recommendations for removing administrative
barriers to practices in rural areas, health
professional shortage areas, and medically underserved
areas to participation in such models.
(3) Funding for implementation.--For purposes of
implementing the provisions of and the amendments made by this
section, the Secretary of Health and Human Services shall
provide for the transfer of $50,000,000 from the Supplementary
Medical Insurance Trust Fund established under section 1841 of
the Social Security Act (42 U.S.C. 1395t) to the Centers for
Medicare & Medicaid Program Management Account for each of the
fiscal years 2014 through 2017. Amounts transferred under this
paragraph shall be available until expended.
(d) Improving Quality Reporting for Composite Scores.--
(1) Changes for group reporting option.--
(A) In general.--Section 1848(m)(3)(C)(ii) of the
Social Security Act (42 U.S.C. 1395w-4(m)(3)(C)(ii)) is
amended by inserting ``and, for 2014 and subsequent
years, may provide'' after ``shall provide''.
(B) Clarification of qualified clinical data
registry reporting to group practices.--Section
1848(m)(3)(D) of the Social Security Act (42 U.S.C.
1395w-4(m)(3)(D)) is amended by inserting ``and, for
2015 and subsequent years, subparagraph (A) or (C)''
after ``subparagraph (A)''.
(2) Changes for multiple reporting periods and alternative
criteria for satisfactory reporting.--Section 1848(m)(5)(F) of
the Social Security Act (42 U.S.C. 1395w-4(m)(5)(F)) is
amended--
(A) by striking ``and subsequent years'' and
inserting ``through reporting periods occurring in
2013''; and
(B) by inserting ``and, for reporting periods
occurring in 2014 and subsequent years, the Secretary
may establish'' following ``shall establish''.
(3) Physician feedback program reports succeeded by reports
under vbp program.--Section 1848(n) of the Social Security Act
(42 U.S.C. 1395w-4(n)) is amended by adding at the end the
following new paragraph:
``(11) Reports ending with 2016.--Reports under the Program
shall not be provided after December 31, 2016. See subsection
(q)(13) for reports beginning with 2017.''.
(4) Coordination with satisfying meaningful ehr use
clinical quality measure reporting requirement.--Section
1848(o)(2)(A)(iii) of the Social Security Act (42 U.S.C. 1395w-
4(o)(2)(A)(iii)) is amended by inserting ``and subsection
(q)(5)(C)(ii)(II)'' after ``Subject to subparagraph (B)(ii)''.
(e) Promoting Alternative Payment Models.--
(1) Incentive payments for participation in eligible
alternative payment models.--Section 1833 of the Social
Security Act (42 U.S.C. 1395l) is amended by adding at the end
the following new subsection:
``(z) Incentive Payments for Participation in Eligible Alternative
Payment Models.--
``(1) Payment incentive.--
``(A) In general.--In the case of covered
professional services furnished by an eligible
professional during a year that is in the period
beginning with 2017 and ending with 2022 and for which
the professional is a qualifying APM participant, in
addition to the amount of payment that would otherwise
be made for such covered professional services under
this part for such year, there also shall be paid to
such professional an amount equal to 5 percent of the
payment amount for the covered professional services
under this part for the preceding year. For purposes of
the previous sentence, the payment amount for the
preceding year may be an estimation for the full
preceding year based on a period of such preceding year
that is less than the full year. The Secretary shall
establish policies to implement this subparagraph in
cases where payment for covered professional services
furnished by a qualifying APM participant in an
alternative payment model is made to an entity
participating in the alternative payment model rather
than directly to the qualifying APM participant.
``(B) Form of payment.--Payments under this
subsection shall be made in a lump sum, on an annual
basis, as soon as practicable.
``(C) Treatment of payment incentive.--Payments
under this subsection shall not be taken into account
for purposes of determining actual expenditures under
an alternative payment model and for purposes of
determining or rebasing any benchmarks used under the
alternative payment model.
``(D) Coordination.--The amount of the additional
payment for an item or service under this subsection or
subsection (m) shall be determined without regard to
any additional payment for the item or service under
subsection (m) and this subsection, respectively. The
amount of the additional payment for an item or service
under this subsection or subsection (x) shall be
determined without regard to any additional payment for
the item or service under subsection (x) and this
subsection, respectively. The amount of the additional
payment for an item or service under this subsection or
subsection (y) shall be determined without regard to
any additional payment for the item or service under
subsection (y) and this subsection, respectively.
``(2) Qualifying apm participant.--For purposes of this
subsection, the term `qualifying APM participant' means the
following:
``(A) 2017 and 2018.--With respect to 2017 and
2018, an eligible professional for whom the Secretary
determines that at least 25 percent of payments under
this part for covered professional services furnished
by such professional during the most recent period for
which data are available (which may be less than a
year) were attributable to such services furnished
under this part through an entity that participates in
an eligible alternative payment model with respect to
such services.
``(B) 2019 and 2020.--With respect to 2019 and
2020, an eligible professional described in either of
the following clauses:
``(i) Medicare revenue threshold option.--
An eligible professional for whom the Secretary
determines that at least 50 percent of payments
under this part for covered professional
services furnished by such professional during
the most recent period for which data are
available (which may be less than a year) were
attributable to such services furnished under
this part through an entity that participates
in an eligible alternative payment model with
respect to such services.
``(ii) Combination all-payer and medicare
revenue threshold option.--An eligible
professional--
``(I) for whom the Secretary
determines, with respect to items and
services furnished by such professional
during the most recent period for which
data are available (which may be less
than a year), that at least 50 percent
of the sum of--
``(aa) payments described
in clause (i); and
``(bb) all other payments,
regardless of payer (other than
payments made by the Secretary
of Defense or the Secretary of
Veterans Affairs under chapter
55 of title 10, United States
Code, or title 38, United
States Code, or any other
provision of law, and other
than payments made under title
XIX in a State in which no
medical home or alternative
payment model is available
under the State program under
that title).
meet the requirement described in
clause (iii)(I) with respect to
payments described in item (aa) and
meet the requirement described in
clause (iii)(II) with respect to
payments described in item (bb);
``(II) for whom the Secretary
determines at least 25 percent of
payments under this part for covered
professional services furnished by such
professional during the most recent
period for which data are available
(which may be less than a year) were
attributable to such services furnished
under this part through an entity that
participates in an eligible alternative
payment model with respect to such
services; and
``(III) who provides to the
Secretary such information as is
necessary for the Secretary to make a
determination under subclause (I), with
respect to such professional.
``(iii) Requirement.--For purposes of
clause (ii)(I)--
``(I) the requirement described in
this subclause, with respect to
payments described in item (aa) of such
clause, is that such payments are made
under an eligible alternative payment
model; and
``(II) the requirement described in
this subclause, with respect to
payments described in item (bb) of such
clause, is that such payments are made
under an arrangement in which--
``(aa) quality measures
comparable to measures under
the performance category
described in section
1848(q)(2)(B)(i) apply;
``(bb) certified EHR
technology is used; and
``(cc) the eligible
professional (AA) bears more
than nominal financial risk if
actual aggregate expenditures
exceeds expected aggregate
expenditures; or (BB) is a
medical home (with respect to
beneficiaries under title XIX)
that meets criteria comparable
to medical homes expanded under
section 1115A(c).
``(C) Beginning in 2021.--With respect to 2021 and
each subsequent year, an eligible professional
described in either of the following clauses:
``(i) Medicare revenue threshold option.--
An eligible professional for whom the Secretary
determines that at least 75 percent of payments
under this part for covered professional
services furnished by such professional during
the most recent period for which data are
available (which may be less than a year) were
attributable to such services furnished under
this part through an entity that participates
in an eligible alternative payment model with
respect to such services.
``(ii) Combination all-payer and medicare
revenue threshold option.--An eligible
professional--
``(I) for whom the Secretary
determines, with respect to items and
services furnished by such professional
during the most recent period for which
data are available (which may be less
than a year), that at least 75 percent
of the sum of--
``(aa) payments described
in clause (i); and
``(bb) all other payments,
regardless of payer (other than
payments made by the Secretary
of Defense or the Secretary of
Veterans Affairs under chapter
55 of title 10, United States
Code, or title 38, United
States Code, or any other
provision of law, and other
than payments made under title
XIX in a State in which no
medical home or alternative
payment model is available
under the State program under
that title.
meet the requirement described in
clause (iii)(I) with respect to
payments described in item (aa) and
meet the requirement described in
clause (iii)(II) with respect to
payments described in item (bb);
``(II) for whom the Secretary
determines at least 25 percent of
payments under this part for covered
professional services furnished by such
professional during the most recent
period for which data are available
(which may be less than a year) were
attributable to such services furnished
under this part through an entity that
participates in an eligible alternative
payment model with respect to such
services; and
``(III) who provides to the
Secretary such information as is
necessary for the Secretary to make a
determination under subclause (I), with
respect to such professional.
``(iii) Requirement.--For purposes of
clause (ii)(I)--
``(I) the requirement described in
this subclause, with respect to
payments described in item (aa) of such
clause, is that such payments are made
under an eligible alternative payment
model; and
``(II) the requirement described in
this subclause, with respect to
payments described in item (bb) of such
clause, is that such payments are made
under an arrangement in which--
``(aa) quality measures
comparable to measures under
the performance category
described in section
1848(q)(2)(B)(i) apply;
``(bb) certified EHR
technology is used; and
``(cc) the eligible
professional (AA) bears more
than nominal financial risk if
actual aggregate expenditures
exceeds expected aggregate
expenditures; or (BB) is a
medical home (with respect to
beneficiaries under title XIX)
that meets criteria comparable
to medical homes expanded under
section 1115A(c).
``(3) Additional definitions.--In this subsection:
``(A) Covered professional services.--The term
`covered professional services' has the meaning given
that term in section 1848(k)(3)(A).
``(B) Eligible professional.--The term `eligible
professional' has the meaning given that term in
section 1848(k)(3)(B).
``(C) Alternative payment model (apm).--The term
`alternative payment model' means any of the following:
``(i) A model under section 1115A (other
than a health care innovation award).
``(ii) An accountable care organization
under section 1899.
``(iii) A demonstration under section
1866C.
``(iv) A demonstration required by Federal
law.
``(D) Eligible alternative payment model (apm).--
``(i) In general.--The term `eligible
alternative payment model' means, with respect
to a year, an alternative payment model--
``(I) that requires use of
certified EHR technology (as defined in
subsection (o)(4));
``(II) that provides for payment
for covered professional services based
on quality measures comparable to
measures under the performance category
described in section 1848(q)(2)(B)(i);
and
``(III) that satisfies the
requirement described in clause (ii).
``(ii) Additional requirement.--For
purposes of clause (i)(III), the requirement
described in this clause, with respect to a
year and an alternative payment model, is that
the alternative payment model--
``(I) is one in which one or more
entities bear financial risk for
monetary losses under such model that
are in excess of a nominal amount; or
``(II) is a medical home expanded
under section 1115A(c).
``(4) Limitation.--There shall be no administrative or
judicial review under section 1869, 1878, or otherwise, of the
following:
``(A) The determination that an eligible
professional is a qualifying APM participant under
paragraph (2) and the determination that an alternative
payment model is an eligible alternative payment model
under paragraph (3)(D).
``(B) The determination of the amount of the 5
percent payment incentive under paragraph (1)(A),
including any estimation as part of such
determination.''.
(2) Coordination conforming amendments.--Section 1833 of
the Social Security Act (42 U.S.C. 1395l) is further amended--
(A) in subsection (x)(3), by adding at the end the
following new sentence: ``The amount of the additional
payment for a service under this subsection and
subsection (z) shall be determined without regard to
any additional payment for the service under subsection
(z) and this subsection, respectively.''; and
(B) in subsection (y)(3), by adding at the end the
following new sentence: ``The amount of the additional
payment for a service under this subsection and
subsection (z) shall be determined without regard to
any additional payment for the service under subsection
(z) and this subsection, respectively.''.
(3) Encouraging development and testing of certain
models.--Section 1115A(b)(2) of the Social Security Act (42
U.S.C. 1315a(b)(2)) is amended--
(A) in subparagraph (B), by adding at the end the
following new clauses:
``(xxi) Focusing primarily on physicians'
services (as defined in section 1848(j)(3))
furnished by physicians who are not primary
care practitioners.
``(xxii) Focusing on practices of 10 or
fewer professionals.
``(xxiii) Focusing primarily on title XIX,
working in conjunction with the Center for
Medicaid and CHIP Services within the Centers
for Medicare & Medicaid Services.''; and
(B) in subparagraph (C)(viii), by striking ``other
public sector or private sector payers'' and inserting
``other public sector payers, private sector payers, or
Statewide payment models''.
(4) Construction regarding telehealth services.--Nothing in
the provisions of, or amendments made by, this Act shall be
construed as precluding an alternative payment model or a
qualifying APM participant (as those terms are defined in
section 1833(z) of the Social Security Act, as added by
paragraph (1)) from furnishing a telehealth service for which
payment is not made under section 1834(m) of the Social
Security Act (42 U.S.C. 1395m(m)).
(5) Plan for integrating medicare advantage alternative
payment models.--Not later than July 1, 2015, the Secretary of
Health and Human Services shall submit to Congress a plan to
integrate Medicare Advantage alternative payment models that
take into account a budget neutral value-based modifier.
(f) Study and Report on Fraud Related to Alternative Payment Models
Under the Medicare Program.--
(1) Study.--The Secretary of Health and Human Services, in
consultation with the Inspector General of the Department of
Health and Human Services, shall conduct a study that--
(A) examines the applicability of the Federal fraud
prevention laws to items and services furnished under
title XVIII of the Social Security Act for which
payment is made under an alternative payment model (as
defined in section 1833(z)(3)(C) of such Act (42 U.S.C.
1395l(z)(3)(C)));
(B) identifies aspects of such alternative payment
models that are vulnerable to fraudulent activity; and
(C) examines the implications of waivers to such
laws granted in support of such alternative payment
models, including under any potential expansion of such
models.
(2) Report.--Not later than 2 years after the date of the
enactment of this Act, the Secretary shall submit to Congress a
report containing the results of the study conducted under
paragraph (1). Such report shall include recommendations for
actions to be taken to reduce the vulnerability of such
alternative payment models to fraudulent activity. Such report
also shall include, as appropriate, recommendations of the
Inspector General for changes in Federal fraud prevention laws
to reduce such vulnerability.
(g) Improving Payment Accuracy.--
(1) Studies and reports of effect of certain information on
quality and resource use .--
(A) Study using existing medicare data.--
(i) Study.--The Secretary of Health and
Human Services (in this subsection referred to
as the ``Secretary'') shall conduct a study
that examines the effect of individuals'
socioeconomic status on quality and resource
use outcome measures for individuals under the
Medicare program. The study shall use
information collected on such individuals in
carrying out such program, such as urban and
rural location, eligibility for Medicaid
(recognizing and accounting for varying
Medicaid eligibility across States), and
eligibility for benefits under the supplemental
security income (SSI) program. The Secretary
shall carry out this paragraph acting through
the Assistant Secretary for Planning and
Evaluation.
(ii) Report.--Not later than 2 years after
the date of the enactment of this Act, the
Secretary shall submit to Congress a report on
the study conducted under clause (i).
(B) Study using other data.--
(i) Study.--The Secretary shall conduct a
study that examines the impact of risk factors,
such as those described in section 1848(p)(3)
of the Social Security Act (42 U.S.C. 1395w-
4(p)(3)), race, health literacy, limited
English proficiency (LEP), and patient
activation, on quality and resource use outcome
measures under the Medicare program. In
conducting such study the Secretary may use
existing Federal data and collect such
additional data as may be necessary to complete
the study.
(ii) Report.--Not later than 5 years after
the date of the enactment of this Act, the
Secretary shall submit to Congress a report on
the study conducted under clause (i).
(C) Examination of data in conducting studies.--In
conducting the studies under subparagraphs (A) and (B),
the Secretary shall examine what non-Medicare data
sets, such as data from the American Community Survey
(ACS), can be useful in conducting the types of studies
under such paragraphs and how such data sets that are
identified as useful can be coordinated with Medicare
administrative data in order to improve the overall
data set available to do such studies and for the
administration of the Medicare program.
(D) Recommendations to account for information in
payment adjustment mechanisms.--If the studies
conducted under subparagraphs (A) and (B) find a
relationship between the factors examined in the
studies and quality and resource use outcome measures,
then the Secretary shall also provide recommendations
for how the Centers for Medicare & Medicaid Services
should--
(i) obtain access to the necessary data (if
such data is not already being collected) on
such factors, including recommendations on how
to address barriers to the Centers in accessing
such data; and
(ii) account for such factors in
determining payment adjustments based on
quality and resource use outcome measures under
the eligible professional value-based
performance incentive program under section
1848(q) of the Social Security Act (42 U.S.C.
1395w-4(q)) and, as the Secretary determines
appropriate, other similar provisions of title
XVIII of such Act.
(E) Funding.--There are hereby appropriated from
the Federal Supplemental Medical Insurance Trust Fund
to the Secretary to carry out this paragraph
$6,000,000, to remain available until expended.
(2) CMS activities.--
(A) Hierarchal condition category (hcc)
improvement.--Taking into account the relevant studies
conducted and recommendations made in reports under
paragraph (1), the Secretary, on an ongoing basis,
shall estimate how an individual's health status and
other risk factors affect quality and resource use
outcome measures and, as feasible, shall incorporate
information from quality and resource use outcome
measurement (including care episode and patient
condition groups) into the eligible professional value-
based performance incentive program under section
1848(q) of the Social Security Act and, as the
Secretary determines appropriate, other similar
provisions of title XVIII of such Act.
(B) Accounting for other factors in payment
adjustment mechanisms.--
(i) In general.--Taking into account the
studies conducted and recommendations made in
reports under paragraph (1), the Secretary
shall account for identified factors (other
than those applied under subparagraph (A)) with
an effect on quality and resource use outcome
measures when determining payment adjustments
under the eligible professional value-based
performance incentive program under section
1848(q) of the Social Security Act and, as the
Secretary determines appropriate, other similar
provisions of title XVIII of such Act.
(ii) Accessing data.--The Secretary shall
collect or otherwise obtain access to the data
necessary to carry out this paragraph through
existing and new data sources.
(iii) Periodic analyses.--The Secretary
shall carry out periodic analyses, at least
every 3 years, based on the factors referred to
in clause (i) so as to monitor changes in
possible relationships.
(C) Funding.--There are hereby appropriated from
the Federal Supplemental Medical Insurance Trust Fund
to the Secretary to carry out this paragraph
$10,000,000, to remain available until expended.
(3) Strategic plan for accessing race and ethnicity data.--
Not later than 18 months after the date of the enactment of
this Act, the Secretary shall develop and report to Congress on
a strategic plan for collecting or otherwise accessing data on
race and ethnicity for purposes of carrying out the Medicare
program.
(h) Collaborating With the Physician, Practitioner, and Other
Stakeholder Communities to Improve Resource Use Measurement.--Section
1848 of the Social Security Act (42 U.S.C. 1395w-4), as amended by
subsection (c), is further amended by adding at the end the following
new subsection:
``(r) Collaborating With the Physician, Practitioner, and Other
Stakeholder Communities To Improve Resource Use Measurement.--
``(1) In general.--In order to involve the physician,
practitioner, and other stakeholder communities in enhancing
the infrastructure for resource use measurement, including for
purposes of the value-based performance incentive program under
subsection (q) and alternative payment models under section
1833(z), the Secretary shall undertake the steps described in
the succeeding provisions of this subsection.
``(2) Development of care episode and patient condition
groups and classification codes.--
``(A) In general.--In order to classify similar
patients into distinct care episode groups and distinct
patient condition groups, the Secretary shall undertake
the steps described in the succeeding provisions of
this paragraph.
``(B) Public availability of existing efforts to
design an episode grouper.--Not later than 60 days
after the date of the enactment of this subsection, the
Secretary shall post on the Internet website of the
Centers for Medicare & Medicaid Services a list of the
episode groups developed pursuant to subsection
(n)(9)(A) and related descriptive information.
``(C) Stakeholder input.--The Secretary shall
accept, through the date that is 60 days after the day
the Secretary posts the list pursuant to subparagraph
(B), suggestions from physician specialty societies,
applicable practitioner organizations, and other
stakeholders for episode groups in addition to those
posted pursuant to such subparagraph, and specific
clinical criteria and patient characteristics to
classify patients into--
``(i) distinct care episode groups; and
``(ii) distinct patient condition groups.
``(D) Development of proposed classification
codes.--
``(i) In general.--Taking into account the
information described in subparagraph (B) and
the information received under subparagraph
(C), the Secretary shall--
``(I) establish distinct care
episode groups and distinct patient
condition groups, which account for at
least an estimated two-thirds of
expenditures under parts A and B; and
``(II) assign codes to such groups.
``(ii) Care episode groups.--In
establishing the care episode groups under
clause (i), the Secretary shall take into
account--
``(I) the patient's clinical
problems at the time items and services
are furnished during an episode of
care, such as the clinical conditions
or diagnoses, whether or not inpatient
hospitalization is anticipated or
occurs, and the principal procedures or
services planned or furnished; and
``(II) other factors determined
appropriate by the Secretary.
``(iii) Patient condition groups.--In
establishing the patient condition groups under
clause (i), the Secretary shall take into
account--
``(I) the patient's clinical
history at the time of each medical
visit, such as the patient's
combination of chronic conditions,
current health status, and recent
significant history (such as
hospitalization and major surgery
during a previous period, such as 3
months); and
``(II) other factors determined
appropriate by the Secretary, such as
eligibility status under this title
(including eligibility under section
226(a), 226(b), or 226A, and dual
eligibility under this title and title
XIX).
``(E) Draft care episode and patient condition
groups and classification codes.--Not later than 120
days after the end of the comment period described in
subparagraph (C), the Secretary shall post on the
Internet website of the Centers for Medicare & Medicaid
Services a draft list of the care episode and patient
condition codes established under subparagraph (D) (and
the criteria and characteristics assigned to such
code).
``(F) Solicitation of input.--The Secretary shall
seek, through the date that is 60 days after the
Secretary posts the list pursuant to subparagraph (E),
comments from physician specialty societies, applicable
practitioner organizations, and other stakeholders,
including individuals entitled to benefits under part A
or enrolled under this part, regarding the care episode
and patient condition groups (and codes) posted under
subparagraph (E). In seeking such comments, the
Secretary shall use one or more mechanisms (other than
notice and comment rulemaking) that may include use of
open door forums, town hall meetings, or other
appropriate mechanisms.
``(G) Operational list of care episode and patient
condition groups and codes.--Not later than 120 days
after the end of the comment period described in
subparagraph (F), taking into account the comments
received under such subparagraph, the Secretary shall
post on the Internet website of the Centers for
Medicare & Medicaid Services an operational list of
care episode and patient condition codes (and the
criteria and characteristics assigned to such code).
``(H) Subsequent revisions.--Not later than
November 1 of each year (beginning with 2016), the
Secretary shall, through rulemaking, make revisions to
the operational lists of care episode and patient
condition codes as the Secretary determines may be
appropriate. Such revisions may be based on experience,
new information developed pursuant to subsection
(n)(9)(A), and input from the physician specialty
societies, applicable practitioner organizations, and
other stakeholders, including individuals entitled to
benefits under part A or enrolled under this part.
``(3) Attribution of patients to physicians or
practitioners.--
``(A) In general.--In order to facilitate the
attribution of patients and episodes (in whole or in
part) to one or more physicians or applicable
practitioners furnishing items and services, the
Secretary shall undertake the steps described in the
succeeding provisions of this paragraph.
``(B) Development of patient relationship
categories and codes.--The Secretary shall develop
patient relationship categories and codes that define
and distinguish the relationship and responsibility of
a physician or applicable practitioner with a patient
at the time of furnishing an item or service. Such
patient relationship categories shall include different
relationships of the physician or applicable
practitioner to the patient (and the codes may reflect
combinations of such categories), such as a physician
or applicable practitioner who--
``(i) considers themself to have the
primary responsibility for the general and
ongoing care for the patient over extended
periods of time;
``(ii) considers themself to be the lead
physician or practitioner and who furnishes
items and services and coordinates care
furnished by other physicians or practitioners
for the patient during an acute episode;
``(iii) furnishes items and services to the
patient on a continuing basis during an acute
episode of care, but in a supportive rather
than a lead role;
``(iv) furnishes items and services to the
patient on an occasional basis, usually at the
request of another physician or practitioner;
or
``(v) furnishes items and services only as
ordered by another physician or practitioner.
``(C) Draft list of patient relationship categories
and codes.--Not later than 180 days after the date of
the enactment of this subsection, the Secretary shall
post on the Internet website of the Centers for
Medicare & Medicaid Services a draft list of the
patient relationship categories and codes developed
under subparagraph (B).
``(D) Stakeholder input.--The Secretary shall seek,
through the date that is 60 days after the Secretary
posts the list pursuant to subparagraph (C), comments
from physician specialty societies, applicable
practitioner organizations, and other stakeholders,
including individuals entitled to benefits under part A
or enrolled under this part, regarding the patient
relationship categories and codes posted under
subparagraph (C). In seeking such comments, the
Secretary shall use one or more mechanisms (other than
notice and comment rulemaking) that may include open
door forums, town hall meetings, or other appropriate
mechanisms.
``(E) Operational list of patient relationship
categories and codes.--Not later than 120 days after
the end of the comment period described in subparagraph
(D), taking into account the comments received under
such subparagraph, the Secretary shall post on the
Internet website of the Centers for Medicare & Medicaid
Services an operational list of patient relationship
categories and codes.
``(F) Subsequent revisions.--Not later than
November 1 of each year (beginning with 2016), the
Secretary shall, through rulemaking, make revisions to
the operational list of patient relationship categories
and codes as the Secretary determines appropriate. Such
revisions may be based on experience, new information
developed pursuant to subsection (n)(9)(A), and input
from the physician specialty societies, applicable
practitioner organizations, and other stakeholders,
including individuals entitled to benefits under part A
or enrolled under this part.
``(4) Reporting of information for resource use
measurement.--Claims submitted for items and services furnished
by a physician or applicable practitioner on or after January
1, 2016, shall, as determined appropriate by the Secretary,
include--
``(A) applicable codes established under paragraphs
(2) and (3); and
``(B) the national provider identifier of the
ordering physician or applicable practitioner (if
different from the billing physician or applicable
practitioner).
``(5) Methodology for resource use analysis.--
``(A) In general.--In order to evaluate the
resources used to treat patients (with respect to care
episode and patient condition groups), the Secretary
shall--
``(i) use the patient relationship codes
reported on claims pursuant to paragraph (4) to
attribute patients (in whole or in part) to one
or more physicians and applicable
practitioners;
``(ii) use the care episode and patient
condition codes reported on claims pursuant to
paragraph (4) as a basis to compare similar
patients and care episodes and patient
condition groups; and
``(iii) conduct an analysis of resource use
(with respect to care episodes and patient
condition groups of such patients), as the
Secretary determines appropriate.
