[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2570 Referred in Senate (RFS)]
114th CONGRESS
1st Session
H. R. 2570
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
June 18, 2015
Received; read twice and referred to the Committee on Finance
_______________________________________________________________________
AN ACT
To amend title XVIII of the Social Security Act with respect to the
treatment of patient encounters in ambulatory surgical centers in
determining meaningful EHR use, establish a demonstration program
requiring the utilization of Value-Based Insurance Design to
demonstrate that reducing the copayments or coinsurance charged to
Medicare beneficiaries for selected high-value prescription medications
and clinical services can increase their utilization and ultimately
improve clinical outcomes and lower health care expenditures, 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.
This Act may be cited as the ``Strengthening Medicare Advantage
through Innovation and Transparency for Seniors Act of 2015''.
SEC. 2. TREATMENT OF PATIENT ENCOUNTERS IN AMBULATORY SURGICAL CENTERS
IN DETERMINING MEANINGFUL EHR USE.
Section 1848(o)(2) of the Social Security Act (42 U.S.C. 1395w-
4(o)(2)) is amended by adding at the end of the following new
subparagraph:
``(D) Treatment of patient encounters at ambulatory
surgical centers.--
``(i) In general.--Subject to clause (ii),
for a payment year after 2015 any patient
encounter of an eligible professional occurring
at an ambulatory surgical center (described in
section 1833(i)(1)(A)) shall not be treated as
a patient encounter in determining whether an
eligible professional qualifies as a meaningful
EHR user. Notwithstanding any other provision
of law, the Secretary may implement this clause
by program instruction or otherwise.
``(ii) Sunset.--Clause (i) shall no longer
apply as of the first payment year that begins
more than 3 years after the date the Secretary
determines, through notice and comment
rulemaking, that certified EHR technology is
applicable to the ambulatory surgical center
setting.''.
SEC. 3. VALUE-BASED INSURANCE DESIGN DEMONSTRATION PROGRAM.
(a) In General.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') shall establish a 3-year
demonstration program to test the use of value-based insurance design
methodologies (as defined in subsection (c)(1)) under eligible Medicare
Advantage plans offered by Medicare Advantage organizations under part
C of title XVIII of the Social Security Act (42 U.S.C. 1395w-21 et
seq.). The Secretary may extend the program to a duration of 4 or 5
years, as determined necessary by the Secretary in coordination with
the Centers for Medicare and Medicaid Innovation.
(b) Demonstration Program Design.--
(1) Selection of medicare advantage sites and eligible
medicare advantage plans.--Not later than 2 years after the
date of the enactment of this Act, the Secretary shall--
(A) select at least two Medicare Advantage sites
with respect to which to conduct the demonstration
program under this section; and
(B) approve eligible Medicare Advantage plans to
participate in such demonstration program.
In selecting Medicare Advantage sites under subparagraph (A),
the Secretary shall take into account area differences as well
as the availability of health maintenance organization plans
and preferred provider organization plans offered in such
sites.
(2) Start of demonstration.--The demonstration program
shall begin not later than the third plan year beginning after
the date of the enactment of this Act.
(3) Eligible medicare advantage plans.--For purposes of
this section, the term ``eligible Medicare Advantage plan''
means a Medicare Advantage plan under part C of title XVIII of
the Social Security Act (42 U.S.C. 1395w-21 et seq.) that meets
the following requirements:
(A) The plan is an Medicare Advantage regional plan
(as defined in paragraph (4) of section 1859(b) of such
Act (42 U.S.C. 1395w-28(b))) or Medicare Advantage
local plan (as defined in paragraph (5) of such
section) offered in the Medicare Advantage region
selected under paragraph (1)(A).
(B) The plan has--
(i)(I) a quality rating under section
1853(o) of such Act (42 U.S.C. 1395w-23(o)) of
4 stars or higher based on the most recent data
available for such year, or (II) in the case of
a specialized Medicare Advantage plan for
special needs individuals, as defined in
section 1859(b)(6)(A) of such Act (42 U.S.C.
1395w-28(b)(6)(A)), a quality rating under
section 1853(o) of such Act (42 U.S.C. 1395w-
23(o)) equal to or higher than the national
average for special needs plans (excluding
Institutional-Special needs plans) based on the
most recent data available for such year; and
(ii) at least 20 percent of the population
to whom the plan is offered in a service area
consists of subsidy eligible individuals (as
defined in section 1860D-14(a)(3)(A) of the
Social Security Act (42 U.S.C. 1395w-
114(a)(3)(A))).
(4) Disclosure to beneficiaries.--The Secretary shall
provide to each individual eligible to enroll under a Medicare
Advantage plan approved to participate under the demonstration
program during a plan year for which the plan is so selected--
(A) notification that the plan is participating in
such demonstration program;
(B) background information on the demonstration
program;
(C) clinical data derived from the studies
resulting from the demonstration program; and
(D) notification of the potential benefits that the
individual will receive, and of the other potential
impacts that the individual will experience, on account
of the participation of the plan in the demonstration
program.