``(B) Analysis of patients of physicians and
practitioners.--In conducting the analysis described in
subparagraph (A)(iii) with respect to patients
attributed to physicians and applicable practitioners,
the Secretary shall, as feasible--
``(i) use the claims data experience of
such patients by patient condition codes during
a common period, such as 12 months; and
``(ii) use the claims data experience of
such patients by care episode codes--
``(I) in the case of episodes
without a hospitalization, during
periods of time (such as the number of
days) determined appropriate by the
Secretary; and
``(II) in the case of episodes with
a hospitalization, during periods of
time (such as the number of days)
before, during, and after the
hospitalization.
``(C) Measurement of resource use.--In measuring
such resource use, the Secretary--
``(i) shall use per patient total allowed
amounts for all services under part A and this
part (and, if the Secretary determines
appropriate, part D) for the analysis of
patient resource use, by care episode codes and
by patient condition codes; and
``(ii) may, as determined appropriate, use
other measures of allowed amounts (such as
subtotals for categories of items and services)
and measures of utilization of items and
services (such as frequency of specific items
and services and the ratio of specific items
and services among attributed patients or
episodes).
``(D) Stakeholder input.--The Secretary shall seek
comments from the physician specialty societies,
applicable practitioner organizations, and other
stakeholders, including individuals entitled to
benefits under part A or enrolled under this part,
regarding the resource use methodology established
pursuant to this paragraph. In seeking comments the
Secretary shall use one or more mechanisms (other than
notice and comment rulemaking) that may include open
door forums, town hall meetings, or other appropriate
mechanisms.
``(6) Limitation.--There shall be no administrative or
judicial review under section 1869, section 1878, or otherwise
of--
``(A) care episode and patient condition groups and
codes established under paragraph (2);
``(B) patient relationship categories and codes
established under paragraph (3); and
``(C) measurement of, and analyses of resource use
with respect to, care episode and patient condition
codes and patient relationship codes pursuant to
paragraph (5).
``(7) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to this section.
``(8) Definitions.--In this section:
``(A) Physician.--The term `physician' has the
meaning given such term in section 1861(r).
``(B) Applicable practitioner.--The term
`applicable practitioner' means--
``(i) a physician assistant, nurse
practitioner, and clinical nurse specialist (as
such terms are defined in section 1861(aa)(5));
and
``(ii) beginning January 1, 2017, such
other eligible professionals (as defined in
subsection (k)(3)(B)) as specified by the
Secretary.
``(9) Clarification.--The provisions of sections
1890A(b)(2) and 1890B shall not apply to this subsection.''.
SEC. 102. PRIORITIES AND FUNDING FOR QUALITY MEASURE DEVELOPMENT.
Section 1848 of the Social Security Act (42 U.S.C. 1395w-4), as
amended by subsections (c) and (h) of section 101, is further amended
by inserting at the end the following new subsection:
``(s) Priorities and Funding for Quality Measure Development.--
``(1) Plan identifying measure development priorities and
timelines.--
``(A) Draft measure development plan.--
``(i) Draft plan.--
``(I) In general.--Not later than
October 1, 2014, the Secretary shall
develop, and post on the Internet
website of the Centers for Medicare &
Medicaid Services, a draft plan for the
development of quality measures for
application under the applicable
provisions.
``(II) Requirement.--Such plan
shall address how measures used by
private payers and integrated delivery
systems could be incorporated under
such subsection.
``(ii) Consideration.--In developing the
draft plan under subparagraph (A), the
Secretary shall consider--
``(I) gap analyses conducted by the
entity with a contract under section
1890(a) or other contractors or
entities; and
``(II) whether measures are
applicable across health care settings.
``(iii) Priorities.--In developing the
draft plan under subparagraph (A), the
Secretary shall give priority to the following
types of measures:
``(I) Outcome measures including
patient reported outcome and functional
status measures.
``(II) Patient experience measures.
``(III) Care coordination measures.
``(IV) Measures of appropriate use
of services, including measures of over
use.
``(iv) Definition of applicable
provisions.--In this subsection, the term
`applicable provisions' means the following
provisions:
``(I) Subsection (q)(2)(B)(i).
``(II) Section 1833(z)(2)(C).
``(B) Stakeholder input.--The Secretary shall
accept through December 1, 2014, comments on the draft
plan posted under paragraph (1)(A) from the public,
including health care providers, payers, consumers, and
other stakeholders.
``(C) Operational measure development plan.--Not
later than February 1, 2015, taking into account the
comments received under subparagraph (B), the Secretary
shall post on the Internet website of the Centers for
Medicare & Medicaid Services an operational plan for
the development of quality measures for use under
subsection (q)(2)(A)(i).
``(2) Contracts and other arrangements for quality measure
development.--
``(A) In general.--The Secretary shall enter into
contracts or other arrangements with entities for the
purpose of developing, improving, updating, or
expanding quality measures for application under the
applicable provisions. Such entities may include
physician specialty societies and other practitioner
organizations.
``(B) Prioritization.--
``(i) In general.--In entering into
contracts or other arrangements under
subparagraph (A), the Secretary shall give
priority to the development of the types of
measures described in paragraph (1)(A)(iii).
``(ii) Consideration.--In selecting
measures for development under this subsection,
the Secretary shall consider whether such
measures would be electronically specified.
``(3) Annual report by the secretary.--
``(A) In general.--Not later than February 1, 2016,
and annually thereafter, the Secretary shall post on
the Internet website of the Centers for Medicare &
Medicaid Services a report on the progress made in
developing quality measures for application under the
applicable provisions.
``(B) Requirements.--Each report submitted pursuant
to paragraph (1) shall include the following:
``(i) A description of the Secretary's
efforts to implement this subsection.
``(ii) With respect to the measures
developed during the previous year--
``(I) a description of the total
number of quality measures developed
and the types of such measures, such as
an outcome or patient experience
measure;
``(II) the name of each measure
developed;
``(III) the name of the developer
and steward of each measure;
``(IV) with respect to each type of
measure, an estimate of the total
amount expended under this title to
develop all measures of such type; and
``(V) whether the measure would be
electronically specified.
``(iii) With respect to measures in
development at the time of the report--
``(I) the information described in
clause (ii), if available; and
``(II) a timeline for completion of
the development of such measures.
``(iv) An update on the progress in
developing the types of measures described in
paragraph (1)(A)(iii), including a description
of issues affecting such progress.
``(v) A list of quality topics and concepts
that are being considered for development of
measures and the rationale for the selection of
topics and concepts including their
relationship to gap analyses.
``(vi) A description of any updates to the
plan under paragraph (1) (including newly
identified gaps and the status of previously
identified gaps) and the inventory of measures
applicable under the applicable provisions.
``(vii) Other information the Secretary
determines to be appropriate.
``(4) Stakeholder input.--With respect to measures
applicable under the applicable provisions, the Secretary shall
seek stakeholder input with respect to--
``(A) the identification of gaps where no quality
measures exist, particularly with respect to the types
of measures described in paragraph (1)(A)(iii);
``(B) prioritizing quality measure development to
address such gaps; and
``(C) other areas related to quality measure
development determined appropriate by the Secretary.
``(5) Funding.--For purposes of carrying out this
subsection, the Secretary shall provide for the transfer, from
the Federal Supplementary Medical Insurance Trust Fund under
section 1841, of $15,000,000 to the Centers for Medicare &
Medicaid Services Program Management Account for each of fiscal
years 2014 through 2018. Amounts transferred under this
paragraph shall remain available through the end of fiscal year
2021.''.
SEC. 103. ENCOURAGING CARE MANAGEMENT FOR INDIVIDUALS WITH CHRONIC CARE
NEEDS.
(a) In General.--Section 1848(b) of the Social Security Act (42
U.S.C. 1395w-4(b)) is amended by adding at the end the following new
paragraph:
``(8) Encouraging care management for individuals with
chronic care needs.--
``(A) In general.--In order to encourage the
management of care by an applicable provider (as
defined in subparagraph (B)) for individuals with
chronic care needs the Secretary shall--
``(i) establish one or more HCPCS codes for
chronic care management services for such
individuals; and
``(ii) subject to subparagraph (D), make
payment (as the Secretary determines to be
appropriate) under this section for such
management services furnished on or after
January 1, 2015, by an applicable provider.
``(B) Applicable provider defined.--For purposes of
this paragraph, the term `applicable provider' means a
physician (as defined in section 1861(r)(1)), physician
assistant or nurse practitioner (as defined in section
1861(aa)(5)(A)), or clinical nurse specialist (as
defined in section 1861(aa)(5)(B)) who furnishes
services as part of a patient-centered medical home or
a comparable specialty practice that--
``(i) is recognized as such a medical home
or comparable specialty practice by an
organization that is recognized by the
Secretary for purposes of such recognition as
such a medical home or practice; or
``(ii) meets such other comparable
qualifications as the Secretary determines to
be appropriate.
``(C) Budget neutrality.--The budget neutrality
provision under subsection (c)(2)(B)(ii)(II) shall
apply in establishing the payment under subparagraph
(A)(ii).
``(D) Policies relating to payment.--In carrying
out this paragraph, with respect to chronic care
management services, the Secretary shall--
``(i) make payment to only one applicable
provider for such services furnished to an
individual during a period;
``(ii) not make payment under subparagraph
(A) if such payment would be duplicative of
payment that is otherwise made under this title
for such services (such as in the case of
hospice care or home health services); and
``(iii) not require that an annual wellness
visit (as defined in section 1861(hhh)) or an
initial preventive physical examination (as
defined in section 1861(ww)) be furnished as a
condition of payment for such management
services.''.
(b) Education and Outreach.--
(1) Campaign.--
(A) In general.--The Secretary of Health and Human
Services (in this subsection referred to as the
``Secretary'') shall conduct an education and outreach
campaign to inform professionals who furnish items and
services under part B of title XVIII of the Social
Security Act and individuals enrolled under such part
of the benefits of chronic care management services
described in section 1848(b)(8) of the Social Security
Act, as added by subsection (a), and encourage such
individuals with chronic care needs to receive such
services.
(B) Requirements.--Such campaign shall--
(i) be directed by the Office of Rural
Health Policy of the Department of Health and
Human Services and the Office of Minority
Health of the Centers for Medicare & Medicaid
Services; and
(ii) focus on encouraging participation by
underserved rural populations and racial and
ethnic minority populations.
(2) Report.--
(A) In general.--Not later than December 31, 2017,
the Secretary shall submit to Congress a report on the
use of chronic care management services described in
such section 1848(b)(8) by individuals living in rural
areas and by racial and ethnic minority populations.
Such report shall--
(i) identify barriers to receiving chronic
care management services; and
(ii) make recommendations for increasing
the appropriate use of chronic care management
services.
SEC. 104. ENSURING ACCURATE VALUATION OF SERVICES UNDER THE PHYSICIAN
FEE SCHEDULE.
(a) Authority To Collect and Use Information on Physicians'
Services in the Determination of Relative Values.--
(1) In general.--Section 1848(c)(2) of the Social Security
Act (42 U.S.C. 1395w-4(c)(2)) is amended by adding at the end
the following new subparagraph:
``(M) Authority to collect and use information on
physicians' services in the determination of relative
values.--
``(i) Collection of information.--
Notwithstanding any other provision of law, the
Secretary may collect or obtain information on
the resources directly or indirectly related to
furnishing services for which payment is made
under the fee schedule established under
subsection (b). Such information may be
collected or obtained from any eligible
professional or any other source.
``(ii) Use of information.--Notwithstanding
any other provision of law, subject to clause
(v), the Secretary may (as the Secretary
determines appropriate) use information
collected or obtained pursuant to clause (i) in
the determination of relative values for
services under this section.
``(iii) Types of information.--The types of
information described in clauses (i) and (ii)
may, at the Secretary's discretion, include any
or all of the following:
``(I) Time involved in furnishing
services.
``(II) Amounts and types of
practice expense inputs involved with
furnishing services.
``(III) Prices (net of any
discounts) for practice expense inputs,
which may include paid invoice prices
or other documentation or records.
``(IV) Overhead and accounting
information for practices of physicians
and other suppliers.
``(V) Any other element that would
improve the valuation of services under
this section.
``(iv) Information collection mechanisms.--
Information may be collected or obtained
pursuant to this subparagraph from any or all
of the following:
``(I) Surveys of physicians, other
suppliers, providers of services,
manufacturers, and vendors.
``(II) Surgical logs, billing
systems, or other practice or facility
records.
``(III) Electronic health records.
``(IV) Any other mechanism
determined appropriate by the
Secretary.
``(v) Transparency of use of information.--
``(I) In general.--Subject to
subclauses (II) and (III), if the
Secretary uses information collected or
obtained under this subparagraph in the
determination of relative values under
this subsection, the Secretary shall
disclose the information source and
discuss the use of such information in
such determination of relative values
through notice and comment rulemaking.
``(II) Thresholds for use.--The
Secretary may establish thresholds in
order to use such information,
including the exclusion of information
collected or obtained from eligible
professionals who use very high
resources (as determined by the
Secretary) in furnishing a service.
``(III) Disclosure of
information.--The Secretary shall make
aggregate information available under
this subparagraph but shall not
disclose information in a form or
manner that identifies an eligible
professional or a group practice, or
information collected or obtained
pursuant to a nondisclosure agreement.
``(vi) Incentive to participate.--The
Secretary may provide for such payments under
this part to an eligible professional that
submits such solicited information under this
subparagraph as the Secretary determines
appropriate in order to compensate such
eligible professional for such submission. Such
payments shall be provided in a form and manner
specified by the Secretary.
``(vii) Administration.--Chapter 35 of
title 44, United States Code, shall not apply
to information collected or obtained under this
subparagraph.
``(viii) Definition of eligible
professional.--In this subparagraph, the term
`eligible professional' has the meaning given
such term in subsection (k)(3)(B).
``(ix) Funding.--For purposes of carrying
out this subparagraph, in addition to funds
otherwise appropriated, the Secretary shall
provide for the transfer, from the Federal
Supplementary Medical Insurance Trust Fund
under section 1841, of $2,000,000 to the
Centers for Medicare & Medicaid Services
Program Management Account for each fiscal year
beginning with fiscal year 2014. Amounts
transferred under the preceding sentence for a
fiscal year shall be available until
expended.''.
(2) Limitation on review.--Section 1848(i)(1) of the Social
Security Act (42 U.S.C. 1395w-4(i)(1)) is amended--
(A) in subparagraph (D), by striking ``and'' at the
end;
(B) in subparagraph (E), by striking the period at
the end and inserting ``, and''; and
(C) by adding at the end the following new
subparagraph:
``(F) the collection and use of information in the
determination of relative values under subsection
(c)(2)(M).''.
(b) Authority for Alternative Approaches To Establishing Practice
Expense Relative Values.--Section 1848(c)(2) of the Social Security Act
(42 U.S.C. 1395w-4(c)(2)), as amended by subsection (a), is amended by
adding at the end the following new subparagraph:
``(N) Authority for alternative approaches to
establishing practice expense relative values.--The
Secretary may establish or adjust practice expense
relative values under this subsection using cost,
charge, or other data from suppliers or providers of
services, including information collected or obtained
under subparagraph (M).''.
(c) Revised and Expanded Identification of Potentially Misvalued
Codes.--Section 1848(c)(2)(K)(ii) of the Social Security Act (42 U.S.C.
1395w-4(c)(2)(K)(ii)) is amended to read as follows:
``(ii) Identification of potentially
misvalued codes.--For purposes of identifying
potentially misvalued codes pursuant to clause
(i)(I), the Secretary shall examine codes (and
families of codes as appropriate) based on any
or all of the following criteria:
``(I) Codes that have experienced
the fastest growth.
``(II) Codes that have experienced
substantial changes in practice
expenses.
``(III) Codes that describe new
technologies or services within an
appropriate time period (such as 3
years) after the relative values are
initially established for such codes.
``(IV) Codes which are multiple
codes that are frequently billed in
conjunction with furnishing a single
service.
``(V) Codes with low relative
values, particularly those that are
often billed multiple times for a
single treatment.
``(VI) Codes that have not been
subject to review since implementation
of the fee schedule.
``(VII) Codes that account for the
majority of spending under the
physician fee schedule.
``(VIII) Codes for services that
have experienced a substantial change
in the hospital length of stay or
procedure time.
``(IX) Codes for which there may be
a change in the typical site of service
since the code was last valued.
``(X) Codes for which there is a
significant difference in payment for
the same service between different
sites of service.
``(XI) Codes for which there may be
anomalies in relative values within a
family of codes.
``(XII) Codes for services where
there may be efficiencies when a
service is furnished at the same time
as other services.
``(XIII) Codes with high intra-
service work per unit of time.
``(XIV) Codes with high practice
expense relative value units.
``(XV) Codes with high cost
supplies.
``(XVI) Codes as determined
appropriate by the Secretary.''.
(d) Target for Relative Value Adjustments for Misvalued Services.--
(1) In general.--Section 1848(c)(2) of the Social Security
Act (42 U.S.C. 1395w-4(c)(2)), as amended by subsections (a)
and (b), is amended by adding at the end the following new
subparagraph:
``(O) Target for relative value adjustments for
misvalued services.--With respect to fee schedules
established for each of 2015 through 2018, the
following shall apply:
``(i) Determination of net reduction in
expenditures.--For each year, the Secretary
shall determine the estimated net reduction in
expenditures under the fee schedule under this
section with respect to the year as a result of
adjustments to the relative values established
under this paragraph for misvalued codes.
``(ii) Budget neutral redistribution of
funds if target met and counting overages
towards the target for the succeeding year.--If
the estimated net reduction in expenditures
determined under clause (i) for the year is
equal to or greater than the target for the
year--
``(I) reduced expenditures
attributable to such adjustments shall
be redistributed for the year in a
budget neutral manner in accordance
with subparagraph (B)(ii)(II); and
``(II) the amount by which such
reduced expenditures exceeds the target
for the year shall be treated as a
reduction in expenditures described in
clause (i) for the succeeding year, for
purposes of determining whether the
target has or has not been met under
this subparagraph with respect to that
year.
``(iii) Exemption from budget neutrality if
target not met.--If the estimated net reduction
in expenditures determined under clause (i) for
the year is less than the target for the year,
reduced expenditures in an amount equal to the
target recapture amount shall not be taken into
account in applying subparagraph (B)(ii)(II)
with respect to fee schedules beginning with
2015.
``(iv) Target recapture amount.--For
purposes of clause (iii), the target recapture
amount is, with respect to a year, an amount
equal to the difference between--
``(I) the target for the year; and
``(II) the estimated net reduction
in expenditures determined under clause
(i) for the year.
``(v) Target.--For purposes of this
subparagraph, with respect to a year, the
target is calculated as 0.5 percent of the
estimated amount of expenditures under the fee
schedule under this section for the year.''.
(2) Conforming amendment.--Section 1848(c)(2)(B)(v) of the
Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)(v)) is amended
by adding at the end the following new subclause:
``(VIII) Reductions for misvalued
services if target not met.--Effective
for fee schedules beginning with 2015,
reduced expenditures attributable to
the application of the target recapture
amount described in subparagraph
(O)(iii).''.
(e) Phase-in of Significant Relative Value Unit (RVU) Reductions.--
(1) In general.--Section 1848(c) of the Social Security Act
(42 U.S.C. 1395w-4(c)) is amended by adding at the end the
following new paragraph:
``(7) Phase-in of significant relative value unit (rvu)
reductions.--Effective for fee schedules established beginning
with 2015, if the total relative value units for a service for
a year would otherwise be decreased by an estimated amount
equal to or greater than 20 percent as compared to the total
relative value units for the previous year, the applicable
adjustments in work, practice expense, and malpractice relative
value units shall be phased-in over a 2-year period.''.
(2) Conforming amendments.--Section 1848(c)(2) of the
Social Security Act (42 U.S.C. 1395w-4(c)(2)) is amended--
(A) in subparagraph (B)(ii)(I), by striking
``subclause (II)'' and inserting ``subclause (II) and
paragraph (7)''; and
(B) in subparagraph (K)(iii)(VI)--
(i) by striking ``provisions of
subparagraph (B)(ii)(II)'' and inserting
``provisions of subparagraph (B)(ii)(II) and
paragraph (7)''; and
(ii) by striking ``under subparagraph
(B)(ii)(II)'' and inserting ``under
subparagraph (B)(ii)(I)''.
(f) Authority To Smooth Relative Values Within Groups of
Services.--Section 1848(c)(2)(C) of the Social Security Act (42 U.S.C.
1395w-4(c)(2)(C)) is amended--
(1) in each of clauses (i) and (iii), by striking ``the
service'' and inserting ``the service or group of services''
each place it appears; and
(2) in the first sentence of clause (ii), by inserting ``or
group of services'' before the period.
(g) GAO Study and Report on Relative Value Scale Update
Committee.--
(1) Study.--The Comptroller General of the United States
(in this subsection referred to as the ``Comptroller General'')
shall conduct a study of the processes used by the Relative
Value Scale Update Committee (RUC) to provide recommendations
to the Secretary of Health and Human Services regarding
relative values for specific services under the Medicare
physician fee schedule under section 1848 of the Social
Security Act (42 U.S.C. 1395w-4).
(2) Report.--Not later than 1 year after the date of the
enactment of this Act, the Comptroller General shall submit to
Congress a report containing the results of the study conducted
under paragraph (1).
SEC. 105. PROMOTING EVIDENCE-BASED CARE.
(a) Recognizing Appropriate Use Criteria for Certain Imaging
Services.--
(1) In general.--Section 1834 of the Social Security Act
(42 U.S.C. 1395m) is amended by adding at the end the following
new subsection:
``(p) Recognizing Appropriate Use Criteria for Certain Imaging
Services.--
``(1) Program established.--
``(A) In general.--The Secretary shall establish a
program to promote the use of appropriate use criteria
(as defined in subparagraph (B)) for applicable imaging
services (as defined in subparagraph (C)) furnished in
an applicable setting (as defined in subparagraph (D))
by ordering professionals and furnishing professionals
(as defined in subparagraphs (E) and (F),
respectively).
``(B) Appropriate use criteria defined.--In this
subsection, the term `appropriate use criteria' means
criteria, only developed or endorsed by national
professional medical specialty societies or other
provider-led entities, to assist ordering professionals
and furnishing professionals in making the most
appropriate treatment decision for a specific clinical
condition. To the extent feasible, such criteria shall
be evidence-based.
``(C) Applicable imaging service defined.--In this
subsection, the term `applicable imaging service' means
an advanced diagnostic imaging service (as defined in
subsection (e)(1)(B)) for which the Secretary
determines--
``(i) one or more applicable appropriate
use criteria specified under paragraph (2)
apply;
``(ii) there are one or more qualified
clinical decision support mechanisms listed
under paragraph (3)(C); and
``(iii) one or more of such mechanisms is
available free of charge.
``(D) Applicable setting defined.--In this
subsection, the term `applicable setting' means a
physician's office, a hospital outpatient department
(including an emergency department), an ambulatory
surgical center, and any other provider-led outpatient
setting determined appropriate by the Secretary.
``(E) Ordering professional defined.--In this
subsection, the term `ordering professional' means a
physician (as defined in section 1861(r)) or a
practitioner described in section 1842(b)(18)(C) who
orders an applicable imaging service for an individual.
``(F) Furnishing professional defined.--In this
subsection, the term `furnishing professional' means a
physician (as defined in section 1861(r)) or a
practitioner described in section 1842(b)(18)(C) who
furnishes an applicable imaging service for an
individual.
``(2) Establishment of applicable appropriate use
criteria.--
``(A) In general.--Not later than November 15,
2015, the Secretary shall through rulemaking, and in
consultation with physicians, practitioners, and other
stakeholders, specify applicable appropriate use
criteria for applicable imaging services only from
among appropriate use criteria developed or endorsed by
national professional medical specialty societies or
other provider-led entities.
``(B) Considerations.--In specifying applicable
appropriate use criteria under subparagraph (A), the
Secretary shall take into account whether the
criteria--
``(i) have stakeholder consensus;
``(ii) have been determined to be
scientifically valid and are evidence based;
and
``(iii) are based on studies that are
published and reviewable by stakeholders.
``(C) Revisions.--The Secretary shall periodically
update and revise (as appropriate) such specification
of applicable appropriate use criteria.
``(D) Treatment of multiple applicable appropriate
use criteria.--In the case where the Secretary
determines that more than one appropriate use criteria
applies with respect to an applicable imaging service,
the Secretary shall specify one or more applicable
appropriate use criteria under this paragraph for the
service.
``(3) Mechanisms for consultation with applicable
appropriate use criteria.--
``(A) Identification of mechanisms to consult with
applicable appropriate use criteria.--
``(i) In general.--The Secretary shall
specify one or more qualified clinical decision
support mechanisms that could be used by
ordering professionals to consult with
applicable appropriate use criteria for
applicable imaging services.
``(ii) Consultation.--The Secretary shall
consult with physicians, practitioners, and
other stakeholders in specifying mechanisms
under this paragraph.
``(iii) Inclusion of certain mechanisms.--
Mechanisms specified under this paragraph may
include any or all of the following that meet
the requirements described in subparagraph
(B)(ii):
``(I) Use of clinical decision
support modules in certified EHR
technology (as defined in section
1848(o)(4)).
``(II) Use of private sector
clinical decision support mechanisms
that are independent from certified EHR
technology, which may include use of
clinical decision support mechanisms
available from medical specialty
organizations.
``(III) Use of a clinical decision
support mechanism established by the
Secretary.
``(B) Qualified clinical decision support
mechanisms.--
``(i) In general.--For purposes of this
subsection, a qualified clinical decision
support mechanism is a mechanism that the
Secretary determines meets the requirements
described in clause (ii).
``(ii) Requirements.--The requirements
described in this clause are the following:
``(I) The mechanism makes available
to the ordering professional applicable
appropriate use criteria specified
under paragraph (2) and the supporting
documentation for the applicable
imaging service ordered.
``(II) In the case where there are
more than one applicable appropriate
use criteria specified under such
paragraph for an applicable imaging
service, the mechanism indicates the
criteria that it uses for the service.
``(III) The mechanism determines
the extent to which an applicable
imaging service ordered is consistent
with the applicable appropriate use
criteria so specified.
``(IV) The mechanism generates and
provides to the ordering professional a
certification or documentation that
documents that the qualified clinical
decision support mechanism was
consulted by the ordering professional.
``(V) The mechanism is updated on a
timely basis to reflect revisions to
the specification of applicable
appropriate use criteria under such
paragraph.
``(VI) The mechanism meets privacy
and security standards under applicable
provisions of law.
``(VII) The mechanism performs such
other functions as specified by the
Secretary, which may include a
requirement to provide aggregate
feedback to the ordering professional.
``(C) List of mechanisms for consultation with
applicable appropriate use criteria.--
``(i) Initial list.--Not later than April
1, 2016, the Secretary shall publish a list of
mechanisms specified under this paragraph.
``(ii) Periodic updating of list.--The
Secretary shall periodically update the list of
qualified clinical decision support mechanisms
specified under this paragraph.
``(4) Consultation with applicable appropriate use
criteria.--
``(A) Consultation by ordering professional.--
Beginning with January 1, 2017, subject to subparagraph
(C), with respect to an applicable imaging service
ordered by an ordering professional that would be
furnished in an applicable setting and paid for under
an applicable payment system (as defined in
subparagraph (D)), an ordering professional shall--
``(i) consult with a qualified decision
support mechanism listed under paragraph
(3)(C); and
``(ii) provide to the furnishing
professional the information described in
clauses (i) through (iii) of subparagraph (B).
``(B) Reporting by furnishing professional.--
Beginning with January 1, 2017, subject to subparagraph
(C), with respect to an applicable imaging service
furnished in an applicable setting and paid for under
an applicable payment system (as defined in
subparagraph (D)), payment for such service may only be
made if the claim for the service includes the
following:
``(i) Information about which qualified
clinical decision support mechanism was
consulted by the ordering professional for the
service.
``(ii) Information regarding--
``(I) whether the service ordered
would adhere to the applicable
appropriate use criteria specified
under paragraph (2);
``(II) whether the service ordered
would not adhere to such criteria; or
``(III) whether such criteria was
not applicable to the service ordered.
``(iii) The national provider identifier of
the ordering professional (if different from
the furnishing professional).
``(C) Exceptions.--The provisions of subparagraphs
(A) and (B) and paragraph (6)(A) shall not apply to the
following:
``(i) Emergency services.--An applicable
imaging service ordered for an individual with
an emergency medical condition (as defined in
section 1867(e)(1)).
``(ii) Inpatient services.--An applicable
imaging service ordered for an inpatient and
for which payment is made under part A.
``(iii) Alternative payment models.--An
applicable imaging service ordered by an
ordering professional with respect to an
individual attributed to an alternative payment
model (as defined in section 1833(z)(3)(C)).
``(iv) Significant hardship.--An applicable
imaging service ordered by an ordering
professional who the Secretary may, on a case-
by-case basis, exempt from the application of
such provisions if the Secretary determines,
subject to annual renewal, that consultation
with applicable appropriate use criteria would
result in a significant hardship, such as in
the case of a professional who practices in a
rural area without sufficient Internet access.
``(D) Applicable payment system defined.--In this
subsection, the term `applicable payment system' means
the following:
``(i) The physician fee schedule
established under section 1848(b).
``(ii) The prospective payment system for
hospital outpatient department services under
section 1833(t).
``(iii) The ambulatory surgical center
payment systems under section 1833(i).
``(5) Identification of outlier ordering professionals.--
``(A) In general.--With respect to applicable
imaging services furnished beginning with 2017, the
Secretary shall determine, on a periodic basis (which
may be annually), ordering professionals who are
outlier ordering professionals.
``(B) Outlier ordering professionals.--The
determination of an outlier ordering professional
shall--
``(i) be based on low adherence to
applicable appropriate use criteria specified
under paragraph (2), which may be based on
comparison to other ordering professionals; and
``(ii) include data for ordering
professionals for whom prior authorization
under paragraph (6)(A) applies.
``(C) Use of two years of data.--The Secretary
shall use two years of data to identify outlier
ordering professionals under this paragraph.
``(D) Consultation with stakeholders.--The
Secretary shall consult with physicians, practitioners
and other stakeholders in developing methods to
identify outlier ordering professionals under this
paragraph.
``(6) Prior authorization for ordering professionals who
are outliers.--
``(A) In general.--Beginning January 1, 2020,
subject to paragraph (4)(C), with respect to services
furnished during a year, the Secretary shall, for a
period determined appropriate by the Secretary, apply
prior authorization for applicable imaging services
that are ordered by an outlier ordering professional
identified under paragraph (5).
``(B) Funding.--For purposes of carrying out this
paragraph, the Secretary shall provide for the
transfer, from the Federal Supplementary Medical
Insurance Trust Fund under section 1841, of $5,000,000
to the Centers for Medicare & Medicaid Services Program
Management Account for each of fiscal years 2019
through 2021. Amounts transferred under the preceding
sentence shall remain available until expended.''.
(2) Conforming amendment.--Section 1833(t)(16) of the
Social Security Act (42 U.S.C. 1395l(t)(16)) is amended by
adding at the end the following new subparagraph:
``(E) Application of appropriate use criteria for
certain imaging services.--For provisions relating to
the application of appropriate use criteria for certain
imaging services, see section 1834(p).''.
(b) Establishment of Appropriate Use Program for Other Part B
Services.--Section 1834 of the Social Security Act (42 U.S.C. 1395m),
as amended by subsection (a), is amended by adding at the end the
following new subsection:
``(q) Establishment of Appropriate Use Program for Other Part B
Services.--
``(1) Establishment.--
``(A) In general.--The Secretary may establish an
appropriate use program for services under this part
(other than applicable imaging services under
subsection (p)) using a process that is comparable to
the process under such subsection. With respect to
appropriate use criteria, such process shall replicate
the provider-developed or provider-endorsed criteria
framework for appropriate use criteria for applicable
imaging services under such subsection.
``(B) Requirements.--In determining whether to
establish a program under subparagraph (A), the
Secretary shall take into consideration--
``(i) the applicability of the provider-
developed or provider-endorsed criteria
framework for appropriate use criteria for
applicable imaging services under subsection
(p);
``(ii) the implementation of provider-
developed or provider-endorsed appropriate use
criteria for such applicable imaging services;
and
``(iii) the report under paragraph (2).
``(C) Input from stakeholders in advance of
rulemaking.--Before issuing a notice of proposed
rulemaking to establish a program under subparagraph
(A), the Secretary shall issue an advance notice of
proposed rulemaking.
``(2) Report on experience of imaging appropriate use
criteria program.--Not later than 18 months after the date of
the enactment of this subsection, the Comptroller General of
the United States shall submit to Congress a report that
includes a description of the extent to which appropriate use
criteria could be used for other services under this part, such
as radiation therapy and clinical diagnostic laboratory
services.''.
SEC. 106. EMPOWERING BENEFICIARY CHOICES THROUGH ACCESS TO INFORMATION
ON PHYSICIANS' SERVICES.
(a) Transferring Freestanding Physician Compare Provision to the
Social Security Act.--
(1) In general.--Section 10331 of Public Law 111-148 is
transferred and redesignated as subsection (t) of section 1848
of the Social Security Act (42 U.S.C. 1395w-4), as amended by
subsections (c) and (h) of section 101 and by section 102.
(2) Conforming redesignations.--Section 1848(t) of the
Social Security Act (42 U.S.C. 1395w-4(t)), as transferred and
redesignated by paragraph (1), is further amended--
(A) by striking the subsection heading and
inserting the following new subsection heading:
``Public Reporting of Performance and Other Information
on Physician Compare'';
(B) by redesignating subsections (a) through (i) as
paragraphs (1) through (9), respectively, and indenting
appropriately;
(C) in paragraph (1), as redesignated by
subparagraph (B)--
(i) by redesignating paragraphs (1) and (2)
as subparagraphs (A) and (B), respectively, and
indenting appropriately;
(ii) in subparagraph (B), as redesignated
by clause (i), by redesignating subparagraphs
(A) through (G) as clauses (i) through (vii),
respectively, and indenting appropriately;
(D) in paragraph (2), as redesignated by
subparagraph (B), by redesignating paragraphs (1)
through (7) as subparagraphs (A) through (G),
respectively, and indenting appropriately; and
(E) in paragraph (9), as redesignated by
subparagraph (B), by redesignating paragraphs (1)
through (4) as subparagraphs (A) through (D),
respectively, and indenting appropriately.
(3) Conforming amendments.--Section 1848(t) of the Social
Security Act (42 U.S.C. 1395w-4(t)), as amended by paragraph
(2), is further amended--
(A) in paragraph (1)--
(i) in subparagraph (A)--
(I) by striking ``the Medicare
program under section 1866(j) of the
Social Security Act (42 U.S.C.
1395cc(j))'' and inserting ``the
program under this title under section
1866(j)''; and
(II) by striking ``of such Act (42
U.S.C. 1395w-4)''; and
(ii) in subparagraph (B), in the matter
preceding clause (i)--
(I) by striking ``subsection (c)''
and inserting ``paragraph (3)'';
(II) by striking ``the Medicare
program under such section 1866(j)''
and inserting ``the program under this
title under section 1866(j)''; and
(III) by striking ``this section''
and inserting ``this subsection'';
(B) in paragraph (2)--
(i) in the matter preceding subparagraph
(A), by striking ``subsection (a)(2)'' and
inserting ``paragraph (1)(B)'';
(ii) in subparagraph (D), by striking ``the
Medicare program'' and inserting ``the program
under this title''; and
(iii) in each of subparagraphs (F) and (G),
by striking ``this section'' and inserting
``this subsection'';
(C) in paragraph (3), by striking ``this section''
and inserting ``this subsection'';
(D) in paragraph (4)--
(i) by striking ``of the Social Security
Act, as added by section 3014 of this Act'';
and
(ii) by striking ``this section'' and
inserting ``this subsection'';
(E) in paragraph (5)--
(i) by striking ``this subsection (a)(2)''
and inserting ``paragraph (1)(B)''; and
(ii) by striking ``(Public Law 110-275)'';
(F) in paragraph (6), by striking ``subsection
(a)(1)'' and inserting ``paragraph (1)(A)'';
(G) in paragraph (7)--
(i) by striking ``subsection (f)'' and
inserting ``paragraph (6)''; and
(ii) by striking ``title XVIII of the
Social Security Act'' and inserting ``this
title'';
(H) in paragraph (8)--
(i) by striking ``subparagraphs (A) through
(G) of subsection (a)(2)'' and inserting
``clauses (i) through (vii) of paragraph
(1)(B)'';
(ii) by striking ``title XVIII of the
Social Security Act'' and inserting ``this
title''; and
(iii) by striking ``such title'' and
inserting ``this title''; and
(I) in paragraph (9)--
(i) in the matter preceding subparagraph
(8), by striking ``this section'' and inserting
``this subsection'';
(ii) in subparagraph (A), by striking ``of
the Social Security Act (42 U.S.C. 1395w-4)'';
(iii) in subparagraph (B), by striking ``of
such Act (42 U.S.C. 1395x(r))'';
(iv) in subparagraph (C), by striking
``subsection (a)(1)'' and inserting ``paragraph
(1)(A)''; and
(v) by striking subparagraph (D).
(b) Public Availability of Medicare Data.--Section 1848(t) of the
Social Security Act (42 U.S.C. 1395w-4(t)), as amended by subsection
(a), is further amended--
(1) by redesignating paragraph (9) as paragraph (10);
(2) by inserting after paragraph (8) the following new
paragraph:
``(9) Public availability of eligible professional claims
data.--
``(A) In general.--The Secretary shall make
publicly available on Physician Compare the information
described in subparagraph (B) with respect to eligible
professionals.
``(B) Information described.--The following
information, with respect to an eligible professional,
is described in this subparagraph:
``(i) Information on the number of services
furnished by the eligible professional, which
may include information on the most frequent
services furnished or groupings of services.
``(ii) Information on submitted charges and
payments for services under this part.
``(iii) A unique identifier for the
eligible professional that is available to the
public, such as a national provider identifier.
``(C) Searchability.--The information made
available under this paragraph shall be searchable by
at least the following:
``(i) The specialty or type of the eligible
professional.
``(ii) Characteristics of the services
furnished, such as volume or groupings of
services.
``(iii) The location of the eligible
professional.
``(D) Disclosure.--The information made available
under this paragraph shall indicate, where appropriate,
that publicized information may not be representative
of the eligible professional's entire patient
population, the variety of services furnished by the
eligible professional, or the health conditions of
individuals treated.
``(E) Implementation.--
``(i) Initial implementation.--Physician
Compare shall include the information described
in subparagraph (B)--
``(I) with respect to physicians,
by not later than July 1, 2015; and
``(II) with respect to other
eligible professionals, by not later
than July 1, 2016.
``(ii) Annual updating.--The information
made available under this paragraph shall be
updated on Physician Compare not less
frequently than on an annual basis.
``(F) Opportunity to review and submit
corrections.--The Secretary shall provide for an
opportunity for an eligible professional to review, and
submit corrections for, the information to be made
public with respect to the eligible professional under
this paragraph prior to such information being made
public.''; and
(3) in paragraph (10)(C), as redesignated by paragraph (1),
by inserting ``(or a successor website)'' before the period at
the end.
SEC. 107. EXPANDING CLAIMS DATA AVAILABILITY TO IMPROVE CARE.
(a) Expansion of Uses of Claims Data by Qualified Entities.--
Section 1874(e) of the Social Security Act (42 U.S.C. 1395kk(e)) is
amended by adding at the end the following new paragraphs:
``(5) Expansion of uses of claims data by qualified
entities.--
``(A) Expansion.--To the extent consistent with
applicable information, privacy, security, and
disclosure laws, beginning July 1, 2014,
notwithstanding paragraph (4)(B) (other than clause
(iii) of such paragraph) and the second sentence of
paragraph (4)(D), a qualified entity may, as determined
appropriate by the Secretary, do any or all of the
following:
``(i)(I) Use the combined data described in
paragraph (4)(B)(iii) to conduct analyses,
other than for reports described in paragraph
(4), for entities described in subparagraph (B)
for non-public uses, as determined appropriate
by the Secretary, such as for the purposes
described in subclause (II).
``(II) The purposes described in this
subclause are assisting providers of services
and suppliers in developing and participating
in quality and patient care improvement
activities (including developing new models of
care), population health management, and
disease monitoring, and the purposes described
in subparagraph (C).
``(ii) Provide or sell such analyses to
entities described in subparagraph (B).
``(iii) Provide entities described in
clauses (i), (ii), (v), and (vi) of
subparagraph (B) with access to the combined
data described in paragraph (4)(B)(iii) through
a qualified data enclave (as defined in
subparagraph (F)) that is maintained by the
qualified entity, or through an approved
alternative method (as defined in subparagraph
(G)), in order for entities described in such
clauses to conduct analyses for non-public
uses, such as for the purposes described in
clause (i)(II) (but excluding the purposes
described in subparagraph (C)).
``(B) Entities described.--For the purpose of
subparagraph (A) clauses (i) and (ii), the entities
described in this subparagraph are the following:
``(i) A provider of services.
``(ii) A supplier.
``(iii) Subject to subparagraph (C), an
employer (as defined in section 3(5) of the
Employee Retirement Insurance Security Act of
1974).
``(iv) A health insurance issuer (as
defined in section 2791 of the Public Health
Service Act) that provides data under paragraph
(4)(B)(iii).
``(v) A medical society or hospital
association.
``(vi) Other entities approved by the
Secretary (other than an employer (as so
defined) and a health insurance issuer (as so
defined)).
``(C) Limitation for employers with respect to
analyses.--Any analyses provided or sold under this
paragraph to an employer (as so defined) may only be
used by such employer for purposes of providing health
insurance to employees and retirees of the employer.
``(D) Protection of patient identification in
analyses.--
``(i) In general.--Except as provided in
clause (ii), an analysis provided or sold under
this paragraph shall not contain information
that individually identifies a patient.
``(ii) Information on patients of the
provider of services or supplier.--An analysis
that is provided or sold under this paragraph
to a provider of services or supplier may
contain data that individually identifies a
patient of such provider or supplier but only
with respect to items and services furnished by
such provider or supplier to such patient.
``(iii) Opportunity for providers of
services and suppliers to review.--Prior to a
qualified entity providing or selling an
analysis under this paragraph to an entity
described in subparagraph (B), to the extent
that such analysis would individually identify
a provider of services or supplier who is not
being provided or sold such analysis, such
qualified entity shall provide an opportunity
for such provider or supplier to review and
submit corrections to such analysis.
``(E) No redisclosure of analyses or data.--An
entity described in subparagraph (B) that is provided
or sold analyses under this paragraph, or an entity
described in subparagraph (A)(iii) that receives data
under this paragraph through a qualified data enclave
or an approved alternative method, shall not redisclose
or make public such analyses, such data, or analyses
using such data.
``(F) Requirements for a qualified data enclave.--
``(i) Definition.--For purposes of this
paragraph, the term `qualified data enclave'
means a data enclave that the Secretary
determines meets the following:
``(I) The data enclave is a virtual
private network or comparable
mechanism.
``(II) Subject to the requirements
described in clause (ii) and such other
requirements as the Secretary may
specify, the data enclave is capable of
providing access to the combined data
described in subparagraph (A)(iii).
``(ii) Enclave access requirements.--The
requirements described in this clause are the
following:
``(I) A qualified data enclave
shall preclude any entity that obtains
access to the data from removing or
extracting the data from such enclave.
``(II) Subject to the succeeding
sentence, the enclave shall preclude
access to data that individually
identifies a patient, including data on
the patient's name and date of birth
and such other data as the Secretary
shall specify. Such data enclave may
provide providers of services and
suppliers with access to such
individually identifiable patient data
but only with respect to items and
services furnished by such provider or
supplier to such patient.
``(III) Access to data in the
enclave shall not be provided to any
entity unless the qualified entity and
the entity have entered into a data use
agreement, the terms of which contain
the requirements of this paragraph and
paragraph (6) and such other terms the
Secretary may specify.
``(G) Approved alternative method.--For purposes of
this paragraph, the term `approved alternative method'
means a method of providing access to the data
described in subparagraph (A)(iii) (other than through
a qualified data enclave) to entities described in such
paragraph that the Secretary determines meets the
following:
``(i) The method is as secure as a
qualified data enclave.
``(ii) The method meets the requirements
applicable to a qualified data enclave under
subclauses (II) and (III) of subparagraph
(F)(ii).
``(iii) The method meets other requirements
determined appropriate by the Secretary.
``(H) Annual reports.--Any qualified entity that
provides or sells analyses pursuant to subparagraph
(A)(ii), or provides access to a data through an
approved data enclave or an approved alternative
method, shall annually submit to the Secretary a report
that includes--
``(i) a summary of the analyses provided or
sold, including the number of such analyses,
the number of purchasers of such analyses, and
the total amount of fees received for such
analyses;
``(ii) a description of the topics and
purposes of such analyses;
``(iii) information on the entities who
obtained access to data pursuant to
subparagraph (A)(iii), the uses of the data,
and the total amount of fees received for
providing such access; and
``(iv) other information determined
appropriate by the Secretary.
``(6) Civil monetary penalties for a breach of a data use
agreement.--A data use agreement under this subsection shall
provide for civil monetary penalties (as determined appropriate
by the Secretary) for a breach of such agreement.''.
(b) Expansion of Data Available to Qualified Entities.--Section
1874(e) of the Social Security Act (42 U.S.C. 1395kk(e)) is amended--
(1) in the subsection heading, by striking ``Medicare'';
and
(2) in paragraph (3)--
(A) by inserting after the first sentence the
following new sentence: ``Effective July 1, 2014, if
the Secretary determines appropriate, the data
described in this paragraph may also include
standardized extracts (as determined by the Secretary)
of claims data under titles XIX and XXI for assistance
provided under such titles for one or more specified
geographic areas and time periods requested by a
qualified entity.''; and
(B) in the last sentence, by inserting ``or under
titles XIX or XXI'' before the period at the end.
(c) Access to Medicare Data by Qualified Clinical Data Registries
To Facilitate Quality Improvement.--Section 1848(m)(3)(E) of the Social
Security Act (42 U.S.C. 1395w-4(m)(3)(E)) is amended by adding at the
end the following new clause:
``(vi) Access to medicare data to
facilitate quality improvement.--
``(I) In general.--To the extent
consistent with applicable information,
privacy, security, and disclosure laws,
and subject to other requirements as
the Secretary may specify, beginning
July 1, 2014, the Secretary shall, if
requested by a qualified clinical data
registry under this subparagraph,
subject to subclauses (II) and (III),
provide data as described in section
1874(e)(3) (in a form and manner
determined to be appropriate) to such
registry for purposes of linking such
data with clinical data and performing
analyses and research to support
quality improvement or patient safety.
``(II) Protection.--A qualified
clinical data registry may not publicly
report any data made available under
subclause (I) (or any analyses or
research described in such subclause)
that individually identifies a provider
of services, supplier, or individual
unless the registry obtains the consent
of such provider, supplier, or
individual prior to such reporting.
``(III) Fee.--The data described in
subclause (I) shall be made available
to qualified clinical data registries
at a fee equal to the cost of making
such data available. Any fee collected
pursuant to the preceding sentence
shall be deposited in the Centers for
Medicare & Medicaid Services Program
Management Account.''.
(d) Revision of Placement of Fees.--Section 1874(e)(4)(A) of the
Social Security Act (42 U.S.C. 1395kk(e)(4)(A)) is amended, in the
second sentence--
(1) by inserting ``, for periods prior to July 1, 2014,''
after ``deposited''; and
(2) by inserting the following before the period at the
end: ``, and, beginning July 1, 2014, into the Centers for
Medicare & Medicaid Services Program Management Account''.
TITLE II--EXTENSIONS AND OTHER PROVISIONS
Subtitle A--Medicare Extensions
SEC. 201. WORK GEOGRAPHIC ADJUSTMENT.
Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)(E)) is amended by striking ``and before January 1, 2014,''.
SEC. 202. MEDICARE PAYMENT FOR THERAPY SERVICES.
(a) Repeal of Therapy Cap and 1-year Extension of Threshold for
Manual Medical Review.--Section 1833(g) of the Social Security Act (42
U.S.C. 1395l(g)) is amended--
(1) in paragraph (4)--
(A) by striking ``This subsection'' and inserting
``Except as provided in paragraph (5)(C), this
subsection''; and
(B) by inserting the following before the period at
the end: ``or with respect to services furnished on or
after the date of enactment of the SGR Repeal and
Medicare Beneficiary Access Act of 2013''.
(2) in paragraph (5)(C)--
(A) in clause (i), by inserting ``and before
January 1, 2015,'' after ``2012,''; and
(B) by adding at the end the following new clause:
``(iii) With respect to services furnished during the period
beginning on the date of enactment of the SGR Repeal and Medicare
Beneficiary Access Act of 2013, and ending on December 31, 2014, the
provisions of this paragraph shall only apply to the extent necessary
to carry out the manual medical review process under this
subparagraph.''.
(b) Medical Review of Outpatient Therapy Services.--
(1) Medical review of outpatient therapy services.--Section
1833 of the Social Security Act (42 U.S.C. 1395l), as amended
by section 101(e), is amended by adding at the end the
following new subsection:
``(aa) Medical Review of Outpatient Therapy Services.--
``(1) In general.--
``(A) Process for medical review.--The Secretary
shall implement a process for the medical review (as
described in paragraph (2)) of outpatient therapy
services (as defined in paragraph (10)) and, subject to
paragraph (12), apply such process to such services
furnished on or after January 1, 2015, focusing on
services identified under subparagraph (B).
``(B) Identification of services for review.--Under
the process, the Secretary shall identify services for
medical review, using such factors as the Secretary
determines appropriate, which may include the
following:
``(i) Services furnished by a therapy
provider (as defined in paragraph (10)) whose
pattern of billing is higher compared to peers.
``(ii) Services furnished by a therapy
provider who, in a prior period, has a high
claims denial percentage or is least compliant
with other applicable requirements under this
title.
``(iii) Services furnished by a therapy
provider that is newly enrolled under this
title.
``(iv) Services furnished by a therapy
provider who has questionable billing
practices, such as billing medically unlikely
units of services in a day.
``(v) Services furnished to treat a type of
medical condition.
``(vi) Services identified by use of the
standardized data elements required to be
reported under section 1834(p).
``(vii) Services furnished by a single
therapy provider or a group that includes a
therapy provider identified by factors
described in this subparagraph.
``(viii) Other services as determined
appropriate by the Secretary.
``(2) Medical review.--
``(A) Prior authorization medical review.--
``(i) In general.--Subject to the
succeeding provisions of this subparagraph, the
Secretary shall use prior authorization medical
review for outpatient therapy services
furnished to an individual above one or more
thresholds established by the Secretary, such
as a dollar threshold or a threshold based on
factors such as the type of outpatient therapy
service or setting.
``(ii) Ending application of prior
authorization for a therapy provider.--The
Secretary shall end the application of prior
authorization medical review to outpatient
therapy services furnished by a therapy
provider if the Secretary determines that the
provider has a low denial rate under such prior
authorization. The Secretary may subsequently
reapply prior authorization medical review to
such therapy provider if the Secretary
determines it to be appropriate.
``(iii) Prior authorization of multiple
services.--The Secretary shall, where
practicable, provide for prior authorization
medical review for multiple services at a
single time, such as services in a therapy plan
of care described in section 1861(p)(2).
``(B) Other types of medical review.--The Secretary
may use pre-payment review or post-payment review for
services identified under paragraph (1)(B) that are not
subject to prior authorization medical review under
subparagraph (A).
``(C) Limitation for law enforcement activities.--
The Secretary may determine that medical review under
this subsection does not apply in the case where fraud
may be involved.
``(3) Review contractors.--The Secretary shall conduct
prior authorization medical review of outpatient therapy
services under this subsection using medicare administrative
contractors (as described in section 1874A) or other review
contractors (other than contractors under section 1893(h) or
contractors paid on a contingent basis).
``(4) No payment without prior authorization.--With respect
to an outpatient therapy service for which prior authorization
medical review under this subsection applies, no payment shall
be made under this part for the service unless a prior
authorization determination is made, in advance of furnishing
such service, that such service would meet the applicable
requirements of section 1862(a)(1)(A).
``(5) Submission of information.--A therapy provider may
submit the information necessary for medical review by fax, by
mail, or by electronic means. The Secretary shall make
available the electronic means described in the preceding
sentence as soon as practicable, but not later than 24 months
after the date of enactment of this subsection.
``(6) Timeliness.--The Secretary shall make a prior
authorization determination under this subsection within 10
business days of the date of the Secretary's receipt of medical
documentation needed to make such determination or the
Secretary shall be deemed to have found the services to meet
the applicable requirements of section 1862(a)(1)(A).
``(7) Construction.--With respect to an outpatient therapy
service that has been affirmed by medical review under this
subsection, nothing in this subsection shall be construed to
preclude the subsequent denial of a claim for such service that
does not meet other applicable requirements under this Act.
``(8) Beneficiary protections.--With respect to services
furnished on or after January 1, 2015, where payment may not be
made as a result of application of medical review under this
subsection, section 1879 shall apply in the same manner as such
section applies to a denial that is made by reason of section
1862(a)(1).
``(9) Implementation.--
``(A) Authority.--The Secretary may implement the
provisions of this subsection by interim final rule
with comment period.
``(B) Administration.--Chapter 35 of title 44,
United States Code, shall not apply to medical review
under this subsection.
``(10) Definitions.--For purposes of this subsection:
``(A) Outpatient therapy services.--The term
`outpatient therapy services' means the following
services for which payment is made under section 1848,
1834(g), or 1834(k):
``(i) Physical therapy services of the type
described in section 1861(p).
``(ii) Speech-language pathology services
of the type described in such section though
the application of section 1861(ll)(2).
``(iii) Occupational therapy services of
the type described in section 1861(p) through
the operation of section 1861(g).
``(B) Therapy provider.--The term `therapy
provider' means a provider of services (as defined in
section 1861(u)) or a supplier (as defined in section
1861(d)) who submits a claim for outpatient therapy
services.
``(11) Funding.--For purposes of implementing this
subsection, the Secretary shall provide for the transfer, from
the Federal Supplementary Medical Insurance Trust Fund under
section 1841, of $35,000,000 to the Centers for Medicare &
Medicaid Services Program Management Account for each fiscal
year (beginning with fiscal year 2014). Amounts transferred
under this paragraph shall remain available until expended.