(c) Value-Based Insurance Design Methodologies.--
(1) Definition.--For purposes of this section, the term
``value-based insurance design methodology'' means a
methodology for identifying specific prescription medications,
and clinical services that are payable under title XVIII of the
Social Security Act, for which the reduction of copayments,
coinsurance, or both, would improve the management of specific
chronic clinical conditions because of the high value and
effectiveness of such medications and services for such
specific chronic clinical conditions, as approved by the
Secretary.
(2) Use of methodologies to reduce copayments and
coinsurance.--A Medicare Advantage organization offering an
eligible Medicare Advantage plan approved to participate under
the demonstration program, for each plan year for which the
plan is so selected and using value-based insurance design
methodologies--
(A) shall identify each prescription medication and
clinical service covered under such plan for which the
plan proposes to reduce or eliminate the copayment or
coinsurance, with respect to the management of specific
chronic clinical conditions (as specified by the
Secretary) of Medicare Advantage eligible individuals
(as defined in section 1851(a)(3) of the Social
Security Act (42 U.S.C. 1395w-21(a)(3))) enrolled under
such plans, for such plan year;
(B) may, for such plan year, reduce or eliminate
copayments, coinsurance, or both for such prescription
medication and clinical services so identified with
respect to the management of such conditions of such
individuals--
(i) if such reduction or elimination is
evidence-based and for the purpose of
encouraging such individuals in such plan to
use such prescription medications and clinical
services (such as preventive care, primary
care, specialty visits, diagnostic tests,
procedures, and durable medical equipment) with
respect to such conditions; and
(ii) for the purpose of encouraging such
individuals in such plan to use health care
providers that such organization has identified
with respect to such plan year as being high
value providers; and
(C) if a reduction or elimination is applied
pursuant to subparagraph (B), with respect to such
medication and clinical services, shall, for such plan
year, count toward the deductible applicable to such
individual under such plan amounts that would have been
payable by the individual as copayment or coinsurance
for such medication and services if the reduction or
elimination had not been applied.
(3) Prohibition of increases of copayments and
coinsurance.--In no case may any Medicare Advantage plan
participating in the demonstration program increase, for any
plan year for which the plan is so participating, the amount of
copayments or coinsurance for any item or service covered under
such plan for purposes of discouraging the use of such item or
service.
(d) Report on Implementation.--
(1) In general.--Not later than 1 year after the date on
which the demonstration program under this section begins under
subsection (b)(2), the Secretary shall submit to Congress a
report on the status of the implementation of the demonstration
program.
(2) Elements.--The report required by paragraph (1) shall,
with respect to eligible Medicare Advantage plans participating
in the demonstration program for the first plan year of such
program, include the following:
(A) A list of each medication and service
identified pursuant to subsection (c)(2)(A) for such
plan with respect to such plan year.
(B) For each such medication or service so
identified, the amount of the copayment or coinsurance
required under such plan with respect to such plan year
for such medication or service and the amount of the
reduction of such copayment or coinsurance from a
previous plan year.
(C) For each provider identified pursuant to
subsection (c)(2)(B)(ii) for such plan with respect to
such plan year, a statement of the amount of the
copayment or coinsurance required under such plan with
respect to such plan year and the amount of the
reduction of such copayment or coinsurance from the
previous plan year.
(e) Review and Assessment of Utilization of Value-Based Insurance
Design Methodologies.--
(1) In general.--The Secretary shall enter into a contract
or agreement with an independent entity to review and assess
the implementation of the demonstration program under this
section. The review and assessment shall include the following:
(A) An assessment of the utilization of value-based
insurance design methodologies by Medicare Advantage
plans participating under such program.
(B) An analysis of whether reducing or eliminating
the copayment or coinsurance for each medication and
clinical service identified pursuant to subsection
(c)(2)(A) resulted in increased adherence to medication
regimens, increased service utilization, improvement in
quality metrics, better health outcomes, and enhanced
beneficiary experience.
(C) An analysis of the extent to which costs to
Medicare Advantage plans under part C of title XVIII of
the Social Security Act participating in the
demonstration program is less than costs to Medicare
Advantage plans under such part that are not
participating in the demonstration program.
(D) An analysis of whether reducing or eliminating
the copayment or coinsurance for providers identified
pursuant to subsection (c)(2)(B)(ii) resulted in
improvement in quality metrics, better health outcomes,
and enhanced beneficiary experience.
(E) An analysis, for each provider so identified,
the extent to which costs to Medicare Advantage plans
under part C of title XVIII of the Social Security Act
participating in the demonstration program is less than
costs to Medicare Advantage plans under such part that
are not participating in the demonstration program.
(F) Such other matters as the Secretary considers
appropriate.
(2) Report.--The contract or agreement entered into under
paragraph (1) shall require such entity to submit to the
Secretary a report on the review and assessment conducted by
the entity under such paragraph in time for the inclusion of
the results of such report in the report required by paragraph
(3). Such report shall include a description, in clear
language, of the manner in which the entity conducted the
review and assessment.