``(12) Scaling back.--
``(A) Periodic determinations.--Beginning with
2017, and every two years thereafter, the Secretary
shall--
``(i) make a determination of the improper
payment rate for outpatient therapy services
for a 12-month period; and
``(ii) make such determination publicly
available.
``(B) Scaling back.--If the improper payment rate
for outpatient therapy services determined for a 12-
month period under subparagraph (A) is 50 percent or
less of the Medicare fee-for-service improper payment
rate for such period, the Secretary shall--
``(i) reduce the amount and extent of
medical review conducted for a prospective year
under the process established in this
subsection; and
``(ii) return an appropriate portion of the
funding provided for such year under paragraph
(11).''.
(2) GAO study and report.--
(A) Study.--The Comptroller General of the United
States shall conduct a study on the effectiveness of
medical review of outpatient therapy services under
section 1833(aa) of the Social Security Act, as added
by paragraph (2). Such study shall include an analysis
of--
(i) aggregate data on--
(I) the number of individuals,
therapy providers, and claims subject
to such review; and
(II) the number of reviews
conducted under such section; and
(ii) the outcomes of such reviews.
(B) Report.--Not later than 3 years after the date
of enactment of this Act, the Comptroller General shall
submit to Congress a report containing the results of
the study under subparagraph (A), together with
recommendations for such legislation and administrative
action as the Comptroller General determines
appropriate.
(c) Collection of Standardized Data Elements for Outpatient Therapy
Services.--
(1) Collection of standardized data elements for outpatient
therapy services.--Section 1834 of the Social Security Act (42
U.S.C. 1395m) is amended by adding at the end the following new
subsection:
``(p) Collection of Standardized Data Elements for Outpatient
Therapy Services.--
``(1) Standardized data elements.--
``(A) In general.--Not later than 6 months after
the date of enactment of this subsection, the Secretary
shall post on the Internet website of the Centers for
Medicare & Medicaid Services a draft list of
standardized data elements for individuals receiving
outpatient therapy services.
``(B) Domains.--Such standardized data elements
shall include information with respect to the following
domains, as determined appropriate by the Secretary:
``(i) Demographic information.
``(ii) Diagnosis.
``(iii) Severity.
``(iv) Affected body structures and
functions.
``(v) Limitations with activities of daily
living and participation.
``(vi) Functional status.
``(vii) Other domains determined to be
appropriate by the Secretary.
``(C) Solicitation of input.--The Secretary shall
accept comments from stakeholders through the date that
is 60 days after the date the Secretary posts the draft
list of standardized data elements pursuant to
subparagraph (A). In seeking such comments, the
Secretary shall use one or more mechanisms to solicit
input from stakeholders that may include use of open
door forums, town hall meetings, requests for
information, or other mechanisms determined appropriate
by the Secretary.
``(D) Operational list of standardized data
elements.--Not later than 120 days after the end of the
comment period described in subparagraph (C), the
Secretary, taking into account such comments, shall
post on the Internet website of the Centers for
Medicare & Medicaid Services an operational list of
standardized data elements.
``(E) Subsequent revisions.--Subsequent revisions
to the operational list of standardized data elements
shall be made through rulemaking. Such revisions may be
based on experience and input from stakeholders.
``(2) System to report standardized data elements.--
``(A) In general.--Not later than 18 months after
the date the Secretary posts the operational list of
standardized data elements pursuant to paragraph
(1)(D), the Secretary shall develop and implement an
electronic system (which may be a web portal) for
therapy providers to report the standardized data
elements for individuals with respect to outpatient
therapy services.
``(B) Consultation.--The Secretary shall seek
comments from stakeholders regarding the best way to
report the standardized data elements.
``(3) Reporting.--
``(A) Frequency of reporting.--The Secretary shall
specify the frequency of reporting standardized data
elements. The Secretary shall seek comments from
stakeholders regarding the frequency of the reporting
of such data elements.
``(B) Reporting requirement.--Beginning on the date
the system to report standardized data elements under
this subsection is operational, no payment shall be
made under this part for outpatient therapy services
furnished to an individual unless a therapy provider
reports the standardized data elements for such
individual.
``(4) Report on new payment system for outpatient therapy
services.--
``(A) In general.--Not later than 18 months after
the date described in paragraph (3)(B), the Secretary
shall submit to Congress a report on the design of a
new payment system for outpatient therapy services. The
report shall include an analysis of the standardized
data elements collected and other appropriate data and
information.
``(B) Features.--Such report shall consider--
``(i) appropriate adjustments to payment
(such as case mix and outliers);
``(ii) payments on an episode of care
basis; and
``(iii) reduced payment for multiple
episodes.
``(C) Consultation.--The Secretary shall consult
with stakeholders regarding the design of such a new
payment system.
``(5) Implementation.--
``(A) Funding.--For purposes of implementing this
subsection, the Secretary shall provide for the
transfer, from the Federal Supplementary Medical
Insurance Trust Fund under section 1841, of $7,000,000
to the Centers for Medicare & Medicaid Services Program
Management Account for each of fiscal years 2014
through 2018. Amounts transferred under this
subparagraph shall remain available until expended.
``(B) Administration.--Chapter 35 of title 44,
United States Code, shall not apply to specification of
the standardized data elements and implementation of
the system to report such standardized data elements
under this subsection.
``(C) Limitation.--There shall be no administrative
or judicial review under section 1869, section 1878, or
otherwise of the specification of standardized data
elements required under this subsection or the system
to report such standardized data elements.
``(D) Definition of outpatient therapy services and
therapy provider.--In this subsection, the terms
`outpatient therapy services' and `therapy provider'
have the meaning given those term in section
1833(aa).''.
(2) Sunset of current claims-based collection of therapy
data.--Section 3005(g)(1) of the Middle Class Tax Extension and
Job Creation Act of 2012 (42 U.S.C. 1395l note) is amended, in
the first sentence, by inserting ``and ending on the date the
system to report standardized data elements under section
1834(p) of the Social Security Act (42 U.S.C. 1395m(p)) is
implemented,'' after ``January 1, 2013,''.
(d) Reporting of Certain Information.--Section 1842(t) of the
Social Security Act (42 U.S.C. 1395u(t)) is amended by adding at the
end the following new paragraph:
``(3) Each request for payment, or bill submitted, by a therapy
provider (as defined in section 1833(aa)(10)) for an outpatient therapy
service (as defined in such section) furnished by a therapy assistant
on or after January 1, 2015, shall include (in a form and manner
specified by the Secretary) an indication that the service was
furnished by a therapy assistant.''.
SEC. 203. MEDICARE AMBULANCE SERVICES.
(a) Extension of Certain Ambulance Add-on Payments.--
(1) Ground ambulance.--Section 1834(l)(13)(A) of the Social
Security Act (42 U.S.C. 1395m(l)(13)(A)) is amended by striking
``January 1, 2014'' and inserting ``January 1, 2019'' each
place it appears.
(2) Super rural ambulance.--Section 1834(l)(12)(A) of the
Social Security Act (42 U.S.C. 1395m(l)(12)(A)) is amended, in
the first sentence, by striking ``January 1, 2014'' and
inserting ``January 1, 2019''.
(b) Requiring Ambulance Providers To Submit Cost and Other
Information.--Section 1834(l) of the Social Security Act (42 U.S.C.
1395m(l)) is amended by adding at the end the following new paragraph:
``(16) Submission of cost and other information.--
``(A) Development of data collection system.--The
Secretary shall develop a data collection system (which
may include use of a cost survey and standardized
definitions) for providers and suppliers of ambulance
services to collect cost, revenue, utilization, and
other information determined appropriate by the
Secretary. Such system shall be designed to submit
information--
``(i) needed to evaluate the
appropriateness of payment rates under this
subsection;
``(ii) on the utilization of capital
equipment and ambulance capacity; and
``(iii) on different types of ambulance
services furnished in different geographic
locations, including rural areas and low
population density areas described in paragraph
(12).
``(B) Specification of data collection system.--
``(i) In general.--Not later than January
1, 2015, the Secretary shall--
``(I) specify the data collection
system under subparagraph (A); and
``(II) identify the providers and
suppliers of ambulance services who
would be required to submit the
information under such data collection
system.
``(ii) Respondents.--Subject to
subparagraph (D)(ii), the Secretary shall
determine an appropriate sample of providers
and suppliers of ambulance services to submit
information under the data collection system
each year.
``(C) Reporting of cost information.--Beginning
July 1, 2015, a 5 percent reduction to payments under
this part shall be made for a 1-year period to a
provider or supplier of ambulance services who--
``(i) is identified under subparagraph
(B)(i)(II) as being required to submit the
information under the data collection system;
and
``(ii) does not submit such information.
``(D) Ongoing data collection.--
``(i) Revision of data collection system.--
The Secretary may revise, as the Secretary
determines appropriate, the data collection
system. The Secretary shall consult with
providers and suppliers of ambulance services
when revising such system.
``(ii) Subsequent data collection.--In
order to continue to evaluate the
appropriateness of payment rates under this
subsection, the Secretary shall require
providers and suppliers of ambulance services
to submit information for years after 2015 as
the Secretary determines appropriate, but in no
case less often than once every 3 years.
``(E) Consultation.--The Secretary shall consult
with stakeholders in carrying out the development of
the system and collection of information under this
paragraph, including the activities described in
subparagraphs (A) and (D). Such consultation shall
include the use of requests for information and other
mechanisms determined appropriate by the Secretary.
``(F) Administration.--Chapter 35 of title 44,
United States Code, shall not apply to the collection
of information required under this subsection.
``(G) Limitations on review.--There shall be no
administrative or judicial review under section 1869,
section 1878, or otherwise of the data collection
system or identification of respondents under this
paragraph.
``(H) Funding for implementation.--For purposes of
carrying out subparagraph (A), the Secretary shall
provide for the transfer, from the Federal
Supplementary Medical Insurance Trust Fund under
section 1841, of $1,000,000 to the Centers for Medicare
& Medicaid Services Program Management Account for
fiscal year 2014. Amounts transferred under this
subparagraph shall remain available until expended.''.
SEC. 204. REVISION OF THE MEDICARE-DEPENDENT HOSPITAL (MDH) PROGRAM.
(a) Permanent Extension of Payment Methodology.--
(1) In general.--Section 1886(d)(5)(G) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(G)) is amended--
(A) in clause (i), by striking ``and before October
1, 2013,''; and
(B) in clause (ii)(II), by striking ``and before
October 1, 2013,''.
(2) Conforming amendments.--
(A) Target amount.--Section 1886(b)(3)(D) of the
Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is
amended--
(i) in the matter preceding clause (i), by
striking ``and before October 1, 2013,''; and
(ii) in clause (iv), by striking ``through
fiscal year 2013'' and inserting ``or a
subsequent fiscal year''.
(B) Hospital value-based purchasing program.--
Section 1886(o)(7)(D)(ii)(I) of the Social Security Act
(42 U.S.C. 1395ww(o)(7)(D)(ii)(I)) is amended by
striking ``(with respect to discharges occurring during
fiscal year 2012 and 2013)''.
(C) Hospital readmission reduction program.--
Section 1886(q)(2)(B)(i) of the Social Security Act (42
U.S.C. 1395ww(q)(2)(B)(i)) is amended by striking
``(with respect to discharges occurring during fiscal
years 2012 and 2013)''.
(D) Permitting hospitals to decline
reclassification.--Section 13501(e)(2) of the Omnibus
Budget Reconciliation Act of 1993 (42 U.S.C. 1395ww
note) is amended by striking ``fiscal year 1998, fiscal
year 1999, or fiscal year 2000 through fiscal year
2013'' and inserting ``or fiscal year 1998 or a
subsequent fiscal year''.
(b) GAO Study and Report on Medicare-dependent Hospitals.--
(1) Study.--The Comptroller General of the United States
shall conduct a study on the following:
(A) The payor mix of medicare-dependent, small
rural hospitals (as defined in section
1886(d)(5)(G)(iv)), how such mix will trend in future
years, and whether or not the requirement under
subclause (IV) of such section should be revised.
(B) The characteristics of medicare-dependent,
small rural hospitals that meet the requirement of such
subclause (IV) through the application of paragraph
(a)(iii)(A) or (a)(iii)(B) of section 412.108 of the
Code of Federal Regulations, including Medicare
inpatient and outpatient utilization, payor mix, and
financial status, including Medicare and total margins,
and whether or not Medicare payments for such hospitals
should be revised.
(C) Such other items related to medicare-dependent,
small rural hospitals as the Comptroller General
determines appropriate.
(2) Report.--Not later than 12 months after the date of the
enactment of this Act, the Comptroller General of the United
States shall submit to Congress a report on the study conducted
under paragraph (1), together with recommendations for such
legislation and administrative action as the Comptroller
General determines appropriate.
(c) Implementation.--Notwithstanding any other provision of law,
the Secretary of Health and Human Services may implement the provisions
of, and the amendments made by, this section through program
instruction or otherwise.
SEC. 205. REVISION OF MEDICARE INPATIENT HOSPITAL PAYMENT ADJUSTMENT
FOR LOW-VOLUME HOSPITALS.
(a) In General.--Section 1886(d)(12) of the Social Security Act (42
U.S.C. 1395ww(d)(12)) is amended--
(1) in subparagraph (B)--
(A) in the subparagraph heading, by inserting ``for
fiscal years 2005 through 2010'' after ``increase'';
and
(B) in the matter preceding clause (i), by striking
``and for discharges occurring in fiscal year 2014 and
subsequent years'';
(2) in subparagraph (C)(i), by striking ``fiscal years
2011, 2012, and 2013'' and inserting ``fiscal year 2011 and
subsequent fiscal years'' each place it appears; and
(3) in subparagraph (D)--
(A) in the heading, by striking ``Temporary
applicable percentage increase'' and inserting
``Applicable percentage increase for fiscal year 2011
and subsequent fiscal years''; and
(B) by striking ``fiscal years 2011, 2012, and
2013'' and inserting ``fiscal year 2011 or a subsequent
fiscal year'';
(b) Implementation.--Notwithstanding any other provision of law,
the Secretary of Health and Human Services may implement the provisions
of, and the amendments made by, this section through program
instruction or otherwise.
SEC. 206. SPECIALIZED MEDICARE ADVANTAGE PLANS FOR SPECIAL NEEDS
INDIVIDUALS.
(a) Extension.--Section 1859(f)(1) of the Social Security Act (42
U.S.C. 1395w-28(f)(1)) is amended--
(1) by striking ``enrollment.--In the case'' and inserting
``enrollment.--
``(A) In general.--Subject to subparagraphs (B) and
(C), in the case'';
(2) in subparagraph (A), as added by paragraph (1), by
striking ``and for periods before January 1, 2015''; and
(3) by adding at the end the following new subparagraphs:
``(B) Application to dual snps.--Subparagraph (A)
shall only apply to a specialized MA plan for special
needs individuals described in subsection (b)(6)(B)(ii)
for periods before January 1, 2021.
``(C) Application to severe or disabling chronic
condition snps.--Subparagraph (A) shall only apply to a
specialized MA plan for special needs individuals
described in subsection (b)(6)(B)(iii) for periods
before January 1, 2018.''.
(b) Increased Integration of Dual SNPs.--
(1) In general.--Section 1859(f) of the Social Security Act
(42 U.S.C. 1395w-28(f)) is amended--
(A) in paragraph (3), by adding at the end the
following new subparagraph:
``(F) The plan meets the requirements applicable
under paragraph (8).''; and
(B) by adding at the end the following new
paragraph:
``(8) Increased integration of dual snps.--
``(A) Designated contact.--The Secretary, acting
through the Federal Coordinated Health Care Office
(Medicare-Medicaid Coordination Office) established
under section 2602 of the Patient Protection and
Affordable Care Act (in this paragraph referred to as
the `MMCO'), shall serve as a dedicated point of
contact for States to address misalignments that arise
with the integration of specialized MA plans for
special needs individuals described in subsection
(b)(6)(B)(ii) under this paragraph. Consistent with
such role, the MMCO shall--
``(i) establish a uniform process for
disseminating to State Medicaid agencies
information under this title impacting
contracts between such agencies and such plans
under this subsection; and
``(ii) establish basic resources for States
interested in exploring such plans as a
platform for integration.
``(B) Unified appeals process.--
``(i) In general.--Not later than April 1,
2015, the Secretary shall establish procedures
unifying the appeals procedures under sections
1852(g), 1902(a)(3), and 1902(a)(5) for items
and services provided by specialized MA plans
for special needs individuals described in
subsection (b)(6)(B)(ii) under this title and
title XIX. The Secretary shall solicit comment
in developing such procedures from States,
plans, beneficiary representatives, and other
relevant stakeholders.
``(ii) Procedures.--To the extent
compatible with a unified process, the
procedures established under clause (i) shall--
``(I) adopt the most protective
provisions for the enrollee under
current law, including continuation of
benefits under title XIX pending appeal
if an appeal is filed in a timely
manner;
``(II) take into account
differences in State plans under title
XIX;
``(III) be easily navigable by an
enrollee; and
``(IV) include the elements
described in clause (iii).
``(iii) Elements described.--The following
elements are described in this clause:
``(I) Single notification of all
applicable appeal rights under this
title and title XIX.
``(II) Notices written in plain
language and available in a language
and format that is accessible to the
enrollee.
``(III) Unified timeframes for
internal and external appeals
processes, such as an individual's
filing of appeals, a plan's
acknowledgment and resolution of
appeals, and notification of appeals
decisions.
``(IV) Mechanisms to allow the plan
to track and resolve grievances.
``(C) Requirement for unified appeals.--
``(i) In general.--For 2016 and subsequent
years, the contract of a specialized MA plan
for special needs individuals described in
subsection (b)(6)(B)(ii) with a State Medicaid
agency under this subsection shall require the
use of unified appeals procedures as described
in subparagraph (B).
``(ii) Consideration of application for
other snps.--The Secretary shall consider
applying the unified appeals process described
in subparagraph (B) to specialized MA plans for
special needs individuals described in
subsection (b)(6)(B)(i) and subsection
(b)(6)(B)(iii).
``(D) Requirement for full integration for certain
dual snps.--
``(i) Requirement.--Subject to the
succeeding provisions of this subparagraph, for
2018 and subsequent years, a specialized MA
plan for special needs individuals described in
subsection (b)(6)(B)(ii) shall--
``(I) integrate all benefits under
this title and title XIX; and
``(II) meet the requirements of a
fully integrated plan described in
section 1853(a)(1)(B)(iv)(II) (other
than the requirement that the plan have
similar average levels of frailty, as
determined by the Secretary, as the
PACE program), including with respect
to long-term care services or
behavioral health services to the
extent State law permits capitation of
those services under such plan.
``(ii) Initial sanctions for failure to
meet requirement for 2018 or 2019.--For each of
2018 and 2019, if the Secretary determines that
a plan has failed to meet the requirement
described in clause (i), the Secretary shall
impose one of the following on the plan:
``(I) A reduction in payments under
this part.
``(II) Closing enrollment in the
plan.
``(III) Sanctioning the plan in
accordance with section 1857(g).
``(IV) Other reasonable action
(other than the sanction described in
clause (iii)) the Secretary determines
appropriate.
``(iii) Sanctions for failure to meet
requirement for 2020 and subsequent years.--For
2020 and subsequent years, if the Secretary
determines that a plan has failed to meet the
requirement described in clause (i), the plan
shall be deemed to no longer meet the
definition of a specialized MA plan for special
needs individuals described in subsection
(b)(6)(B)(ii).
``(iv) Limitation.--This subparagraph shall
not apply to a specialized MA plan for special
needs individuals described in subsection
(b)(6)(B)(ii) that only enrolls individuals for
whom the only medical assistance to which the
individuals are entitled under the State plan
is medicare cost sharing described in section
1905(p)(3)(A)(ii).''.
(2) Conforming amendment to responsibilities of federal
coordinated health care office (mmco).--Section 2602(d) of the
Patient Protection and Affordable Care Act (42 U.S.C. 1315b(d))
is amended by adding at the end the following new paragraph:
``(6) To act as a designated contact for States under
subsection (f)(8)(A) of section 1859 of the Social Security Act
(42 U.S.C. 1395w-28) with respect to the integration of
specialized MA plans for special needs individuals described in
subsection (b)(6)(B)(ii) of such section.''.
(c) Improvements to Care Management Requirements for Severe or
Disabling Chronic Condition SNPs.--Section 1859(f)(5) of the Social
Security Act (42 U.S.C. 1395w-28(f)(5)) is amended--
(1) by striking ``all snps.--The requirements'' and
inserting ``all snps.--
``(A) In general.--Subject to subparagraph (B), the
requirements'';
(2) by redesignating subparagraphs (A) and (B) as clauses
(i) and (ii), respectively, and indenting appropriately;
(3) in clause (ii), as redesignated by paragraph (2), by
redesignating clauses (i) through (iii) as subclauses (I)
through (III), respectively, and indenting appropriately; and
(4) by adding at the end the following new subparagraph:
``(B) Improvements to care management requirements
for severe or disabling chronic condition snps.--For
2016 and subsequent years, in the case of a specialized
MA plan for special needs individuals described in
subsection (b)(6)(B)(iii), the requirements described
in this paragraph include the following:
``(i) The interdisciplinary team under
subparagraph (A)(ii)(III) includes a team of
providers with demonstrated expertise,
including training in an applicable specialty,
in treating individuals similar to the targeted
population of the plan.
``(ii) Requirements developed by the
Secretary to provide face-to-face encounters
with individuals enrolled in the plan.
``(iii) As part of the model of care under
clause (i) of subparagraph (A), the results of
the initial assessment and annual reassessment
under clause (ii)(I) of such subparagraph of
each individual enrolled in the plan are
addressed in the individual's individualized
care plan under clause (ii)(II) of such
subparagraph.
``(iv) As part of the annual evaluation and
approval of such model of care, the Secretary
shall take into account whether the plan
fulfilled the previous year's goals (as
required under the model of care).
``(v) The Secretary shall establish a
minimum benchmark for each element of the model
of care of a plan. The Secretary shall only
approve a plan's model of care under this
paragraph if each element of the model of care
meets the minimum benchmark applicable under
the preceding sentence.''.
(d) GAO Study on Quality Improvement.--
(1) Study.--The Comptroller General of the United States
shall conduct a study on how the Secretary of Health and Human
Services could change the quality measurement system under the
Medicare Advantage program under part C of title XVIII of the
Social Security Act (42 U.S.C. 1395w-21 et seq.) to allow an
accurate comparison of the quality of care provided by
specialized MA plans for special needs individuals (as defined
in section 1859(b)(6) of such Act (42 U.S.C. 1395w-28(b)(6)),
both for individual plans and such plans overall, compared to
the quality of care delivered by the original Medicare fee-for-
service program under parts A and B of such title and other
Medicare Advantage plans under such part C across similar
populations.
(2) Report.--Not later than July 1, 2016, the Comptroller
General shall submit to Congress a report containing the
results of the study under paragraph (1), together with
recommendations for such legislation and administrative action
as the Comptroller General determines appropriate.
(e) Changes to Quality Ratings and Measurement of SNPs.--Section
1853(o) of the Social Security Act (42 U.S.C. 1395w-23(o)) is amended
by adding at the end the following new paragraph:
``(6) Changes to quality ratings of snps.--
``(A) Emphasis on improvement across snps.--Subject
to subparagraph (B), beginning in plan year 2016, in
the case of a specialized MA plan for special needs
individuals, the Secretary shall increase the emphasis
on the plan's improvement or decline in performance
when determining the star rating of the plan under this
subsection for the year as follows:
``(i) At least 25 percent, but not more
than 33 percent, of the total star rating of
the plan shall be based on improvement or
decline in performance.
``(ii) Improvement or decline in
performance under this subparagraph shall be
measured based on net change in the individual
star rating measures of the plan, with
appropriate weight given to specific individual
star ratings measures, such as readmission
rates, as determined by the Secretary.
``(iii) The Secretary shall make an
appropriate adjustment to the improvement
rating of a plan under this subparagraph if the
plan has achieved a 5-star rating or the
highest rating possible overall or for an
individual measure in order to ensure that the
plan is not punished in cases where it is not
possible to improve.
``(B) No application to certain plans.--
Subparagraph (A) shall not apply, with respect to a
year, to a specialized MA plan for special needs
individuals that has a rating that does not exceed two-
and-one-half stars.
``(C) Quality measurement at the plan level.--
``(i) In general.--The Secretary may
require reporting for and apply under this
subsection quality measures at the plan level
for specialized MA plan for special needs
individuals instead of at the contract level.
``(ii) Consideration.--The Secretary shall
take into consideration the minimum number of
enrollees in a specialized MA plan for special
needs individuals in order to determine if a
valid measurement of quality at the plan level
is possible under clause (i).
``(iii) Application.--If the Secretary
applies quality measurement at the plan level
under this subparagraph--
``(I) such quality measurement
shall include Medicare Health Outcomes
Survey (HOS), Healthcare Effectiveness
Data and Information Set (HEDIS), and
Consumer Assessment of Healthcare
Providers and Systems (CAHPS) measures;
and
``(II) payment and other
administrative actions linked to
quality measurement (including the 5-
star rating system under this
subsection) shall be applied at the
plan level in accordance with this
subparagraph.''.
SEC. 207. REASONABLE COST REIMBURSEMENT CONTRACTS.
(a) One-year Transition and Notice Regarding Transition.--Section
1876(h)(5)(C) of the Social Security Act (42 U.S.C. 1395mm(h)(5)(C)) is
amended--
(1) in clause (ii), in the matter preceding subclause (I),
by striking ``For any'' and inserting ``Subject to clause (iv),
for any''; and
(2) by adding at the end the following new clauses:
``(iv) In the case of an eligible organization that is offering a
reasonable cost reimbursement contract that may no longer be extended
or renewed because of the application of clause (ii)--
``(I) notwithstanding such clause, such contract may be
extended or renewed for one last reasonable cost reimbursement
contract year;
``(II) the organization may not enroll any new enrollees
under such contract during such last reasonable cost
reimbursement contract year; and
``(III) on a date determined by the Secretary prior to the
beginning of such last reasonable cost reimbursement contract
year, the organization shall provide notice to the Secretary as
to whether or not the organization will apply to have the
contract converted over and offered as a Medicare Advantage
plan under part C for the year following such last reasonable
cost reimbursement contract year.
``(v) If an eligible organization that is offering a reasonable
cost reimbursement contract that is extended or renewed pursuant to
clause (iv) provides the notice described in clause (iv)(III) that the
contract will be converted--
``(I) the deemed enrollment under section 1851(c)(4) shall
apply; and
``(II) the special rule for quality increases under
1853(o)(3)(A)(iv) shall apply.''.
(b) Deemed Enrollment From Reasonable Cost Reimbursement Contracts
Converted to Medicare Advantage Plans.--
(1) In general.--Section 1851(c) of the Social Security Act
(42 U.S.C. 1395w-21(c)) is amended--
(A) in paragraph (1), by striking ``Such
elections'' and inserting ``Subject to paragraph (4),
such elections''; and
(B) by adding at the end the following:
``(4) Deemed enrollment relating to converted reasonable
cost reimbursement contracts.--
``(A) In general.--On the first day of the annual,
coordinated election period under subsection (e)(3) for
plan years beginning on or after January 1, 2016, an MA
eligible individual described in clause (i) or (ii) of
subparagraph (B) is deemed to have elected to receive
benefits under this title through an applicable MA plan
(and shall be enrolled in such plan) beginning with
such plan year, if--
``(i) the individual is enrolled in a
reasonable cost reimbursement contract under
section 1876(h) in the previous plan year;
``(ii) such reasonable cost reimbursement
contract was extended or renewed for one last
reasonable cost reimbursement contract year
pursuant to section 1876(h)(5)(C)(iv);
``(iii) the eligible organization that is
offering such reasonable cost reimbursement
contract provided the notice described in
subclause (III) of such section that the
contract was to be converted;
``(iv) the applicable MA plan--
``(I) is the plan that was
converted from the reasonable cost
reimbursement contract described in
clause (iii);
``(II) is offered by the same
entity (or an organization affiliated
with such entity) that entered into
such contract; and
``(III) is offered in the service
area where the individual resides;
``(v) the amount of the MA monthly basic
beneficiary premium for such applicable MA plan
with respect to the plan year does not exceed
monthly premiums under such reasonable cost
reimbursement contract for the previous plan
year by more than 10 percent;
``(vi) the applicable MA plan provides
benefits, premiums, and access to providers
that are comparable to the benefits, premiums,
and access to providers under such reasonable
cost reimbursement contract for the previous
plan year; and
``(vii) the applicable MA plan--
``(I) allows enrollees
transitioning from the converted
reasonable cost contract to such plan
to maintain current providers and
course of treatment at the time of
enrollment for at least 90 days after
enrollment; and
``(II) during such period, pays
non-contracting providers for items and
services furnished to the enrollee an
amount that is not less than the amount
of payment applicable for those items
and services under the original
medicare fee-for-service program under
parts A and B.
``(B) MA eligible individuals described.--
``(i) Without prescription drug coverage.--
An MA eligible individual described in this
clause, with respect to a plan year, is an MA
eligible individual who is enrolled in a
reasonable cost reimbursement contract under
section 1876(h) in the previous plan year and
who does not, for such previous plan year,
receive any prescription drug coverage under
part D, including coverage under section 1860D-
22.
``(ii) With prescription drug coverage.--An
MA eligible individual described in this
clause, with respect to a plan year, is an MA
eligible individual who is enrolled in a
reasonable cost reimbursement contract under
section 1876(h) in the previous plan year and
who, for such previous plan year, receives
prescription drug coverage under part D--
``(I) through such contract; or
``(II) through a prescription drug
plan, if the sponsor of such plan is
the same entity (or an organization
affiliated with such entity) that
entered into such contract.
``(C) Applicable ma plan defined.--In this
paragraph, the term `applicable MA plan' means, in the
case of an individual described in--
``(i) subparagraph (B)(i), an MA plan that
is not an MA-PD plan; and
``(ii) subparagraph (B)(ii), an MA-PD plan.
``(D) Identification of deemed individuals.--Not
later than 30 days before the first day of the annual,
coordinated election period under subsection (e)(3) for
plan years beginning on or after January 1, 2016, the
Secretary shall identify the individuals who will be
subject to deemed elections under subparagraph (A) on
the first day of such period.''.
(2) Beneficiary option to discontinue or change ma plan or
ma-pd plan after deemed enrollment.--
(A) In general.--Section 1851(e)(2) of the Social
Security Act (42 U.S.C. 1395w-21(e)(4)) is amended by
adding at the end the following:
``(F) Special period for certain deemed
elections.--
``(i) In general.--At any time during the
period beginning after the last day of the
annual, coordinated election period under
paragraph (3) in which an individual is deemed
to have elected to enroll in an MA plan or MA-
PD plan under subsection (c)(4) and ending on
the last day of February of the first plan year
for which the individual is enrolled in such
plan, such individual may change the election
under subsection (a)(1) (including changing the
MA plan or MA-PD plan in which the individual
is enrolled).
``(ii) Limitation of one change.--An
individual may exercise the right under clause
(i) only once during the applicable period
described in such clause. The limitation under
this clause shall not apply to changes in
elections effected during an annual,
coordinated election period under paragraph (3)
or during a special enrollment period under
paragraph (4).''.
(B) Conforming amendments.--
(i) Plan requirement for open enrollment.--
Section 1851(e)(6)(A) of the Social Security
Act (42 U.S.C. 1395w-21(e)(6)(A)) is amended by
striking ``paragraph (1),'' and inserting
``paragraph (1), during the period described in
paragraph (2)(F),''.
(ii) Part d.--Section 1860D-1(b)(1)(B) of
such Act (42 U.S.C. 1395w-101(b)(1)(B)) is
amended--
(I) in clause (ii), by adding ``and
paragraph (4)'' after ``paragraph
(3)(A)''; and
(II) in clause (iii) by striking
``and (E)'' and inserting ``(E), and
(F)''.
(3) Treatment of esrd for deemed enrollment.--Section
1851(a)(3)(B) of the Social Security Act (42 U.S.C. 1395w-
21(a)(3)(B)) is amended by adding at the end the following
flush sentence:
``An individual who develops end-stage renal disease
while enrolled in a reasonable cost reimbursement
contract under section 1876(h) shall be treated as an
MA eligible individual for purposes of applying the
deemed enrollment under subsection (c)(4).''.
(c) Information Requirements.--Section 1851(d)(2)(B) of the Social
Security Act (42 U.S.C. 1395w-21(d)(2)(B)) is amended--
(1) by striking the subparagraph heading and inserting the
following: ``(i) notification to newly eligible medicare
advantage eligible individuals.--''; and
(2) by adding at the end the following:
``(ii) Notification related to certain deemed
elections.--The Secretary shall, not later than 15 days
prior to the first day of the annual, coordinated
election period under subsection (e)(3) of a year, mail
to any individual identified by the Secretary under
subsection (c)(4)(D) for such year--
``(I) a notification that such individual
will, on such day, be deemed to have made an
election to receive benefits under this title
through an MA plan or MA-PD plan (and shall be
enrolled in such plan) for the next plan year
under subsection (c)(4)(A), but that the
individual may make a different election during
the annual, coordinated election period for
such year;
``(II) the information described in
subparagraph (A);
``(III) a description of the differences
between such MA plan or MA-PD plan and the
reasonable cost reimbursement contract in which
the individual was most recently enrolled with
respect to benefits covered under such plans,
including cost-sharing, premiums, drug
coverage, and provider networks; and
``(IV) information about the special period
for elections under subsection (e)(2)(F).''.
(d) Treatment of Transition Plan for Quality Rating for Payment
Purposes.--Section 1853(o)(3)(A) of the Social Security Act (42 U.S.C.
1395w-23(o)(3)(A)) is amended by adding at the end the following new
clause:
``(iv) Special rule for first 2 plan years
for plans that were converted from a reasonable
cost reimbursement contract.--In applying
paragraph (1) for the first 2 plan years under
this part in the case of a plan that is a new
MA plan (as defined in clause (iii)(II)) to
which deemed enrollment applies under section
1851(e)(4), the Secretary shall use the star
rating that applied to the converted reasonable
cost reimbursement contract for the year
preceding the first plan year for such plan
under this part.''.
SEC. 208. QUALITY MEASURE ENDORSEMENT AND SELECTION.
(a) Contract With an Entity Regarding Input on the Selection of
Measures.--
(1) In general.--Title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) is amended--
(A) by redesignating section 1890A as section
1890B; and
(B) by inserting after section 1890 the following
new section:
``contract with an entity regarding input on the selection of measures
``Sec. 1890A (a) Contract.--
``(1) In general.--For purposes of activities conducted
under this Act, the Secretary shall identify and have in effect
a contract with an entity that meets the requirements described
in subsection (c). Such contract shall provide that the entity
will perform the duties described in subsection (b).
``(2) Timing for first contract.--The first contract under
paragraph (1) shall begin on October 1, 2014.
``(3) Period of contract.--A contract under paragraph (1)
shall be for a period of 3 years (except as may be renewed
after a subsequent bidding process).
``(4) Competitive procedures.--Competitive procedures (as
defined in section 4(5) of the Office of Federal Procurement
Policy Act (41 U.S.C. 403(5))) shall be used to enter into a
contract under paragraph (1).
``(b) Duties.--The duties described in this subsection are the
following:
``(c) Requirements Described.--The requirements described in this
subsection are the following:
``(1) Private nonprofit, board membership, membership fees,
and not a measure developer.--The requirements described in
paragraphs (1), (2), (7), and (8) of section 1890(c).
``(2) Experience.--The entity has at least 4 years of
experience working with quality and efficiency measures.''.
(2) Duties of entity.--
(A) Transfer of priority setting process.--
Paragraph (1) of section 1890(b) of the Social Security
Act (42 U.S.C. 1395aaa(b)) is redesignated as paragraph
(1) of section 1890A(b) of such Act, as added by
paragraph (1).
(B) Transfer of multi-stakeholder process.--
Paragraphs (7) and (8) of such section 1890(b) are
redesignated as paragraphs (2) and (3), respectively,
of section 1890A(b) of such Act, as added by paragraph
(1) and amended by subparagraph (A).
(C) Additional duties.--Section 1890A(b) of such
Act, as added by paragraph (1) and amended by
subparagraphs (A) and (B), is amended by adding at the
end the following new paragraphs:
``(4) Facilitation to better coordinate and align public
and private sector use of quality measures.--
``(A) In general.--The entity shall facilitate
increased coordination and alignment between the public
and private sector with respect to quality and
efficiency measures.
``(B) Reports.--The entity shall prepare and make
available to the public annual reports on its findings
under this paragraph. Such public availability shall
include posting each report on the Internet website of
the entity.
``(5) Gap analysis.--The entity shall conduct an ongoing
analysis of--
``(A) gaps in endorsed quality and efficiency
measures, which shall include measures that are within
priority areas identified by the Secretary under the
national strategy established under section 399HH of
the Public Health Service Act; and
``(B) areas where quality measures are unavailable
or inadequate to identify or address such gaps.
``(6) Annual report to congress and the secretary;
secretarial publication and comment.--
``(A) Annual report.--By not later than March 1 of
each year, the entity shall submit to Congress and the
Secretary a report containing--
``(i) a description of--
``(I) the recommendations made
under paragraph (1);
``(II) the matters described in
clauses (i) and (ii) of paragraph
(2)(A);
``(III) the results of the analysis
under paragraph (5); and
``(IV) the performance by the
entity of the duties required under the
contract entered into with the
Secretary under subsection (a); and
``(ii) any other items determined
appropriate by the Secretary.
``(B) Secretarial review and publication of annual
report.--Not later than 6 months after receiving a
report under subparagraph (A) for a year, the Secretary
shall--
``(i) review such report; and
``(ii) publish such report in the Federal
Register, together with any comments of the
Secretary on such report.''.
(D) Additional amendments.--Section 1890A(b) of
such Act, as so added and amended, is amended--
(i) in paragraph (2)--
(I) in the heading of subparagraph
(B) by inserting ``and efficiency''
after ``Quality'';
(II) in subparagraph (B)(i)(III),
by striking ``this Act'' and inserting
``this title''; and
(III) by adding at the end the
following new subparagraphs:
``(E) Input.--In providing the input described in
subparagraph (A), the multi-stakeholder groups--
``(i) shall include a detailed description
of the rationale for each recommendation made
by the multi-stakeholder group, including in
areas relating to--
``(I) the expected impact that
implementing the measure will have on
individuals;
``(II) the burden on providers of
services and suppliers;
``(III) the expected influence over
the behavior of providers of services
and suppliers;
``(IV) the applicability of a
measure for more than one setting or
program; and
``(V) other areas determined in
consultation with the Secretary; and
``(ii) may consider whether it is
appropriate to provide separate recommendations
with respect to measures for internal use,
public reporting, and payment provisions.
``(F) Equal representation.--In convening multi-
stakeholder groups pursuant to this paragraph, the
entity shall, to the extent feasible, make every effort
to ensure such groups are balanced across
stakeholders.''; and
(ii) in paragraph (3), by striking ``Not
later'' and all that follows through the period
at the end and inserting the following: ``Not
later than the applicable dates described in
section 1890B(a)(3) of each year (or, as
applicable, the timeframe described in section
1890A(a)(4)), the entity shall transmit to the
Secretary the input of the multi-stakeholder
group under paragraph (2).''.
(b) Revisions to Contract With Consensus-based Entity.--
(1) Contract.--Section 1890(a) of the Social Security Act
(42 U.S.C. 1395aaa(a)) is amended--
(A) in paragraph (1), by striking ``, such as the
National Quality Forum,''; and
(B) in paragraph (3), by striking ``4 years'' and
inserting ``3 years''.
(2) Duties.--Section 1890(b) of the Social Security Act (42
U.S.C. 1395aaa(b)), as amended by subsection (a)(2), is
amended--
(A) by redesignating paragraphs (2) and (3) as
paragraphs (1) and (2), respectively;
(B) in paragraph (2), as redesignated by
subparagraph (A), by striking ``paragraph (2)'' and
inserting ``paragraph (1)'';
(C) by striking paragraphs (5) and (6); and
(D) by adding at the end the following new
paragraphs:
``(3) Facilitation to better coordinate and align public
and private sector use of quality measures.--
``(A) In general.--The entity shall facilitate
increased coordination and alignment between the public
and private sector with respect to quality and
efficiency measures.
``(B) Reports.--The entity shall prepare and make
available to the public annual reports on its findings
under this paragraph. Such public availability shall
include posting each report on the Internet website of
the entity.
``(4) Annual report to congress and the secretary;
secretarial publication and comment.--
``(A) Annual report.--By not later than March 1 of
each year, the entity shall submit to Congress and the
Secretary a report containing--
``(i) a description of--
``(I) the coordination of quality
initiatives under this Act with quality
initiatives implemented by other
payers;
``(II) areas in which evidence is
insufficient to support endorsement of
quality measures in priority areas
identified by the Secretary under the
national strategy established under
section 399HH of the Public Health
Service Act and where targeted research
may address such gaps; and
``(III) the performance by the
entity of the duties required under the
contract entered into with the
Secretary under subsection (a); and
``(ii) any other items determined
appropriate by the Secretary.
``(B) Secretarial review and publication of annual
report.--Not later than 6 months after receiving a
report under subparagraph (A) for a year, the Secretary
shall--
``(i) review such report; and
``(ii) publish such report in the Federal
Register, together with any comments of the
Secretary on such report.''.
(3) Requirements.--Section 1890(c) of the Social Security
Act (42 U.S.C. 1395aaa(c)) is amended by adding at the end the
following new paragraph:
``(8) Not a measure developer.--The entity is not a measure
developer.''.
(c) Revisions to Duties of the Secretary Regarding Use of
Measures.--
(1) In general.--Section 1890B(a) of the Social Security
Act (42 U.S.C. 1395aaa-1(a)), as redesignated by subsection
(a)(1)(A), is amended--
(A) by striking ``section 1890(b)(7)(B)'' each
place it appears and inserting ``section
1890A(b)(2)(B)'';
(B) in paragraph (1)--
(i) by striking ``section 1890(b)(7)'' and
inserting ``section 1890A(b)(2)''; and
(ii) by striking ``section 1890'' and
inserting ``section 1890A'';
(C) by striking paragraphs (2) and (3) and
inserting the following:
``(2) Public availability of measures considered for
selection.--Subject to paragraph (4), not later than October 1
or December 31 of each year, the Secretary shall make available
to the public a list of quality and efficiency measures
described in section 1890A(b)(2)(B) that the Secretary is
considering under this title. The Secretary shall provide for
an appropriate balance of the number of measures to be made
available by each such date in a year.
``(3) Transmission of multi-stakeholder input.--
``(A) In general.--Subject to paragraph (4), not
later than the applicable date described in
subparagraph (B) of each year, the entity with a
contract under section 1890A shall, pursuant to
subsection (b)(3) of such section, transmit to the
Secretary the input of multi-stakeholder groups
described in paragraph (1).
``(B) Applicable date described.--The applicable
date described in this subparagraph for a year is--
``(i) February 1 with respect to quality
and efficiency measures made available under
paragraph (2) by October 1 of the preceding
year; and
``(ii) April 1 with respect to quality and
efficiency measures made available under
paragraph (2) by December 31 of the preceding
year.'';
(D) by redesignating--
(i) paragraph (6) as paragraph (8); and
(ii) paragraphs (4) and (5) as paragraphs
(5) and (6), respectively;
(E) by inserting after paragraph (3) the following
new paragraph:
``(4) Limited process for additional multi-stakeholder
input.--In addition to the Secretary making measures publically
available pursuant to the dates described in paragraph (2) and
multi-stakeholder groups transmitting the input pursuant to the
applicable dates described in paragraph (3)--
``(A) the Secretary may, at times that do not meet
the time requirements described in paragraph (2), make
available to the public a limited number of quality and
efficiency measures described in section 1890A(b)(2)
that the Secretary is considering under this title; and
``(B) if the Secretary uses the authority under
subparagraph (A), the entity with a contract under
section 1890A shall, pursuant to section 1890A(b)(3),
transmit to the Secretary on a timely basis the input
from a multi-stakeholder group described in paragraph
(1) with respect to such measures.'';
(F) in paragraph (6), as redesignated by
subparagraph (D)(ii), by inserting ``or that has not
been recommended by the multi-stakeholder group under
section 1890A(b)(2)'' before the period at the end; and
(G) by inserting after paragraph (6) the following
new paragraph:
``(7) Concordance rates.--For each year (beginning with
2015), the Secretary shall include a list of concordance rates
for each type of provider of services and supplier in the
annual final rule applicable to such type of provider or
supplier.''.
(2) Review.--Section 1890B(c) of the Social Security Act
(42 U.S.C. 1395aaa-1(c)), as redesignated by subsection
(a)(1)(A), is amended--
(A) in paragraph (1)(A), by striking ``section
1890(b)(7)(B)'' and inserting ``section
1890A(b)(2)(B)''; and
(B) in paragraph (2)--
(i) in subparagraph (A), by striking
``and'' at the end;
(ii) in subparagraph (B), by striking the
period at the end and inserting ``; and''; and
(iii) by adding at the end the following
new subparagraph:
``(C) take into consideration the benefits of the
alignment of measures between the public and private
sector.''.
(d) Funding for Quality Measure Endorsement and Selection.--
(1) Fiscal year 2014.--In addition to amounts transferred
under section 3014(c) of the Patient Protection and Affordable
Care Act (Public Law 111-148), for purposes of carrying out
section 1890 and section 1890A (other than subsections (e) and
(f)), the Secretary shall provide for the transfer, from the
Federal Hospital Insurance Trust Fund under section 1817 and
the Federal Supplementary Medical Insurance Trust Fund under
section 1841, in such proportion as the Secretary determines
appropriate, to the Centers for Medicare & Medicaid Services
Program Management Account of $7,000,000 for fiscal year 2014.
Amounts transferred under the preceding sentence shall remain
available until expended.
(2) Fiscal years 2015 through 2017.--Section 1890B of the
Social Security Act (42 U.S.C. 1395aaa-1), as redesignated by
subsection (a)(1)(A), is amended by adding at the end the
following new subsection:
``(g) Funding.--
``(1) In general.--For purposes of carrying out this
section (other than subsections (e) and (f)) and sections 1890
and 1890A, the Secretary shall provide for the transfer, from
the Federal Hospital Insurance Trust Fund under section 1817
and the Federal Supplementary Medical Insurance Trust Fund
under section 1841, in such proportion as the Secretary
determines appropriate, to the Centers for Medicare & Medicaid
Services Program Management Account of $25,000,000 for each of
fiscal years 2015 through 2017.
``(2) Availability.--Amounts transferred under paragraph
(1) shall remain available until expended.''.
(3) Conforming amendment.--Subsection (d) of section 1890
of the Social Security Act (42 U.S.C. 1395aaa) is repealed.
(e) Conforming Amendments.--(1) Section 1848(m)(3)(E)(iii) of the
Social Security Act (42 U.S.C. 1395w-4(m)(3)(E)(iii)) is amended by
striking ``section 1890(b)(7) and 1890A(a)'' and inserting ``section
1890A(b)(2) and 1890B(a)''.
(2) Section 1866D(b)(2)(C) of the Social Security Act (42 U.S.C.
1395cc-4(b)(2)(C)) is amended by striking ``section 1890 and 1890A''
and inserting ``sections 1890, 1890A, and 1890B''.
(3) Section 1899A(n)(2)(A) of the Social Security Act (42 U.S.C.
1395cc-4(n)(2)(A)) is amended by striking ``section 1890(b)(7)(B)'' and
inserting ``section 1890A(b)(2)(B)''.
(f) Effective Date.--
(1) In general.--The amendments made by this section shall
take effect on October 1, 2014, and shall apply with respect to
contract periods under sections 1890 and 1890A of the Social
Security Act that begin on or after such date.
(2) New contracts beginning with fiscal year 2015.--The
Secretary of Health and Human Services shall enter into a new
contract under both sections 1890 and 1890A of the Social
Security Act, as amended by this Act, for a contract period
beginning on October 1, 2014.
SEC. 209. PERMANENT EXTENSION OF FUNDING OUTREACH AND ASSISTANCE FOR
LOW-INCOME PROGRAMS.
(a) Additional Funding for State Health Insurance Programs.--
Subsection (a)(1)(B)(iii) of section 119 of the Medicare Improvements
for Patients and Providers Act of 2008 (42 U.S.C. 1395b-3 note), as
amended by section 3306 of the Patient Protection and Affordable Care
Act (Public Law 111-148) and section 610 of the American Taxpayer
Relief Act of 2012 (Public Law 112-240), is amended by inserting ``and
for each subsequent fiscal year'' after ``fiscal year 2013''.
(b) Additional Funding for Area Agencies on Aging.--Subsection
(b)(1)(B) of such section 119, as so amended, is amended by inserting
``and for each subsequent fiscal year'' after ``fiscal year 2013''.
(c) Additional Funding for Aging and Disability Resource Centers.--
Subsection (c)(1)(B) of such section 119, as so amended, is amended by
inserting ``and for each subsequent fiscal year'' after ``fiscal year
2013''.
(d) Additional Funding for Contract With the National Center for
Benefits and Outreach Enrollment.--Subsection (d)(2) of such section
119, as so amended, is amended by inserting ``and for each subsequent
fiscal year'' after ``fiscal year 2013''.
Subtitle B--Medicaid and Other Extensions
SEC. 211. QUALIFYING INDIVIDUAL PROGRAM.
(a) Extension.--Section 1902(a)(10)(E)(iv) of the Social Security
Act (42 U.S.C. 1396a(a)(10)(E)(iv)) is amended by striking ``December
2013'' and inserting ``December 2018''.
(b) Eliminating Limitations on Eligibility.--Section 1933 of the
Social Security Act (42 U.S.C. 1396u-3) is amended by striking
subsections (b) and (e).
(c) Eliminating Allocations.--Section 1933 of the Social Security
Act (42 U.S.C. 1396u-3) is amended by striking subsections (c) and (g).
(d) Conforming Amendments.--
(1) In general.--Section 1933 of the Social Security Act
(42 U.S.C. 1396u-3), as amended by subsections (b) and (c), is
further amended--
(A) by striking subsection (a) and inserting the
following new subsection:
``(a) Applicable FMAP.--With respect to assistance described in
section 1902(a)(10)(E)(iv) furnished in a State, the Federal medical
assistance percentage shall be equal to 100 percent.'';
(B) by striking subsection (d); and
(C) by redesignating subsection (f) as subsection
(b).
(2) Definition of fmap.--Section 1905(b) of the Social
Security Act (42 U.S.C. 1396d(b)) is amended by striking
``section 1933(d)'' and inserting ``section 1933(a)''.
(e) Effective Date.--The amendments made by this section shall take
effect on January 1, 2014, and shall apply with respect to calendar
quarters beginning on or after such date.
SEC. 212. TRANSITIONAL MEDICAL ASSISTANCE.
(a) Extension.--Sections 1902(e)(1)(B) and 1925(f) of the Social
Security Act (42 U.S.C. 1396a(e)(1)(B), 1396r-6(f)) are each amended by
striking ``December 31, 2013'' and inserting ``December 31, 2018''.
(b) Opt-out Option for States That Expand Adult Coverage and
Provide 12-month Continuous Eligibility Under Medicaid and CHIP.--
(1) In general.--Section 1925 of the Social Security Act
(42 U.S.C. 1396r-6), as amended by subsection (a), is further
amended--
(A) in subsection (a)--
(i) in paragraph (1)(A), by striking
``paragraph (5)'' and inserting ``paragraphs
(5) and (6)''; and
(ii) by adding at the end the following:
``(6) Opt-out option for states that expand adult coverage
and provide 12-month continuous eligibility under medicaid and
chip.--
``(A) In general.--In the case of a State described
in subparagraph (B), the State may elect through a
State plan amendment to have this section and sections
408(a)(11)(A), 1902(a)(52), 1902(e)(1), and 1931(c)(2)
not apply to the State.
``(B) State described.--A State is described in
this subparagraph if the State is one of the 50 States
or the District of Columbia and--
``(i) has elected to provide medical
assistance to individuals under subclause
(VIII) of section 1902(a)(10)(A)(i);
``(ii) has elected under section
1902(e)(12)(A) the option to provide continuous
eligibility for a 12-month period for
individuals under 19 years of age;
``(iii) has elected under section
1902(e)(12)(B) the option to provide continuous
eligibility for a 12-month period for all
categories of individuals described in that
section; and
``(iv) has elected to apply section
1902(e)(12)(A) to the State child health plan
under title XXI.''; and
(B) in subsection (b)(1), by striking ``subsection
(a)(5)'' and inserting ``paragraphs (5) and (6) of
subsection (a)''.
(2) Conforming amendment to 4-month requirement.--Section
1902(e)(1) of the Social Security Act (42 U.S.C. 1396a(e)(1)),
as amended by subsection (a), is further amended--
(A) in subparagraph (B), by striking ``Subparagraph
(A)'' and inserting ``Subject to subparagraph (C),
subparagraph (A)''; and
(B) by adding at the end the following:
``(C) If a State has made an election under section 1925(a)(6),
subparagraph (A) and section 1925 shall not apply to the State.''.
(c) Extension of 12-month Continuous Eligibility Option to Certain
Adult Enrollees Under Medicaid; Clarification of Application to CHIP.--
(1) In general.--Section 1902(e)(12) of the Social Security
Act (42 U.S.C. 1396a(e)(12)) is amended--
(A) by redesignating subparagraphs (A) and (B) as
clauses (i) and (ii), respectively;
(B) by inserting ``(A)'' after ``(12)''; and
(C) by adding at the end the following:
``(B) At the option of the State, the plan may provide that an
individual who is determined to be eligible for benefits under a State
plan approved under this title under any of the following eligibility
categories, or who is redetermined to be eligible for such benefits
under any of such categories, shall be considered to meet the
eligibility requirements met on the date of application and shall
remain eligible for those benefits until the end of the 12-month period
following the date of the determination or redetermination of
eligibility:
``(i) Section 1902(a)(10)(A)(i)(VIII).
``(ii) Section 1931.''.