(3) Report to congress.--Not later than 4 years after the
date on which the demonstration program begins under subsection
(b)(2), the Secretary shall submit to Congress a report on the
review and assessment of the demonstration program conducted
under this subsection. The report shall include the following:
(A) A description of the results of the review and
assessment included in the report submitted pursuant to
paragraph (2).
(B) Such recommendations as the Secretary considers
appropriate for enhancing the utilization of the
methodologies applied under the demonstration program
to all Medicare Advantage plans under part C of title
XVIII of the Social Security Act so as to reduce
copayments and coinsurance under such plans paid by
Medicare beneficiaries for high-value prescription
medications and clinical services for which coverage is
provided under such plans and to otherwise improve the
quality of health care provided under such plans.
(4) Oversight report.--Not later than 3 years after the
date of the enactment of this Act, the Comptroller General of
the United States shall submit to Congress a report on the
demonstration program that includes an assessment, with respect
to individuals enrolled under Medicare Advantage plans approved
to participate under the demonstration program, of the impact
that the age, co-morbidities, and geographic regions of such
individuals had upon the implementation of the demonstration
program by the plans with respect to such individuals.
(f) Savings.--In no case may any reduction in beneficiary
copayments or coinsurance resulting from the implementation of the
demonstration program under this section result in expenditures under
parts A, B, and D of the title XVIII of the Social Security Act that
are greater than such expenditures without application of this section.
(g) Expansion of Demonstration Program.--Taking into account the
review and assessment conducted under subsection (e), the Secretary
may, through notice and comment rulemaking, expand (including
implementation on a nationwide basis) the duration and scope of the
demonstration program under title XVIII of the Social Security Act,
other than under the original medicare fee-for-service program under
parts A and B of such title, to the extent determined appropriate by
the Secretary, if the requirements of paragraphs (1), (2), and (3) of
subsection (c) of section 1115A of the Social Security Act (42 U.S.C.
1315a), as applied to the testing of a model under subsection (b) of
such section, applied to the demonstration under this section.
(h) Waiver Authority.--The Secretary may waive such provisions of
titles XI and XVIII of the Social Security Act as may be necessary to
carry out the demonstration program under this section.
(i) Implementation Funding.--For purposes of carrying out the
demonstration program under this section, 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 Insurance Trust Fund under section 1841 of the
Social Security Act (42 U.S.C. 1395t), including the Medicare
Prescription Drug Account in such Trust Fund, in such proportion as
determined appropriate by the Secretary, of such sums as may be
necessary.
SEC. 4. TREATMENT OF INFUSION DRUGS FURNISHED THROUGH DURABLE MEDICAL
EQUIPMENT.
Section 1842(o)(1) of the Social Security Act (42 U.S.C.
1395u(o)(1)) is amended--
(1) in subparagraph (C), by inserting ``(and including a
drug or biological described in subparagraph (D)(i) furnished
on or after January 1, 2017)'' after ``2005''; and
(2) in subparagraph (D)--
(A) by striking ``infusion drugs'' and inserting
``infusion drugs or biologicals'' each place it
appears; and
(B) in clause (i)--
(i) by striking ``2004'' and inserting
``2004, and before January 1, 2017''; and
(ii) by striking ``for such drug''.
SEC. 5. SENSE OF CONGRESS REGARDING THE IMPLEMENTATION AND DISTRIBUTION
OF QUALITY INCENTIVE PAYMENTS TO MEDICARE ADVANTAGE
PLANS.
It is the sense of Congress that--
(1) the Secretary of Health and Human Services has
incorrectly interpreted subsection (n) of section 1853 of the
Social Security Act (42 U.S.C. 1395w-23) as prohibiting the
provision of any Medicare quality incentive payments under
subsection (o) of such section with respect to Medicare
Advantage plans that exceed the payment benchmark cap under
such subsection (n) for the area served by such plans; and
(2) the Secretary should immediately apply quality
incentive payments under such subsection (o) with respect to
such Medicare Advantage plans without regard to the limits set
forth in such subsection (n).
SEC. 6. MEDICARE IMPROVEMENT FUND.
Section 1898(b)(1) of the Social Security Act (42 U.S.C.
1395iii(b)(1)) is amended by striking ``during and after fiscal year
2020, $0'' and inserting ``after fiscal year 2020, $220,000,000''.
SEC. 7. NON-INCLUSION OF DME INFUSION DRUGS UNDER DME COMPETITIVE
ACQUISITION PROGRAMS.
(a) In General.--Section 1847(a)(2)(A) of the Social Security Act
(42 U.S.C. 1395w-3(a)(2)(A)) is amended--
(1) by striking ``and excluding'' and inserting ``,
excluding''; and
(2) by inserting before the period at the end the
following: ``, and excluding drugs and biologicals described in
section 1842(o)(1)(D)''.
(b) Conforming Amendment.--Section 1842(o)(1)(D)(ii) of the Social
Security Act (42 U.S.C. 1395u(o)(1)(D)(ii)) is amended by striking
``2007'' and inserting ``2007, and before the date of the enactment of
the Strengthening Medicare Advantage through Innovation and
Transparency for Seniors Act of 2015''.
Passed the House of Representatives June 17, 2015.
Attest:
KAREN L. HAAS,
Clerk.