(2) Application to chip.--Section 2107(e)(1) of the Social
Security Act (42 U.S.C. 1397gg(e)(1)) is amended--
(A) by redesignating subparagraphs (E) through (O)
as subparagraphs (F) through (P), respectively; and
(B) by inserting after subparagraph (D), the
following:
``(E) Section 1902(e)(12)(A) (relating to the State
option for 12-month continuous eligibility and
enrollment).''.
(d) Conforming and Technical Amendments Relating to Section 1931
Transitional Coverage Requirements.--
(1) In general.--Section 1931(c) of the Social Security Act
(42 U.S.C. 1396u-1(c)) is amended--
(A) in paragraph (1)--
(i) in the paragraph heading, by striking
``child'' and inserting ``spousal'';
(ii) by striking ``The provisions'' and
inserting ``Subject to paragraph (3), the
provisions''; and
(iii) by striking ``child or'';
(B) in paragraph (2), by striking ``For continued''
and inserting ``Subject to paragraph (3), for
continued''; and
(C) by adding at the end the following:
``(3) Opt-out option for states that expand adult coverage
and provide 12-month continuous eligibility under medicaid and
chip.--
``(A) In general.--In the case of a State described
in subparagraph (B), the State may elect through a
State plan amendment to have paragraphs (1) and (2) of
this subsection and sections 408(a)(11), 1902(a)(52),
1902(e)(1), and 1925 not apply to the State.
``(B) State described.--A State is described in
this subparagraph if the State is one of the 50 States
or the District of Columbia and--
``(i) has elected to provide medical
assistance to individuals under subclause
(VIII) of section 1902(a)(10)(A)(i);
``(ii) has elected under section
1902(e)(12)(A) the option to provide continuous
eligibility for a 12-month period for
individuals under 19 years of age;
``(iii) has elected under section
1902(e)(12)(B) the option to provide continuous
eligibility for a 12-month period for all
categories of individuals described in that
section; and
``(iv) has elected to apply section
1902(e)(12)(A) to the State child health plan
under title XXI.''.
(2) Conforming amendment to section 408.--Section
408(a)(11) of the Social Security Act (42 U.S.C. 608(a)(11) is
amended--
(A) in the paragraph heading, by striking ``child''
and inserting ``spousal''; and
(B) in subparagraph (B)--
(i) in the subparagraph heading, by
striking ``Child'' and inserting ``Spousal'';
and
(ii) by striking ``child or''.
(e) Conforming Amendment Relating to Maintenance of Effort for
Children.--Section 1902(gg)(4) of the Social Security Act (42 U.S.C.
1396a(gg)(4)) is amended by adding at the end the following:
``(C) States that expand adult coverage and elect
to opt-out of transitional coverage.--
``(i) In general.--For purposes of
determining compliance with the requirements of
paragraph (2), a State which exercises the
option under sections 1925(a)(6) and 1931(c)(3)
to provide no transitional medical assistance
or other extended eligibility (as applicable)
shall not, as a result of exercising such
option, be considered to have in effect
eligibility standards, methodologies, or
procedures described in clause (ii) that are
more restrictive than the standards,
methodologies, or procedures in effect under
the State plan or under a waiver of the plan on
the date of enactment of the Patient Protection
and Affordable Care Act.
``(ii) Standards, methodologies, or
procedures described.--The eligibility
standards, methodologies, or procedures
described in this clause are those standards,
methodologies, or procedures applicable to
determining the eligibility for medical
assistance of any child under 19 years of age
(or such higher age as the State may have
elected).''.
(f) Effective Date.--The amendments made by this section shall take
effect on January 1, 2014.
SEC. 213. EXPRESS LANE ELIGIBILITY.
Section 1902(e)(13)(I) of the Social Security Act (42 U.S.C.
1396a(e)(13)(I)) is amended by striking ``September 30, 2014'' and
inserting ``September 30, 2015''.
SEC. 214. PEDIATRIC QUALITY MEASURES.
(a) Continuation of Funding for Pediatric Quality Measures for
Improving the Quality of Children's Health Care.--Section 1139B(e) of
the Social Security Act (42 U.S.C. 1320b-9b(e)) is amended by adding at
the end the following: ``Of the funds appropriated under this
subsection, not less than $15,000,000 shall be used to carry out
section 1139A(b).''.
(b) Elimination of Restriction on Medicaid Quality Measurement
Program.--Section 1139B(b)(5)(A) of the Social Security Act (42 U.S.C.
1320b-9b(b)(5)(A)) is amended by striking ``The aggregate amount
awarded by the Secretary for grants and contracts for the development,
testing, and validation of emerging and innovative evidence-based
measures under such program shall equal the aggregate amount awarded by
the Secretary for grants under section 1139A(b)(4)(A)''.
SEC. 215. SPECIAL DIABETES PROGRAMS.
(a) Special Diabetes Programs for Type I Diabetes.--Section
330B(b)(2)(C) of the Public Health Service Act (42 U.S.C. 254c-
2(b)(2)(C)) is amended by striking ``2014'' and inserting ``2019''.
(b) Special Diabetes Programs for Indians.--Section 330C(c)(2)(C)
of the Public Health Service Act (42 U.S.C. 254c-3(c)(2)(C)) is amended
by striking ``2014'' and inserting ``2019''.
Subtitle C--Human Services Extensions
SEC. 221. ABSTINENCE EDUCATION GRANTS.
(a) In General.--Section 510 of the Social Security Act (42 U.S.C.
710) is amended--
(1) in subsection (a), in the matter preceding paragraph
(1), by striking ``2010 through 2014'' and inserting ``2015
through 2019''; and
(2) in subsection (d)--
(A) by striking ``2010 through 2014'' and inserting
``2015 through 2019''; and
(B) by striking the second sentence.
(b) Effective Date.--The amendments made by this section shall take
effect on October 1, 2014.
SEC. 222. PERSONAL RESPONSIBILITY EDUCATION PROGRAM.
(a) In General.--Section 513 of the Social Security Act (42 U.S.C.
713) is amended--
(1) in subsection (a)--
(A) in paragraph (1)(A), by striking ``2010 through
2014'' and inserting ``2015 through 2019'';
(B) in paragraph (4)--
(i) in subparagraph (A)--
(I) by striking ``2010 or 2011''
and inserting ``2015 or 2016'';
(II) by striking ``2010 through
2014'' and inserting ``2015 through
2019''; and
(III) by striking ``2012 through
2014'' and inserting ``2017 through
2019''; and
(ii) in subparagraph (B)(i)--
(I) by striking ``2012, 2013, and
2014'' and inserting ``2017, 2018, and
2019''; and
(II) by striking ``2010 or 2011''
and inserting ``2015 or 2016''; and
(C) in paragraph (5), by striking ``2009'' and
inserting ``2014'';
(2) in subsection (b)(2)(A), in the matter preceding clause
(i), by inserting ``and youth at risk of becoming victims of
sex trafficking (as defined in section 103(10) of the
Trafficking Victims Protection Act of 2000 (22 U.S.C.
7102(10))) or victims of a severe form of trafficking in
persons described in paragraph (9)(A) of that Act (22 U.S.C.
7102(9)(A)'' after ``adolescents'';
(3) in subsection(c)(1), by inserting ``youth at risk of
becoming victims of sex trafficking (as defined in section
103(10) of the Trafficking Victims Protection Act of 2000 (22
U.S.C. 7102(10))) or victims of a severe form of trafficking in
persons described in paragraph (9)(A) of that Act (22 U.S.C.
7102(9)(A),'' after ``youth in foster care,''; and
(4) in subsection (f), by striking ``2010 through 2014''
and inserting ``2015 through 2019''.
(b) Effective Date.--The amendments made by this section shall take
effect on October 1, 2014.
SEC. 223. FAMILY-TO-FAMILY HEALTH INFORMATION CENTERS.
(a) In General.--Section 501(c) of the Social Security Act (42
U.S.C. 701(c)) is amended--
(1) in paragraph (1)(A)--
(A) in clause (ii), by striking ``and'' after the
semicolon;
(B) in clause (iii), by striking the period and
inserting ``; and''; and
(C) by adding at the end the following:
``(iv) $6,000,000 for each of fiscal years
2014 through 2018.''; and
(2) by striking paragraph (5).
(b) Effective Date.--The amendments made by this section shall take
effect as if enacted on October 1, 2013.
SEC. 224. HEALTH WORKFORCE DEMONSTRATION PROJECT FOR LOW-INCOME
INDIVIDUALS.
Section 2008(c)(1) of the Social Security Act (42 U.S.C.
1397g(c)(1)) is amended by striking `` through 2014'' and inserting
``2012, and only to carry out subsection (a), $85,000,000 for each of
fiscal years 2013 through 2016''.
Subtitle D--Program Integrity
SEC. 231. REDUCING IMPROPER MEDICARE PAYMENTS.
(a) Medicare Administrative Contractor Improper Payment Outreach
and Education Program.--
(1) In general.--Section 1874A of the Social Security Act
(42 U.S.C. 1395kk-1) is amended--
(A) in subsection (a)(4)--
(i) by redesignating subparagraph (G) as
subparagraph (H); and
(ii) by inserting after subparagraph (F)
the following new subparagraph:
``(G) Improper payment outreach and education
program.--Having in place an improper payment outreach
and education program described in subsection (h).'';
and
(B) by adding at the end the following new
subsection:
``(h) Improper Payment Outreach and Education Program.--
``(1) In general.--In order to reduce improper payments
under this title, each medicare administrative contractor shall
establish and have in place an improper payment outreach and
education program under which the contractor, through outreach,
education, training, and technical assistance activities, shall
provide providers of services and suppliers located in the
region covered by the contract under this section with the
information described in paragraph (3). The activities
described in the preceding sentence shall be conducted on a
regular basis.
``(2) Forms of outreach, education, training, and technical
assistance activities.--The outreach, education, training, and
technical assistance activities under a payment outreach and
education program shall be carried out through any of the
following:
``(A) Emails and other electronic communications.
``(B) Webinars.
``(C) Telephone calls.
``(D) In-person training.
``(E) Other forms of communications determined
appropriate by the Secretary.
``(3) Information to be provided through activities.--The
information to be provided to providers of services and
suppliers under a payment outreach and education program shall
include all of the following information:
``(A) A list of the provider's or supplier's most
frequent and expensive payment errors over the last
quarter.
``(B) Specific instructions regarding how to
correct or avoid such errors in the future.
``(C) A notice of all new topics that have been
approved by the Secretary for audits conducted by
recovery audit contractors under section 1893(h).
``(D) Specific instructions to prevent future
issues related to such new audits.
``(E) Other information determined appropriate by
the Secretary.
``(4) Error rate reduction training.--
``(A) In general.--The activities under a payment
outreach and education program shall include error rate
reduction training.
``(B) Requirements.--
``(i) In general.--The training described
in subparagraph (A) shall--
``(I) be provided at least
annually; and
``(II) focus on reducing the
improper payments described in
paragraph (5).
``(C) Invitation.--A medicare administrative
contractor shall ensure that all providers of services
and suppliers located in the region covered by the
contract under this section are invited to attend the
training described in subparagraph (A) either in person
or online.
``(5) Priority.--A medicare administrative contractor shall
give priority to activities under the improper payment outreach
and education program that will reduce improper payments for
items and services that--
``(A) have the highest rate of improper payment;
``(B) have the greatest total dollar amount of
improper payments;
``(C) are due to clear misapplication or
misinterpretation of Medicare policies;
``(D) are clearly due to common and inadvertent
clerical or administrative errors; or
``(E) are due to other types of errors that the
Secretary determines could be prevented through
activities under the program.
``(6) Information on improper payments from recovery audit
contractors.--
``(A) In general.--In order to assist medicare
administrative contractors in carrying out improper
payment outreach and education programs, the Secretary
shall provide each contractor with a complete list of
improper payments identified by recovery audit
contractors under section 1893(h) with respect to
providers of services and suppliers located in the
region covered by the contract under this section. Such
information shall be provided on a quarterly basis.
``(B) Information.--The information described in
subparagraph (A) shall include the following
information:
``(i) The providers of services and
suppliers that have the highest rate of
improper payments.
``(ii) The providers of services and
suppliers that have the greatest total dollar
amounts of improper payments.
``(iii) The items and services furnished in
the region that have the highest rates of
improper payments.
``(iv) The items and services furnished in
the region that are responsible for the
greatest total dollar amount of improper
payments.
``(v) Other information the Secretary
determines would assist the contractor in
carrying out the improper payment outreach and
education program.
``(C) Format of information.--The information
furnished to medicare administrative contractors by the
Secretary under this paragraph shall be transmitted in
a manner that permits the contractor to easily identify
the areas of the Medicare program in which targeted
outreach, education, training, and technical assistance
would be most effective. In carrying out the preceding
sentence, the Secretary shall ensure that--
``(i) the information with respect to
improper payments made to a provider of
services or supplier clearly displays the name
and address of the provider or supplier, the
amount of the improper payment, and any other
information the Secretary determines
appropriate; and
``(ii) the information is in an electronic,
easily searchable database.
``(7) Communications.--All communications with providers of
services and suppliers under a payment outreach and education
program are subject to the standards and requirements of
subsection (g).
``(8) Funding.--After application of paragraph (1)(C) of
section 1893(h), the Secretary shall retain a portion of the
amounts recovered by recovery audit contractors under such
section which shall be available to the program management
account of the Centers for Medicare & Medicaid Services for
purposes of carrying out this subsection and to implement
corrective actions to help reduce the error rate of payments
under this title. The amount retained under the preceding
sentence shall not exceed an amount equal to 25 percent of the
amounts recovered under section 1893(h).''.
(2) Funding conforming amendment.--Section 1893(h)(2) of
the Social Security Act (42 U.S.C. 1395ddd(h)(2)) is amended by
inserting ``or section 1874(h)(8)'' after ``paragraph (1)(C)''.
(3) Effective date.--The amendments made by this subsection
take effect on January 1, 2015.
(b) Transparency.--Section 1893(h)(8) of the Social Security Act
(42 U.S.C. 1395ddd(h)(8)) is amended--
(1) by striking ``report.--The Secretary'' and inserting
``report.--
``(A) In general.--The Secretary''; and
(2) by adding at the end the following new subparagraph:
``(B) Inclusion of certain information.--
``(i) In general.--For reports submitted
under this paragraph for 2015 or a subsequent
year, each such report shall include the
information described in clause (ii) with
respect to each of the following categories of
audits carried out by recovery audit
contractors under this subsection:
``(I) Automated.
``(II) Complex.
``(III) Medical necessity review.
``(IV) Part A.
``(V) Part B.
``(VI) Durable medical equipment.
``(ii) Information described.--For purposes
of clause (i), the information described in
this clause, with respect to a category of
audit described in clause (i), is the result of
all appeals for each individual level of
appeals in such category.''.
(c) Recovery Audit Contractor Demonstration Project.--
(1) In general.--The Secretary shall conduct a
demonstration project under title XVIII of the Social Security
Act that--
(A) targets audits by recovery audit contractors
under section 1893(h) of the Social Security Act (42
U.S.C. 1395ddd(h)) with respect to high error providers
of services and suppliers identified under paragraph
(3); and
(B) rewards low error providers of services and
suppliers identified under such paragraph.
(2) Scope.--
(A) Duration.--The demonstration project shall be
implemented not later than January 1, 2015, and shall
be conducted for a period of three years.
(B) Demonstration area.--In determining the
geographic area of the demonstration project, the
Secretary shall consider the following:
(i) The total number of providers of
services and suppliers in the region.
(ii) The diversity of types of providers of
services and suppliers in the region.
(iii) The level and variation of improper
payment rates of and among individual providers
of services and suppliers in the region.
(iv) The inclusion of a mix of both urban
and rural areas.
(3) Identification of low error and high error providers of
services and suppliers.--
(A) In general.--In conducting the demonstration
project, the Secretary shall identify the following two
groups of providers in accordance with this paragraph:
(i) Low error providers of services and
suppliers.
(ii) High error providers of services and
suppliers.
(B) Analysis.--For purposes of identifying the
groups under subparagraph (A), the Secretary shall
analyze the following as they relate to the total
number and amount of claims submitted in the area and
by each provider:
(i) The improper payment rates of
individual providers of services and suppliers.
(ii) The amount of improper payments made
to individual providers of services and
suppliers.
(iii) The frequency of errors made by the
provider of services or supplier over time.
(iv) Other information determined
appropriate by the Secretary.
(C) Assignment based on composite score.--The
Secretary shall assign selected providers of services
and suppliers under the demonstration program based on
a composite score determined using the analysis under
subparagraph (B) as follows:
(i) Providers of services and suppliers
with high, expensive, and frequent errors shall
receive a high score and be identified as high
error providers of services and suppliers under
subparagraph (A).
(ii) Providers of services and suppliers
with few, inexpensive, and infrequent errors
shall receive a low score and be identified as
low error providers of services and suppliers
under such subparagraph.
(iii) Only a small proportion of the total
providers of services and suppliers and
individual types of providers of services and
suppliers in the geographic area of the
demonstration project shall be assigned to
either group identified under such
subparagraph.
(D) Timeframe of identification.--
(i) In general.--Any identification of a
provider of services or a supplier under
subparagraph (A) shall be for a period of 12
months.
(ii) Reevaluation.--The Secretary shall
reevaluate each such identification at the end
of such period.
(iii) Use of most current information.--In
carrying out the reevaluation under clause (ii)
with respect to a provider of services or
supplier, the Secretary shall--
(I) consider the most current
information available with respect to
the provider of services or supplier
under the analysis under subparagraph
(B); and
(II) take into account improvement
or regression of the provider of
services or supplier.
(4) Adjustment of record request maximum.--Under the
demonstration project, the Secretary shall establish procedures
to--
(A) increase the maximum record request made by
recovery audit contractors to providers of services and
suppliers identified as high error providers of
services and suppliers under paragraph (3); and
(B) decrease the maximum record request made by
recovery audit contractors to providers of services and
suppliers identified as low error providers of services
and supplier under such paragraph.
(5) Additional adjustments.--
(A) In general.--Under the demonstration project,
the Secretary may make additional adjustments to
requirements for recovery audit contractors under
section 1893(h) of the Social Security Act (42 U.S.C.
1395ddd(h)) and the conduct of audits with respect to
low error providers of services and suppliers
identified under paragraph (3) and high error providers
of services and suppliers identified under such
paragraph as the Secretary determines necessary in
order to incentivize reductions in improper payment
rates under title XVIII of such Act (42 U.S.C. 1395 et
seq.).
(B) Limitation.--The Secretary shall not exempt any
group of providers of services or suppliers in the
demonstration project from being subject to audit by a
recovery audit contractor under such section 1893(h).
(6) Evaluation and report.--
(A) Evaluation.--The Inspector General of the
Department of Health and Human Services shall conduct
an evaluation of the demonstration project under this
subsection. The evaluation shall include an analysis
of--
(i) the error rates of providers of
services and suppliers--
(I) identified under paragraph (3)
as low error providers of services and
suppliers;
(II) identified under such
paragraph as high error providers of
services and suppliers; and
(III) that are located in the
geographic area of the demonstration
project and are not identified as
either a low error or high error
provider of services or supplier under
such paragraph; and
(ii) any improvements in the error rates of
those high error providers of services and
suppliers identified under such paragraph.
(B) Report.--Not later than 12 months after
completion of the demonstration project, the Inspector
General shall submit to Congress a report containing
the results of the evaluation conducted under
subparagraph (A), together with recommendations on
whether the demonstration project should be continued
or expanded, including on a permanent or nationwide
basis.
(7) Funding.--
(A) Funding for implementation.--For purposes of
carrying out the demonstration project under this
subsection (other than the evaluation and report under
paragraph (6)), the Secretary shall provide for the
transfer, from the Federal Hospital Insurance Trust
Fund under section 1817 (42 U.S.C. 1395i) and the
Federal Supplementary Medical Insurance Trust Fund
under section 1841 (42 U.S.C. 1395t), in such
proportion as the Secretary determines appropriate, of
$10,000,000 to the Centers for Medicare & Medicaid
Services Program Management Account.
(B) Funding for inspector general evaluation and
report.--For purposes of carrying out the evaluation
and report under paragraph (6), the Secretary shall
provide for the transfer, from the Federal Hospital
Insurance Trust Fund under such section 1817 and the
Federal Supplementary Medical Insurance Trust Fund
under such section 1841, in such proportion as the
Secretary determines appropriate, of $245,000 to the
Inspector General of the Department of Health and Human
Services.
(C) Availability.--Amounts transferred under
subparagraph (A) or (B) shall remain available until
expended.
(8) Definitions.--In this section:
(A) Demonstration project.--The term
``demonstration project'' means the demonstration
project under this subsection.
(B) Provider of services.--The term ``provider of
services'' has the meaning given that term in section
1861(u).
(C) Recovery audit contractor.--The term ``recovery
audit contractor'' means an entity with a contract
under section 1893(h) of the Social Security Act (42
U.S.C. 1395ddd(h)).
(D) Secretary.--The term ``Secretary'' means the
Secretary of Health and Human Services.
(E) Supplier.--The term ``supplier'' has the
meaning given that term in section 1861(d).
SEC. 232. AUTHORITY FOR MEDICAID FRAUD CONTROL UNITS TO INVESTIGATE AND
PROSECUTE COMPLAINTS OF ABUSE AND NEGLECT OF MEDICAID
PATIENTS IN HOME AND COMMUNITY-BASED SETTINGS.
(a) In General.--Section 1903(q)(4)(A) of the Social Security Act
(42 U.S.C. 1396b(q)(4)(A)) is amended to read as follows:
``(4)(A) The entity's function includes a statewide program
for the--
``(i) investigation and prosecution, or referral
for prosecution or other action, of complaints of abuse
or neglect of patients in health care facilities which
receive payments under the State plan under this title
or under a waiver of such plan;
``(ii) at the option of the entity, investigation
and prosecution, or referral for prosecution or other
action, of complaints of abuse or neglect of
individuals in connection with any aspect of the
provision of medical assistance and the activities of
providers of such assistance in a home or community
based setting that is paid for under the State plan
under this title or under a waiver of such plan; and
``(iii) at the option of the entity, investigation
and prosecution, or referral for prosecution or other
action, of complaints of abuse or neglect of patients
residing in board and care facilities.''.
(b) Effective Date.--The amendment made by subsection (a) shall
take effect on January 1, 2015.
SEC. 233. IMPROVED USE OF FUNDS RECEIVED BY THE HHS INSPECTOR GENERAL
FROM OVERSIGHT AND INVESTIGATIVE ACTIVITIES.
(a) In General.--Section 1128C(b) of the Social Security Act (42
U.S.C. 1320a-7c(b)) is amended to read as follows:
``(b) Additional Use of Funds by Inspector General.--
``(1) Collections from medicare and medicaid recovery
actions.--Notwithstanding section 3302 of title 31, United
States Code, or any other provision of law affecting the
crediting of collections, the Inspector General of the
Department of Health and Human Services may receive and retain
three percent of all amounts collected pursuant to civil debt
collection actions related to false claims or frauds involving
the Medicare program under title XVIII or the Medicaid program
under title XIX.
``(2) Crediting.--Funds received by the Inspector General
under paragraph (1) shall be deposited to the credit of any
appropriation available for oversight and enforcement
activities of the Inspector General permitted under subsection
(a), and shall remain available until expended.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to funds received from settlements finalized, or judgements
entered, on or after the date of the enactment of this Act.
SEC. 234. PREVENTING AND REDUCING IMPROPER MEDICARE AND MEDICAID
EXPENDITURES.
(a) Requiring Valid Prescriber National Provider Identifiers on
Pharmacy Claims.--Section 1860D-4(c) of the Social Security Act (42
U.S.C. 1395w-104(c)) is amended by adding at the end the following new
paragraph:
``(4) Requiring valid prescriber national provider
identifiers on pharmacy claims.--
``(A) In general.--For plan year 2015 and
subsequent plan years, subject to subparagraph (B), the
Secretary shall prohibit PDP sponsors of prescription
drug plans from paying claims for prescription drugs
under this part that do not include a valid prescriber
National Provider Identifier.
``(B) Procedures.--The Secretary shall establish
procedures for determining the validity of prescriber
National Provider Identifiers under subparagraph (A).
``(C) Report.--Not later than January 1, 2017, the
Inspector General of the Department of Health and Human
Services shall submit to Congress a report on the
effectiveness of the procedures established under
subparagraph (B).''.
(b) Reforming How CMS Tracks and Corrects the Vulnerabilities
Identified by Recovery Audit Contractors.--Section 1893(h) of the
Social Security Act (42 U.S.C. 1395ddd(h)) is amended--
(1) in paragraph (8), as amended by section 231, by adding
at the end the following new subparagraphs:
``(C) Inclusion of improper payment vulnerabilities
identified.--For reports submitted under this paragraph
for 2015 or a subsequent year, each such report shall
include--
``(i) a description of--
``(I) the types and financial cost
to the program under this title of
improper payment vulnerabilities
identified by recovery audit
contractors under this subsection; and
``(II) how the Secretary is
addressing such improper payment
vulnerabilities; and
``(ii) an assessment of the effectiveness
of changes made to payment policies and
procedures under this title in order to address
the vulnerabilities so identified.
``(D) Limitation.--The Secretary shall ensure that
each report submitted under subparagraph (A) does not
include information that the Secretary determines would
be sensitive or would otherwise negatively impact
program integrity.''; and
(2) by adding at the end the following new paragraph:
``(10) Addressing improper payment vulnerabilities.--The
Secretary shall address improper payment vulnerabilities
identified by recovery audit contractors under this subsection
in a timely manner, prioritized based on the risk to the
program under this title.''.
(c) Strengthening Medicaid Program Integrity Through Flexibility.--
Section 1936 of the Social Security Act (42 U.S.C. 1396u-6) is
amended--
(1) in subsection (a), by inserting ``, or otherwise,''
after ``entities''; and
(2) in subsection (e)--
(A) in paragraph (1), in the matter preceding
subparagraph (A), by inserting ``(including the costs
of equipment, salaries and benefits, and travel and
training)'' after ``Program under this section''; and
(B) in paragraph (3), by striking ``by 100'' and
inserting ``by 100, or such number as determined
necessary by the Secretary to carry out the Program
under this section,''.
(d) Access to the National Directory of New Hires.--Section 453(j)
of the Social Security Act (42 U.S.C. 653(j)) is amended by adding at
the end the following new paragraph:
``(12) Information comparisons and disclosures to assist in
administration of the medicare program and state health subsidy
programs.--
``(A) Disclosure to the administrator of the
centers for medicare & medicaid services.--The
Administrator of the Centers for Medicare & Medicaid
shall have access to the information in the National
Directory of New Hires for purposes of determining the
eligibility of an applicant for, or enrollee in, the
Medicare program under title XVIII or an applicable
State health subsidy program (as defined in section
1413(e) of the Patient Protection and Affordable Care
Act (42 U.S.C. 18083(e)).
``(B) Disclosure to the inspector general of the
department of health and human services.--
``(i) In general.--If the Inspector General
of the Department of Health and Human Services
transmits to the Secretary the names and social
security account numbers of individuals, the
Secretary shall disclose to the Inspector
General information on such individuals and
their employers maintained in the National
Directory of New Hires.
``(ii) Use of information.--The Inspector
General of the Department of Health and Human
Services may use information provided under
clause (i) only for purposes of --
``(I) determining the eligibility
of an applicant for, or enrollee in,
the Medicare program under title XVIII
or an applicable State health subsidy
program (as defined in section 1413(e)
of the Patient Protection and
Affordable Care Act (42 U.S.C.
18083(e)); or
``(II) evaluating the integrity of
the Medicare program or an applicable
State health subsidy program (as so
defined).
``(C) Disclosure to state agencies.--
``(i) In general.--If, for purposes of
determining the eligibility of an applicant
for, or an enrollee in, an applicable State
health subsidy program (as defined in section
1413(e) of the Patient Protection and
Affordable Care Act (42 U.S.C. 18083(e)), a
State agency responsible for administering such
program transmits to the Secretary the names,
dates of birth, and social security account
numbers of individuals, the Secretary shall
disclose to such State agency information on
such individuals and their employers maintained
in the National Directory of New Hires, subject
to this subparagraph.
``(ii) Condition on disclosure by the
secretary.--The Secretary shall make a
disclosure under clause (i) only to the extent
that the Secretary determines that the
disclosure would not interfere with the
effective operation of the program under this
part.
``(iii) Use and disclosure of information
by state agencies.--
``(I) In general.--A State agency
may not use or disclose information
provided under clause (i) except for
purposes of determining the eligibility
of an applicant for, or an enrollee in,
a program referred to in clause (i).
``(II) Information security.--The
State agency shall have in effect data
security and control policies that the
Secretary finds adequate to ensure the
security of information obtained under
clause (i) and to ensure that access to
such information is restricted to
authorized persons for purposes of
authorized uses and disclosures.
``(III) Penalty for misuse of
information.--An officer or employee of
the State agency who fails to comply
with this clause shall be subject to
the sanctions under subsection (l)(2)
to the same extent as if such officer
or employee were an officer or employee
of the United States.
``(iv) Procedural requirements.--State
agencies requesting information under clause
(i) shall adhere to uniform procedures
established by the Secretary governing
information requests and data matching under
this paragraph.
``(v) Reimbursement of costs.--The State
agency shall reimburse the Secretary, in
accordance with subsection (k)(3), for the
costs incurred by the Secretary in furnishing
the information requested under this
subparagraph.''.
(e) Improving the Sharing of Data Between the Federal Government
and State Medicaid Programs.--
(1) In general.--The Secretary of Health and Human Services
(in this subsection referred to as the ``Secretary'') shall
establish a plan to encourage and facilitate the participation
of States in the Medicare-Medicaid Data Match Program (commonly
referred to as the ``Medi-Medi Program'') under section 1893(g)
of the Social Security Act (42 U.S.C. 1395ddd(g)).
(2) Program revisions to improve medi-medi data match
program participation by states.--Section 1893(g)(1)(A) of the
Social Security Act (42 U.S.C. 1395ddd(g)(1)(A)) is amended--
(A) in the matter preceding clause (i), by
inserting ``or otherwise'' after ``eligible entities'';
(B) in clause (i)--
(i) by inserting ``to review claims data''
after ``algorithms''; and
(ii) by striking ``service, time, or
patient'' and inserting ``provider, service,
time, or patient'';
(C) in clause (ii)--
(i) by inserting ``to investigate and
recover amounts with respect to suspect
claims'' after ``appropriate actions''; and
(ii) by striking ``; and'' and inserting a
semicolon;
(D) in clause (iii), by striking the period and
inserting ``; and''; and
(E) by adding at end the following new clause:
``(iv) furthering the Secretary's design,
development, installation, or enhancement of an
automated data system architecture--
``(I) to collect, integrate, and
assess data for purposes of program
integrity, program oversight, and
administration, including the Medi-Medi
Program; and
``(II) that improves the
coordination of requests for data from
States.''.
(3) Providing states with data on improper payments made
for items or services provided to dual eligible individuals.--
(A) In general.--The Secretary shall develop and
implement a plan that allows each State agency
responsible for administering a State plan for medical
assistance under title XIX of the Social Security Act
access to relevant data on improper or fraudulent
payments made under the Medicare program under title
XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.) for health care items or services provided to
dual eligible individuals.
(B) Dual eligible individual defined.--In this
paragraph, the term ``dual eligible individual'' means
an individual who is entitled to, or enrolled for,
benefits under part A of title XVIII of the Social
Security Act (42 U.S.C. 1395c et seq.), or enrolled for
benefits under part B of title XVIII of such Act (42
U.S.C. 1395j et seq.), and is eligible for medical
assistance under a State plan under title XIX of such
Act (42 U.S.C. 1396 et seq.) or under a waiver of such
plan.
Subtitle E--Other Provisions
SEC. 241. COMMISSION ON IMPROVING PATIENT DIRECTED HEALTH CARE.
(a) Findings.--Congress finds the following:
(1) In order to elevate the role of patient choices in the
health care system, the American public must engage in an
informed, national, public debate on how the current health
care system empowers and informs health care decision-making,
and what can be done to improve the likelihood patients receive
the care they want and need.
(2) Research suggests that patients often do not receive
the care they want. As a result, the end of life is associated
with a substantial burden of suffering by the patient and
negative health and financial consequences that extend to
family members and society.
(3) Patients face a complex and fragmented health care
system that may decrease the likelihood that health care
choices are known and carried out. The health care system
should embed principles that take into account patient wishes.
(4) Decisions concerning health care, including end-of-life
issues, affect an increasing number of Americans.
(5) Medical advances are prolonging life expectancy in the
United States both in acute life-threatening situations and
protracted battles with illness. These advances raise new
challenges surrounding health care decision-making.
(6) The United States health care system should promote
consideration of a person's preference in health care decision-
making and end-of-life choices.
(b) Commission.--The Social Security Act is amended by inserting
after section 1150B (42 U.S.C. 1320b-24) the following new section:
``SEC. 1150C. COMMISSION ON IMPROVING PATIENT DIRECTED HEALTH CARE.
``(a) Purposes.--The purposes of this section are to--
``(1) provide a forum for a nationwide public debate on
improving patient self-determination in health care decision-
making;
``(2) identify strategies that ensure every American has
the health care they want; and
``(3) provide recommendations to Congress that result from
the debate.
``(b) Establishment.--The Secretary shall establish an entity to be
known as the Commission on Improving Patient Directed Health Care
(referred to in this section as the `Commission').
``(c) Membership.--
``(1) Number and appointment.--The Commission shall be
composed of 15 members. One member shall be the Secretary. The
Comptroller General of the United States shall appoint 14
members.
``(2) Qualifications.--The membership of the Commission
shall include--
``(A) health care consumers impacted by decision-
making in advance of a health care crisis, such as
individuals of advanced age, individuals with chronic,
terminal and mental illnesses, family care givers, and
individuals with disabilities;
``(B) providers in settings where crucial health
care decision-making occurs, such as those working in
intensive care settings, emergency room departments,
primary care settings, nursing homes, hospice, or
palliative care settings;
``(C) payors ensuring patients get the level of
care they want;
``(D) experts in advance care planning, hospice,
palliative care, information technology, bioethics,
aging policy, disability policy, pediatric ethics,
cultural sensitivity, psychology, and health care
financing;
``(E) individuals who represent culturally diverse
perspectives on patient self-determination and end-of-
life issues; and
``(F) members of the faith community.
``(d) Period of Appointment.--Members of the Commission shall be
appointed for the life of the Commission. Any vacancies shall not
affect the power and duties of the Commission but shall be filled in
the same manner as the original appointment.
``(e) Designation of the Chairperson.--Not later than 15 days after
the date on which all members of the Commission have been appointed,
the Comptroller General shall designate the chairperson of the
Commission.
``(f) Subcommittees.--The Commission may establish subcommittees if
doing so increases the efficiency of the Commission in completing
tasks.
``(g) Duties.--
``(1) Hearings.--Not later than 90 days after the date of
designation of the chairperson under subsection (e), the
Commission shall hold no fewer than 8 hearings to examine--
``(A) the current state of health care decision-
making and advance care planning laws in the United
States at the Federal level and across the States, as
well as options for improving advance care planning
tools, especially with regard to use, portability, and
storage;
``(B) consumer-focused approaches that educate the
American public about patient choices, care planning,
and other end-of-life issues;
``(C) the use of comprehensive, patient-centered
care plans by providers, the impact care plans have on
health care delivery, and methods to expand the use of
high quality care planning tools in both public and
private health care systems;
``(D) the role of electronic medical records and
other technologies in improving patient-directed health
care;
``(E) innovative tools for improving patient
experience with advanced illness, such as palliative
care, hospice, and other models;
``(F) the role social determinants of health, such
as socio-economic status, play in patient self-
direction in health care;
``(G) the use of culturally-competent tools for
health care decision-making;
``(H) strategies for educating providers on care
planning, palliative care, hospice care, and other
issues surrounding honoring patient choices;
``(I) the sociological and psychological factors
that influence health care decision-making and end-of-
life choices; and
``(J) the role of spirituality and religion in
patient self-determination in health care.
``(2) Additional hearings.--The Commission may hold
additional hearings on subjects other than those listed in
paragraph (1) so long as such hearings are determined necessary
by the Commission in carrying out the purposes of this section.
Such additional hearings do not have to be completed within the
time period specified but shall not delay the other activities
of the Commission under this section.
``(3) Number and location of hearings and additional
hearings.--The Commission shall hold no fewer than 8 hearings
as indicated in paragraph (1) and in sufficient number in order
to receive information that reflects--
``(A) the geographic differences throughout the
United States;
``(B) diverse populations; and
``(C) a balance among urban and rural populations.
``(4) Interactive technology.--The Commission may encourage
public participation in hearings through interactive technology
and other means as determined appropriate by the Commission.
``(5) Report to the american people on patient directed
health care.--Not later than 90 days after the hearings
described in paragraphs (1) and (2) are completed, the
Commission shall prepare and make available to health care
consumers through the Internet and other appropriate public
channels, a report to be entitled, `Report to the American
People on Patient Directed Health Care'. Such a report shall be
understandable to the general public and include--
``(A) a summary of--
``(i) the hearings described in such
paragraphs;
``(ii) how the current health care system
empowers and informs decision-making in advance
of a health care crisis;
``(iii) factors that contribute to the
provision of health care that does not adhere
to patient wishes;
``(iv) the impact of care that does not
follow patient choices, particularly at the
end-of-life, on patients, families, providers,
and the health care system;
``(v) the laws surrounding advance care
planning and health care decision-making
including issues of portability, use, and
storage;
``(vi) consumer-focused approaches to
education of the American public about patient
choices, care planning, and other end-of-life
issues;
``(vii) the role of care plans in health
care decision-making;
``(viii) the role of providers in ensuring
patients receive the care they want;
``(ix) the role of electronic medical
records and other technologies in improving
patient directed health care;
``(x) the impact of social determinants on
patient self-direction in health care services;
``(xi) the use of culturally competent
methods for health care decision-making;
``(xii) the sociological and psychological
factors that influence patient self-
determination; and
``(xiii) the role of spirituality and
religion in health care decision-making and
end-of-life care;
``(B) best practices from communities, providers,
and payors that document patient wishes and provide
health care that adheres to those wishes; and
``(C) information on educating providers about
health care decision-making and end-of-life issues.
``(6) Interim requirements.--Not later than 180 days after
the date of completion of the hearings, the Commission shall
prepare and make available to the public through the Internet
and other appropriate public channels, an interim set of
recommendations on patient self-determination in health care
and ways to improve and strengthen the health care system based
on the information and preferences expressed at the community
meetings. There shall be a 90-day public comment period on such
recommendations.
``(h) Recommendations.--Not later than 120 days after the
expiration of the public comment period described in subsection (g)(6),
the Commission shall submit to Congress and the President a final set
of recommendations. The recommendations must be comprehensive and
detailed. The recommendations must contain recommendations or proposals
for legislative or administrative action as the Commission deems
appropriate, including proposed legislative language to carry out the
recommendations or proposals.
``(i) Administration.--
``(1) Executive director.--There shall be an Executive
Director of the Commission who shall be appointed by the
chairperson of the Commission in consultation with the members
of the Commission.
``(2) Compensation.--While serving on the business of the
Commission (including travel time), a member of the Commission
shall be entitled to compensation at the per diem equivalent of
the rate provided for level IV of the Executive Schedule under
section 5315 of title 5, United States Code, and while so
serving away from home and the member's regular place of
business, a member may be allowed travel expenses, as
authorized by the chairperson of the Commission. For purposes
of pay and employment benefits, rights, and privileges, all
personnel of the Commission shall be treated as if they were
employees of the Senate.
``(3) Information from federal agencies.--The Commission
may secure directly from any Federal department or agency such
information as the Commission considers necessary to carry out
this section. Upon request of the Commission the head of such
department or agency shall furnish such information.
``(4) Postal services.--The Commission may use the United
States mails in the same manner and under the same conditions
as other departments and agencies of the Federal Government.
``(j) Detail.--Not more than 5 Federal Government employees
employed by the Department of Labor, 5 Federal Government employees
employed by the Social Security Administration, and 10 Federal
Government employees employed by the Department of Health and Human
Services may be detailed to the Commission under this section without
further reimbursement. Any detail of an employee shall be without
interruption or loss of civil service status or privilege.
``(k) Temporary and Intermittent Services.--The chairperson of the
Commission may procure temporary and intermittent services under
section 3109(b) of title 5, United States Code, at rates for
individuals which do not exceed the daily equivalent of the annual rate
of basic pay prescribed for level V of the Executive Schedule under
section 5316 of such title.
``(l) Annual Report.--Not later than 1 year after the date of
enactment of this Act, and annually thereafter during the existence of
the Commission, the Commission shall report to Congress and make public
a detailed description of the expenditures of the Commission used to
carry out its duties under this section.
``(m) Sunset of Commission.--The Commission shall terminate on the
date that is 4 years after the date on which all the members of the
Commission have been appointed under subsection (c)(1) and
appropriations are first made available to carry out this section.
``(n) Administration Review and Comments.--Not later than 45 days
after receiving the final recommendations of the Commission under
subsection (h), the President shall submit a report to Congress which
shall contain--
``(1) additional views and comments on such
recommendations; and
``(2) recommendations for such legislation and
administrative action as the President considers appropriate.
``(o) Required Congressional Action.--Not later than 45 days after
receiving the report submitted by the President under subsection (n),
each committee of jurisdiction of Congress, the Committee on Finance of
the Senate, the Committee on Health, Education, Labor, and Pensions of
the Senate, the Committee on Ways and Means of the House of
Representatives, the Committee on Energy and Commerce of the House of
Representatives, and the Committee on Education and the Workforce of
the House of Representatives, shall hold at least 1 hearing on such
report and on the final recommendations of the Commission submitted
under subsection (h).
``(p) Authorization of Appropriations.--
``(1) In general.--There are authorized to be appropriated
to carry out this section, $3,000,000 for each of fiscal years
2014 and 2015.
``(2) Report to the american people on patient directed
health care.--There are authorized to be appropriated for the
preparation and dissemination of the Report to the American
People on Patient Directed Health Care described in subsection
(g)(5), such sums as may be necessary for the fiscal year in
which the report is required to be submitted.''.
SEC. 242. EXPANSION OF THE DEFINITION OF INPATIENT HOSPITAL SERVICES
FOR CERTAIN CANCER HOSPITALS.
Section 1861(b)(3) of the Social Security Act (42 U.S.C.
1395x(b)(3)) is amended--
(1) by inserting ``(A)'' after ``(3)''; and
(2) by adding ``and'' after the semicolon at the end; and
(3) by adding at the end the following new subparagraph:
``(B) with respect to a hospital that is described in
section 1886(d)(1)(B)(v) and that, as of the date of the
enactment of the SGR Repeal and Medicare Beneficiary Access Act
of 2013, is located in the same building, or on the same
campus, as another hospital, items and services described in
paragraphs (1) and (2) furnished on or after such date of
enactment by the hospital described in such section or by
others under arrangements with them made by the hospital;''.
SEC. 243. QUALITY MEASURES FOR CERTAIN POST-ACUTE CARE PROVIDERS
RELATING TO NOTICE AND TRANSFER OF PATIENT HEALTH
INFORMATION AND PATIENT CARE PREFERENCES.
(a) Development.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') shall provide for the
development of one or more quality measures under title XVIII of the
Social Security Act (42 U.S.C. 1395 et seq.) to accurately communicate
the existence and provide for the transfer of patient health
information and patient care preferences when an individual transitions
from a hospital to return home or move to other post-acute care
settings.
(b) Use of Measure Developers.--The Secretary shall arrange for the
development of such measures by appropriate measure developers.
(c) Endorsement.--The Secretary shall arrange for such developed
measures to be submitted for endorsement to a consensus-based entity as
described in section 1890(a) of the Social Security Act (42 U.S.C.
1395aaa(a)), as amended by section 208.
(d) Use of Measures.--The Secretary shall, through notice and
comment rulemaking, use such measures under the quality reporting
programs with respect to--
(1) inpatient hospitals under section 1886(b)(3)(B)(viii)
of the Social Security Act (42 U.S.C. 1395ww(b)(3)(B)(viii));
(2) skilled nursing facilities under section 1888(e) of
such Act (42 U.S.C. 1395yy(e));
(3) home health services under section 1895(b)(3)(B)(v) of
such Act (42 U.S.C. 1395fff(b)(3)(B)(v)); and
(4) other providers of services (as defined in section
1861(u) of such Act) and suppliers (as defined in section
1861(d) of such Act) that the Secretary determines appropriate.
SEC. 244. CRITERIA FOR MEDICALLY NECESSARY, SHORT INPATIENT HOSPITAL
STAYS.
(a) In General.--The Secretary of Health and Human Services shall
consult with, and seek input from, interested stakeholders to determine
appropriate criteria for payment under the Medicare program under title
VIII of the Social Security Act of an inpatient hospital admission
that--
(1) is medically necessary; and
(2) is an inpatient hospital stay that is less than two
midnights, as described in section 412.3 of title 42, Code of
Federal Regulation, as finalized in the final rule published by
the Centers for Medicare & Medicaid Services in the Federal
Register on August 19, 2013 (78 Federal Register 50496)
entitled ``Medicare Program; Hospital Inpatient Prospective
Payment Systems for Acute Care Hospitals and the Long-Term Care
Hospital Prospective Payment System and Fiscal Year 2014 Rates;
Quality Reporting Requirements for Specific Providers; Hospital
Conditions of Participation; Payment Policies Related to
Patient Status''.
(b) Interested Stakeholders.--In subsection (a), the term
``interested stakeholders'' means the following:
(1) Hospitals.
(2) Physicians
(3) Medicare administrative contractors under section 1874A
of the Social Security Act (42 U.S.C. 1395kk-1).
(4) Recovery audit contractors under section 1893(h) of
such Act (42 U.S.C. 1395ddd(h)).
(5) Other parties determined appropriate by the Secretary.
SEC. 245. TRANSPARENCY OF REASONS FOR EXCLUDING ADDITIONAL PROCEDURES
FROM THE MEDICARE AMBULATORY SURGICAL CENTER (ASC)
APPROVED LIST.
Section 1833(i)(1) of the Social Security Act (42 U.S.C.
1395l(i)(1)) is amended by adding at the end the following: ``In
updating such lists for application in years beginning after December
31, 2014, for each procedure that was requested to be included on such
lists during the public comment period but which the Secretary does not
propose (in the final rule updating such lists) to so include, the
Secretary shall describe in such final rule the specific safety
criteria for not including such procedure on such lists.''.
SEC. 246. SUPERVISION IN CRITICAL ACCESS HOSPITALS.
(a) General Supervision in Critical Access Hospitals.--Section
1834(g) of the Social Security Act (42 U.S.C. 1395m(g)) is amended by
adding at the end the following new paragraph:
``(6) Supervision.--In the case of services furnished on or
after the date of the enactment of this paragraph, the level of
supervision with respect to outpatient critical access hospital
services shall be general supervision (as defined by the
Secretary).''.
(b) Supervision of Cardiac and Pulmonary Rehabilitation Programs in
Critical Access Hospitals.--Section 1861(eee)(2)(B) of the Social
Security Act (42 U.S.C. 1395x(eee)(2)(B)) is amended by inserting ``,
or in the case of a critical access hospital, a physician, or
(beginning on the date of enactment of the SGR Repeal and Medicare
Beneficiary Access Act of 2013) a nurse practitioner, clinical nurse
specialist, or physician assistant (as such terms are defined in
subsection (aa)(5)),'' after ``a physician''.
SEC. 247. REQUIRING STATE LICENSURE OF BIDDING ENTITIES UNDER THE
COMPETITIVE ACQUISITION PROGRAM FOR CERTAIN DURABLE
MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES
(DMEPOS).
Section 1847(a)(1) of the Social Security Act (42 U.S.C. 1395w-
3(a)(1)) is amended by adding at the end the following new
subparagraph:
``(G) Requiring state licensure of bidding
entities.--With respect to rounds of competitions
beginning on or after the date of enactment of this
subparagraph, the Secretary may only accept a bid from
an entity for an area if the entity meets applicable
State licensure requirements for such area for all
items in such bid.''.
SEC. 248. RECOGNITION OF ATTENDING PHYSICIAN ASSISTANTS AS ATTENDING
PHYSICIANS TO SERVE HOSPICE PATIENTS.
(a) Recognition of Attending Physician Assistants as Attending
Physicians To Serve Hospice Patients.--
(1) In general.--Section 1861(dd)(3)(B) of the Social
Security Act (42 U.S.C. 1395x(dd)(3)(B)) is amended--
(A) by striking ``or nurse'' and inserting ``, the
nurse''; and
(B) by inserting ``, or the physician assistant (as
defined in such subsection)'' after ``subsection
(aa)(5))''.
(2) Clarification of hospice role of physician
assistants.--Section 1814(a)(7)(A)(i)(I) of the Social Security
Act (42 U.S.C. 1395f(a)(7)(A)(i)(I)) is amended by inserting
``or a physician assistant'' after ``a nurse practitioner''.
(b) Effective Date.--The amendments made by this section shall
apply to items and services furnished on or after January 1, 2015.
SEC. 249. REMOTE PATIENT MONITORING PILOT PROJECTS.
(a) Pilot Projects.--
(1) In general.--Not later than 9 months after the date of
the enactment of this Act, the Secretary shall conduct pilot
projects under title XVIII of the Social Security Act for the
purpose of providing incentives to home health agencies to
furnish remote patient monitoring services that reduce
expenditures under such title.
(2) Site requirements.--
(A) Urban and rural.--The Secretary shall conduct
the pilot projects under this section in both urban and
rural areas.
(B) Site in a small state.--The Secretary shall
conduct at least 1 of the pilot projects in a State
with a population of less than 1,000,000.
(b) Medicare Beneficiaries Within the Scope of Projects.--
(1) In general.--The Secretary shall specify the criteria
for identifying those Medicare beneficiaries who shall be
considered within the scope of the pilot projects under this
section for purposes of the application of subsection (c) and
for the assessment of the effectiveness of the home health
agency in achieving the objectives of this section.
(2) Criteria.--The criteria specified under paragraph (1)--
(A) shall include conditions and clinical
circumstances, including congestive heart failure,
diabetes, and chronic pulmonary obstructive disease,
and other conditions determined appropriate by the
Secretary; and
(B) may provide for the inclusion in the projects
of Medicare beneficiaries who begin receiving home
health services under title XVIII of the Social
Security Act after the date of the implementation of
the projects.
(c) Incentives.--
(1) Performance targets.--The Secretary shall establish for
each home health agency participating in a pilot project under
this section a performance target using one of the following
methodologies, as determined appropriate by the Secretary:
(A) Adjusted historical performance target.--The
Secretary shall establish for the agency--
(i) a base expenditure amount equal to the
average total payments made under parts A, B,
and D of title XVIII of the Social Security Act
for Medicare beneficiaries determined to be
within the scope of the pilot project in a base
period determined by the Secretary; and
(ii) an annual per capita expenditure
target for such beneficiaries, reflecting the
base expenditure amount adjusted for risk,
changes in costs, and growth rates.
(B) Comparative performance target.--The Secretary
shall establish for the agency a comparative
performance target equal to the average total payments
made under such parts A, B, and D during the pilot
project for comparable individuals in the same
geographic area that are not determined to be within
the scope of the pilot project.
(2) Payment.--Subject to paragraph (3), the Secretary shall
pay to each home health agency participating in a pilot project
a payment for each year under the pilot project equal to a 75
percent share of the total Medicare cost savings realized for
such year relative to the performance target under paragraph
(1).
(3) Limitation on expenditures.--The Secretary shall limit
payments under this section in order to ensure that the
aggregate expenditures under title XVIII of the Social Security
Act (including payments under this subsection) do not exceed
the amount that the Secretary estimates would have been
expended if the pilot projects under this section had not been
implemented, including any reasonable costs incurred by the
Secretary in the administration of the pilot projects.
(4) No duplication in participation in shared savings
programs.--A home health agency that participates in any of the
following shall not be eligible to participate in the pilot
projects under this section:
(A) A model tested or expanded under section 1115A
of the Social Security Act (42 U.S.C. 1315a) that
involves shared savings under title XVIII of such Act
or any other program or demonstration project that
involves such shared savings.
(B) The independence at home medical practice
demonstration program under section 1866E of such Act
(42 U.S.C. 1395cc-5).
(d) Waiver Authority.--The Secretary may waive such provisions of
titles XI and XVIII of the Social Security Act as the Secretary
determines to be appropriate for the conduct of the pilot projects
under this section.
(e) Report to Congress.--Not later than 3 years after the date that
the first pilot project under this section is implemented, the
Secretary shall submit to Congress a report on the projects. Such
report shall contain--
(1) a detailed description of the projects, including any
changes in clinical outcomes for Medicare beneficiaries under
the projects, Medicare beneficiary satisfaction under the
projects, utilization of items and services under parts A, B,
and D of title XVIII of the Social Security Act by Medicare
beneficiaries under the projects, and Medicare per-beneficiary
and Medicare aggregate spending under the projects;
(2) a detailed description of issues related to the
expansion of the projects under subsection (f);
(3) recommendations for such legislation and administrative
actions as the Secretary considers appropriate; and
(4) other items considered appropriate by the Secretary.
(f) Expansion.--If the Secretary determines that any of the pilot
projects under this section enhance health outcomes for Medicare
beneficiaries and reduce expenditures under title XVIII of the Social
Security Act, the Secretary shall initiate comparable projects in
additional areas.
(g) Payments Have No Effect on Other Medicare Payments to Home
Health Agencies.--A payment under this section shall have no effect on
the amount of payments that a home health agency would otherwise
receive under title XVIII of the Social Security Act for the provision
of home health services.
(h) Study and Report on the Appropriate Valuation for Remote
Patient Monitoring Services Under the Medicare Physician Fee
Schedule.--
(1) Study.--The Secretary shall conduct a study on the
appropriate valuation for remote patient monitoring services
under the Medicare physician fee schedule under section 1848 of
the Social Security Act (42 U.S.C. 1395w-4) in order to
accurately reflect the resources involved in furnishing such
services.
(2) Report.--Not later than 6 months after the date of the
enactment of this Act, the Secretary shall submit to Congress a
report on the study conducted under paragraph (1), together
with such recommendations as the Secretary determines
appropriate.
(i) Definitions.--In this section:
(1) Home health agency.--The term ``home health agency''
has the meaning given that term in section 1861(o) of the
Social Security Act (42 U.S.C. 1395x(o)).
(2) Remote patient monitoring services.--
(A) In general.--The term ``remote patient
monitoring services'' means services furnished in the
home using remote patient monitoring technology which--
(i) shall include patient monitoring or
patient assessment; and
(ii) may include in-home technology-based
professional consultations, patient training
services, clinical observation, treatment, and
any additional services that utilize
technologies specified by the Secretary.
(B) Limitation.--The term ``remote patient
monitoring services'' shall not include a
telecommunication that consists solely of a telephone
audio conversation, facsimile, or electronic text mail
between a health care professional and a patient.
(3) Remote patient monitoring technology.--The term
``remote patient monitoring technology'' means a coordinated
system that uses one or more home-based or mobile monitoring
devices that automatically transmit vital sign data or
information on activities of daily living and may include
responses to assessment questions collected on the devices
wirelessly or through a telecommunications connection to a
server that complies with the Federal regulations (concerning
the privacy of individually identifiable health information)
promulgated under section 264(c) of the Health Insurance
Portability and Accountability Act of 1996, as part of an
established plan of care for that patient that includes the
review and interpretation of that data by a health care
professional.
(4) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
SEC. 250. COMMUNITY-BASED INSTITUTIONAL SPECIAL NEEDS PLAN
DEMONSTRATION PROGRAM.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary'') shall establish a
Community-Based Institutional Special Needs Plan (CBI-SNP)
demonstration program to prevent and delay institutionalization under
Medicaid among targeted low-income Medicare beneficiaries.
(b) Establishment.--The Secretary shall enter into agreements with
not more than 5 specialized MA plans for special needs individuals, as
defined in section 1859(b)(6)(B)(i) of the Social Security Act (42
U.S.C. 1395w-28(b)(6)(B)(i)), to conduct the CBI-SNP demonstration
program. Under the CBI-SNP demonstration program, a targeted low-income
Medicare beneficiary shall receive, as supplemental benefits under
section 1852(a)(3) of such Act (42 U.S.C. 1395w-22(a)(3)), long-term
care services or supports that--
(1) the Secretary determines appropriate for the purposes
of the CBI-SNP demonstration program; and
(2) for which payment may be made under the State plan
under title XIX of such Act (42 U.S.C. 1396 et seq.) of the
State in which the targeted low-income Medicare beneficiary is
located.
(c) Eligible Plans.--To be eligible to participate in the CBI-SNP
demonstration program, a specialized MA plan for special needs
individuals must--
(1) serve special needs individuals (as defined in section
1859(b)(6)(B)(i) of the Social Security Act (42 U.S.C. 1395w-
28(b)(6)(B)(i));
(2) have experience in offering special needs plans for
nursing home-eligible, non-institutionalized Medicare
beneficiaries who live in the community;
(3) be located in a State that the Secretary has determined
will participate in the CBI-SNP demonstration program by
agreeing to make available data necessary for purposes of
conducting the independent evaluation required under subsection
(f); and
(4) meet such other criteria as the Secretary may require.
(d) Targeted Low-income Medicare Beneficiary Defined.--In this
section, the term ``targeted low-income Medicare beneficiary'' means a
Medicare beneficiary who--
(1) is enrolled in a specialized MA plan for special needs
individuals that has been selected to participate in the CBI-
SNP demonstration program;
(2) is a subsidy eligible individual (as defined in section
1860D-14(a)(3)(A) of the Social Security Act (42 U.S.C. 1395w-
114(a)(3)(A)); and
(3) is unable to perform 2 or more activities of daily
living (as defined in section 7702B(c)(2)(B) of the Internal
Revenue Code of 1986).
(e) Implementation Deadline; Duration.--The CBI-SNP demonstration
program shall be implemented not later than January 1, 2016, and shall
be conducted for a period of 3 years.
(f) Independent Evaluation and Reports.--
(1) Independent evaluation.--Not later than 2 years after
the completion of the CBI-SNP demonstration program, the
Secretary shall provide for the evaluation of the CBI-SNP
demonstration program by an independent third party. The
evaluation shall determine whether the CBI-SNP demonstration
program has improved patient care and quality of life for the
targeted low-income Medicare beneficiaries participating in the
CBI-SNP demonstration program. Specifically, the evaluation
shall determine if the CBI-SNP demonstration program has--
(A) reduced hospitalizations or re-
hospitalizations;
(B) reduced Medicaid nursing home facility stays;
and
(C) reduced spenddown of income and assets for
purposes of becoming eligible for Medicaid.
(2) Reports.--Not later than 3 years after the completion
of the CBI-SNP demonstration program, the Secretary shall
submit to Congress a report containing the results of the
evaluation conducted under paragraph (1), together with such
recommendations for legislative or administrative action as the
Secretary determines appropriate.
(g) Funding.--
(1) Funding for implementation.--For purposes of carrying
out the demonstration program under this section (other than
the evaluation and report under subsection (f)), the Secretary
shall provide for the transfer from the Federal Hospital
Insurance Trust Fund under section 1817 of the Social Security
Act (42 U.S.C. 1395i) and the Federal Supplementary Medical
Insurance Trust Fund under section 1841 of such Act (42 U.S.C.
1395t), in such proportion as the Secretary determines
appropriate, of $3,000,000 to the Centers for Medicare &
Medicaid Services Program Management Account.
(2) Funding for evaluation and report.--For purposes of
carrying out the evaluation and report under subsection (f),
the Secretary shall provide for the transfer from the Federal
Hospital Insurance Trust Fund under such section 1817 and the
Federal Supplementary Medical Insurance Trust Fund under such
section 1841, in such proportion as the Secretary determines
appropriate, of $500,000.
(3) Availability.--Amounts transferred under paragraph (1)
or (2) shall remain available until expended.
(h) Budget Neutrality.--In conducting the CBI-SNP demonstration
program, the Secretary shall ensure that the aggregate payments made by
the Secretary do not exceed the amount which the Secretary estimates
would have been expended under titles XVIII and XIX of the Social
Security Act (42 U.S.C. 1395 et seq., 1396 et seq.) if the CBI-SNP
demonstration program had not been implemented.
(i) Paperwork Reduction Act.--Chapter 35 of title 44, United States
Code, shall not apply to the testing and evaluation of the CBI-SNP
demonstration program under this section.
SEC. 251. APPLYING CMMI WAIVER AUTHORITY TO PACE IN ORDER TO FOSTER
INNOVATIONS.
(a) CMMI Waiver Authority.--Subsection (d)(1) of section 1115A of
the Social Security Act (42 U.S.C. 1315a) is amended--
(1) by inserting ``(other than subsections (b)(1)(A) and
(c)(5) of section 1894)'' after ``XVIII''; and
(2) by striking ``and 1903(m)(2)(A)(iii)'' and inserting
``1903(m)(2)(A)(iii), and 1934 (other than subsections
(b)(1)(A) and (c)(5) of such section)''.
(b) Sense of the Senate.--It is the sense of the Senate that the
Secretary of Health and Human Services should use the waiver authority
provided under the amendments made by this section to provide, in a
budget neutral manner, programs of all-inclusive care for the elderly
(PACE programs) with increased operational flexibility to support the
ability of such programs to improve and innovate and to reduce
technical and administrative barriers that have hindered enrollment in
such programs.
SEC. 252. IMPROVE AND MODERNIZE MEDICAID DATA SYSTEMS AND REPORTING.
(a) In General.--The Secretary of Health and Human Services shall
implement a strategic plan to increase the usefulness of data about
State Medicaid programs reported by States to the Centers for Medicare
& Medicaid Services. The strategic plan shall address redundancies and
gaps in Medicaid data systems and reporting through improvements to,
and modernization of, computer and data systems. Areas for improvement
under the plan shall include (but not be limited to) the following:
(1) The reporting of encounter data by managed care plans.
(2) The timeliness and quality of reported data, including
enrollment data.
(3) The consistency of data reported from multiple sources.
(4) Information about State program policies.
(b) Implementation Status Report.--Not later than 1 year after the
date of enactment of this Act, the Secretary of Health and Human
Services shall submit a report to Congress on the status of the
implementation of the strategic plan required under subsection (a).
(c) Authorization of Appropriations.--There is authorized to be
appropriated to the Secretary of Health and Human Services for the
period of fiscal years 2015 through 2109, such sums as may be necessary
to carry out this section.
SEC. 253. FAIRNESS IN MEDICAID SUPPLEMENTAL NEEDS TRUSTS.
(a) In General.--Section 1917(d)(4)(A) of the Social Security Act
(42 U.S.C. 1396p(d)(4)(A)) is amended by inserting ``the individual,''
after ``for the benefit of such individual by''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to trusts established on or after the date of the enactment of
this Act.
SEC. 254. HELPING ENSURE LIFE- AND LIMB-SAVING ACCESS TO PODIATRIC
PHYSICIANS.
(a) Including Podiatrists as Physicians Under the Medicaid
Program.--
(1) In general.--Section 1905(a)(5)(A) of the Social
Security Act (42 U.S.C. 1396d(a)(5)(A)) is amended by striking
``section 1861(r)(1)'' and inserting ``paragraphs (1) and (3)
of section 1861(r)''.
(2) Effective date.--
(A) In general.--Except as provided in subparagraph
(B), the amendment made by paragraph (1) shall apply to
services furnished on or after the date of enactment of
this Act.
(B) Extension of effective date for state law
amendment.--In the case of a State plan under title XIX
of the Social Security Act (42 U.S.C. 1396 et seq.)
which the Secretary of Health and Human Services
determines requires State legislation in order for the
plan to meet the additional requirement imposed by the
amendment made by paragraph (1), the State plan shall
not be regarded as failing to comply with the
requirements of such title solely on the basis of its
failure to meet these additional requirements before
the first day of the first calendar quarter beginning
after the close of the first regular session of the
State legislature that begins after the date of
enactment of this Act. For purposes of the previous
sentence, in the case of a State that has a 2-year
legislative session, each year of the session is
considered to be a separate regular session of the
State legislature.
(b) Modifications to Requirements for Diabetic Shoes to Be Included
Under Medical and Other Health Services Under Medicare.--
(1) In general.--Section 1861(s)(12) of the Social Security
Act (42 U.S.C. 1395x(s)(12)) is amended to read as follows:
``(12) subject to section 4072(e) of the Omnibus Budget
Reconciliation Act of 1987, extra-depth shoes with inserts or
custom molded shoes (in this paragraph referred to as
`therapeutic shoes') with inserts for an individual with
diabetes, if--
``(A) the physician who is managing the
individual's diabetic condition--
``(i) documents that the individual has
diabetes;
``(ii) certifies that the individual is
under a comprehensive plan of care related to
the individual's diabetic condition; and
``(iii) documents agreement with the
prescribing podiatrist or other qualified
physician (as established by the Secretary)
that it is medically necessary for the
individual to have such extra-depth shoes with
inserts or custom molded shoes with inserts;
``(B) the therapeutic shoes are prescribed by a
podiatrist or other qualified physician (as established
by the Secretary) who--
``(i) examines the individual and
determines the medical necessity for the
individual to receive the therapeutic shoes;
and
``(ii) communicates in writing the medical
necessity to the physician described in
subparagraph (A) for the individual to have
therapeutic shoes along with findings that the
individual has peripheral neuropathy with
evidence of callus formation, a history of pre-
ulcerative calluses, a history of previous
ulceration, foot deformity, previous
amputation, or poor circulation; and
``(C) the therapeutic shoes are fitted and
furnished by a podiatrist or other qualified supplier
(as established by the Secretary), such as a pedorthist
or orthotist, who is not the physician described in
subparagraph (A) (unless the Secretary finds that the
physician is the only such qualified individual in the
area);''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply with respect to items and services furnished on or
after January 1, 2015.
SEC. 255. DEMONSTRATION PROGRAM TO IMPROVE COMMUNITY MENTAL HEALTH
SERVICES.
(a) Establishment.--Not later than January 1, 2016, the Secretary
of Health and Human Services (referred to in this section as the
``Secretary''), in coordination with the Administrator of the Substance
Abuse and Mental Health Services Administration, shall award planning
grants to not to exceed 10 States to enable such States to carry out 5-
year demonstration programs to improve the provision of behavioral
health services provided by certified community behavioral health
clinics in the State.
(b) Eligibility.--
(1) Application.--To be eligible to receive a grant under
subsection (a), a State shall--
(A) submit to the Secretary an application at such
time, in such manner, and containing such information
as the Secretary may require;
(B) certify to the Secretary that behavioral health
providers that are provided assistance under the
demonstration program meet the criteria for certified
community behavioral health clinics under subsection
(c);
(C) conduct a financial assessment of the
demonstration program to be carried out under the grant
by providing a detailed estimate of eligible clinics
and Medicaid expenditures over the entire projected
period of the demonstration program; and
(D) comply with any other requirement determined
appropriate by the Secretary.
(2) Waiver of medicaid requirement.--In approving States to
conduct demonstration programs under this section, the
Secretary shall waive section 1902(a)(1) of the Social Security
Act (42 U.S.C. 1396a(a)(1)) (relating to statewideness) as may
be necessary to conduct the demonstration program in accordance
with the requirements of this section
(c) Criteria.--
(1) Criteria for certified community behavioral health
clinics.--The criteria referred to in subsection (b)(1)(B) are
that the center performs each of the following:
(A) Provide services in locations that ensure
services will be available and accessible promptly and
in a manner which preserves human dignity and assures
continuity of care.
(B) Provide services in a mode of service delivery
appropriate for the target population.
(C) Provide individuals with a choice of service
options, including developmentally appropriate evidence
based interventions, where there is more than one
efficacious treatment.
(D) Employ a core clinical staff that is trained to
provide evidence-based practices and is
multidisciplinary and culturally and linguistically
competent, including the availability of translation or
similar services and arrangements if the clinic is
located in a geographic area of limited English-
speaking ability.
(E) Establish an emergency plan to support
continuity of services for individuals during an
emergency or disaster.
(F) Demonstrate the capacity to comply with
behavioral health and related health care quality
measures promulgated by such entities as the National
Quality Forum, the National Committee for Quality
Assurance, or other nationally recognized accrediting
bodies.
(G) Provide services to any individual residing or
employed in the service area of the clinic and ensure
that no patient or consumer will be denied mental
health or other health care services due to an
individual's inability to pay for such services.
(H) Ensure that any fees or payments required by
the clinic for such services will be imposed for
individuals eligible for medical assistance under the
State Medicaid plan under title XIX of the Social
Security Act in accordance with the requirements of
such State plan and for any other individuals will be
reduced or waived to enable the clinic to comply with
subparagraph (G), including preparing a schedule of
fees or payments for the provision of services that is
consistent with locally prevailing rates or charges
designed to cover the reasonable costs to the clinic of
operation along with a corresponding schedule of
discounts to be applied to the payment of such fees or
payments, such discounts to be adjusted on the basis of
the patient's ability to pay.
(I) Report required encounter data, clinical
outcomes data, and quality data.
(J) Provide, directly or through contract, to the
extent covered for adults in the State Medicaid plan
under title XIX of the Social Security Act and for
children in accordance with section 1905(r) of such Act
regarding early and periodic screening, diagnosis, and
treatment, each of the following services:
(i) Screening, assessment, and diagnosis,
including risk assessment.
(ii) Person-centered treatment planning or
similar processes, including risk assessment
and crisis planning.
(iii) Outpatient mental health and
substance use services, including screening,
assessment, diagnosis, psychotherapy, cognitive
behavioral therapy, applied behavioral
analysis, medication management, and integrated
treatment for trauma, mental illness, and
substance abuse which shall be evidence-based
(including cognitive behavioral therapy, long
acting injectable medications, and other such
therapies which are evidence-based).
(iv) Outpatient clinic primary care
screening and monitoring of key health
indicators and health risk (including screening
for diabetes, hypertension, and cardiovascular
disease and monitoring of weight, height, body
mass index (BMI), blood pressure, blood glucose
or HbA1C, and lipid profile).
(v) Crisis mental health services,
including 24-hour mobile crisis teams,
emergency crisis intervention services, and
crisis stabilization.
(vi) Targeted case management (services to
assist individuals gaining access to needed
medical, social, educational, and other
services and applying for income security and
other benefits to which they may be entitled),
and care coordination.
(vii) Psychiatric rehabilitation services
including skills training, assertive community
treatment, family psychoeducation, disability
self-management, supported employment,
supported housing services, therapeutic foster
care services, and such other evidence-based
practices as the Secretary may require.
(viii) Peer support and counselor services
and family supports.
(K) Maintain linkages, and where possible enter
into formal contracts, agreements, or partnerships with
at least one federally qualified health center, unless
there is no such center serving the service area, in
order to ensure that the delivery of behavioral health
care is integrated with primary and preventive care
services, so long as such linkages, contract,
agreement, or partnership meets requirements as
prescribed by the Secretary;
(L) Maintain additional linkages and where possible
enter into formal contracts with the following:
(i) Inpatient psychiatric facilities and
substance use detoxification, post-
detoxification step-down services, and
residential programs.
(ii) Adult and youth peer support and
counselor services.
(iii) Family support services for families
of children with serious mental or substance
use disorders.
(iv) Other community or regional services,
supports, and providers, including schools,
child welfare agencies, juvenile and criminal
justice agencies and facilities, Indian Health
Service youth regional treatment centers,
housing agencies and programs, employers, State
licensed and nationally accredited child
placing agencies for therapeutic foster care
service, and other social and human services.
(v) Onsite or offsite access to primary
care services.
(vi) Enabling services, including outreach,
transportation, and translation.
(vii) Health and wellness services,
including services for tobacco cessation.
(viii) Department of Veterans Affairs
medical centers, independent outpatient
clinics, drop-in centers, and other facilities
of the Department as defined in section 1801 of
title 38, United States Code.
(ix) Inpatient acute care hospitals and
hospital outpatient clinics.
(M) Where feasible, provide outreach and engagement
to encourage individuals who could benefit from mental
health care to freely participate in receiving the
administrative services described in this subsection.
(N) Where feasible, provide intensive, community-
based mental health care for members of the armed
forces and veterans, particularly those members and
veterans located in rural areas, such care to be
consistent with minimum clinical mental health
guidelines promulgated by the Veterans Health
Administration including clinical guidelines contained
in the Uniform Mental Health Services Handbook of such
Administration.
(O) Where feasible, require certified community
behavioral health clinics to provide valid and reliable
trauma screening and functional or developmental
assessment to determine need, match services to needs,
and to measure progress over time.
(2) Regulations.--Prior to the selection of participating
States, and not later than 18 months after the date of the
enactment of this Act, the Secretary, in consultation with the
Substance Abuse and Mental Health Services Administration and
the State Mental Health and Substance Abuse Authorities, shall
issue final regulations for certifying non-profit and local
government behavioral health authorities and Indian Health
Service tribal facilities as community behavioral health
clinics.
(d) Requirements.--In awarding grants under this section, the
Secretary shall--
(1) ensure the geographic diversity of grantee States;
(2) ensure that certified community behavioral health
clinics in such States that are located in rural areas, as
defined by the Secretary, and other mental health professional
shortage areas are fairly and appropriately considered with the
objective of facilitating access to mental health services in
such areas;
(3) take into account the ability of clinics in such States
to provide required services, and the ability of such clinics
to report required data as required under this section; and
(4) take into account the ability of such States to provide
such required services on a statewide basis.
(e) Exemption.--For purposes of this section, certified community
behavioral health clinics that receive payments under section 1902(bb)
of the Social Security Act which are located in rural areas, as defined
by the Secretary, shall be exempt from the requirements contained in
subparagraphs (A) and (J)(v) of subsection (c)(1).
(f) Treatment of Certain Services Provided by Community Behavioral
Health Clinics as Medical Assistance.--
(1) In general.--For purposes of the demonstration program
under this section, community behavioral health clinic services
(as defined in subsection (h)(1)) that are provided by
certified community behavioral health clinics receiving
assistance under this section shall be considered medical
assistance for purposes of payments to States under paragraph
(3)(C).
(2) Grant condition.--As a condition of receiving a grant
under this section, a State shall agree to provide for payment
for community behavioral health clinic services in accordance
with the prospective payment system established by the
Secretary under paragraph (3).
(3) Prospective payment system.--
(A) In general.--Not later than 18 months after the
date of enactment of this Act, the Secretary shall
establish a prospective payment system for community
behavioral health clinic services furnished by a
community behavioral health clinic receiving assistance
under this section in the same manner as payments are
required to be made under section 1902(bb) of the
Social Security Act (42 U.S.C. 1396a(bb)) for services
described in section 1905(a)(2)(C) of such Act (42
U.S.C. 1396d(a)(2)(C)) furnished by a Federally-
qualified health center and services described in
section 1905(a)(2)(B) of such Act (42 U.S.C.
1396d(a)(2)(B)) furnished by a rural health clinic.
(B) Requirements.--The prospective payment system
established by the Secretary under subparagraph (A)
shall provide that--
(i) no payment shall be made for inpatient
care, residential treatment, room and board
expenses, or any other non-ambulatory services,
as determined by the Secretary; and
(ii) no payment shall be made to satellite
facilities of community behavioral health
clinics if such facilities are established
after the date of enactment of this Act.
(C) Payments to states.--The Secretary shall pay
each State awarded a grant under this section an amount
each quarter equal to the enhanced FMAP (as defined in
section 2105(b) of the Social Security Act (42 U.S.C.
1397dd(b)) but without regard to the second and third
sentences of that section) of the State's expenditures
in the quarter for medical assistance for community
behavioral health clinic services provided by certified
community behavioral health clinics in the State that
receive assistance under this section. Payments to
States made under this subparagraph shall be considered
to have been under, and are subject to the requirements
of, section 1903 of the Social Security Act (42 U.S.C.
1396b).
(g) Annual Report.--
(1) In general.--Not later than 1 year after the date on
which the first grants are awarded under this section, and
annually thereafter, the Secretary shall submit to Congress an
annual report on the use of funds provided under the
demonstration program. Each such report shall include--
(A) an assessment of access to community-based
mental health services under the Medicaid program in
the States awarded such grants;
(B) an assessment of the quality and scope of
services provided by certified community behavioral
health clinics under the grants as compared against
community-based mental health services provided in
States that are not receiving such grants; and
(C) an assessment of the impact of the
demonstration programs on the costs of a full range of
mental health services (including inpatient, emergency
and ambulatory services).
(2) Recommendations.--Not later than December 31, 2019, the
Secretary shall submit to Congress recommendations concerning
whether the demonstration programs under this section should be
continued and expanded on a national basis.
(h) Definitions.--In this section:
(1) Community behavioral health clinic services.--The term
``community behavioral health clinic services'' means
ambulatory behavioral health services of the type described in
subparagraphs (J), (M), (N), and (O) of subsection (c)(1) that
are provided by certified community behavioral health clinics
receiving assistance under this section.
(2) State.--The term ``State'' has the meaning given such
term for purposes of title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
(i) Authorization of Appropriations.--There is authorized to be
appropriated to carry out this section, $50,000,000 for fiscal year
2016, to remain available until expended.
SEC. 256. ANNUAL MEDICAID DSH REPORT.
Section 1923 of the Social Security Act (42 U.S.C. 1396r-4) is
amended by adding at the end the following:
``(k) Annual Report to Congress.--
``(1) In general.--Beginning January 1, 2015, and annually
thereafter, the Secretary shall submit a report to Congress on
the program established under this section for making payment
adjustments to disproportionate share hospitals for the purpose
of providing Congress with information relevant to determining
an appropriate level of overall funding for such payment
adjustments during and after the period in which aggregate
reductions in the DSH allotments to States are required under
paragraphs (7) and (8) of subsection (f).
``(2) Required report information.--Except as otherwise
provided, each report submitted under this subsection shall
include the following:
``(A) Information and data relating to changes in
the number of uninsured individuals for the most recent
year for which such data are available as compared to
2013 and as compared to the Congressional Budget Office
estimates of uninsured individuals made at the time of
the enactment of the Patient Protection and Affordable
Care Act (Public Law 111-148) and the Health Care and
Education Reconciliation Act of 2010 (Public Law 111-
152).
``(B) Information and data relating to the extent
to which hospitals continue to incur uncompensated care
costs from providing unreimbursed or under-reimbursed
services to individuals who either are eligible for
medical assistance under the State plan under this
title or under a waiver of such plan or who have no
health insurance (or other source of third party
coverage) for such services.
``(C) Information and data relating to the extent
to which hospitals continue to provide charity care and
unreimbursed or under-reimbursed services, or otherwise
incur bad debt, under the program established under
this title, the State Children's Health Insurance
Program established under title XXI, and State or local
indigent care programs, as reported on cost reports
submitted under title XVIII or such other data as the
Secretary determines appropriate.
``(D) In the first report submitted under this
section, a methodology for estimating the amount of
unpaid patient deductibles, copayments and coinsurance
incurred by hospitals for patients enrolled in
qualified health plans through an American Health
Benefits Exchange, using existing data and minimizing
the administrative burden on hospitals to the extent
possible, and in subsequent reports, data regarding
such uncompensated care costs collected pursuant to
such methodology.
``(E) For each State, information and data relating
to the difference between the DSH allotment for the
State for the fiscal year that began on October 1 of
the year preceding the year in which the report is
submitted and the aggregate amount of uncompensated
care costs for all disproportionate share hospitals in
the State.
``(F) Information and data relating to the extent
to which there are certain vital hospital systems that
are disproportionately experiencing high levels of
uncompensated care and that have multiple other
missions, such as a commitment to graduate medical
education, the provision of tertiary and trauma care
services, providing public health and essential
community services, and providing comprehensive,
coordinated care.
``(G) Such other information and data relevant to
the determination of the level of funding for, and
amount of, State DSH allotments as the Secretary
determines appropriate
``(3) Authorization of appropriations.--There is authorized
to be appropriated to the Secretary for the period of fiscal
years 2015 through 2109, such sums as may be necessary to carry
out this subsection.''.
SEC. 257. IMPLEMENTATION.
To the extent the Secretary of Health and Human Services issues a
regulation to carry out the provisions of this Act, the Secretary
shall, unless otherwise specified in this Act--
(1) issue a notice of proposed rulemaking that includes the
proposed regulation;
(2) provide a period of not less than 60 calendar days for
comments on the proposed regulation;
(3) not more than 24 months following the date of
publication of the proposed rule, publish the final regulation
or take alternative action (such as withdrawing the rule or
proposing a revised rule with a new comment period) on the
proposed regulation; and
(4) not less than 30 days before the effective date of the
final regulation, publish the final regulation or take
alternative action (such as withdrawing the rule or proposing a
revised rule with a new comment period) on the proposed
regulation.
Calendar No. 280
113th CONGRESS
1st Session
S. 1871
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to repeal the Medicare
sustainable growth rate formula and to improve beneficiary access under
the Medicare program, and for other purposes.
_______________________________________________________________________
December 19, 2013
Read twice and placed on the calendar