[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[H.R. 9638 Introduced in House (IH)]
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117th CONGRESS
2d Session
H. R. 9638
To amend title XVIII of the Social Security Act to provide coverage of
ALS-related services under the Medicare program for individuals
diagnosed with amyotrophic lateral sclerosis, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
December 20, 2022
Ms. Schakowsky (for herself, Mr. Quigley, Mr. Fitzpatrick, and Mr.
Crow) introduced the following bill; which was referred to the
Committee on Ways and Means, and in addition to the Committee on Energy
and Commerce, for a period to be subsequently determined by the
Speaker, in each case for consideration of such provisions as fall
within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to provide coverage of
ALS-related services under the Medicare program for individuals
diagnosed with amyotrophic lateral sclerosis, 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 ``Medicare Payment Reform for People
with ALS Act of 2022''.
SEC. 2. PROVIDING FOR COVERAGE OF ALS-RELATED SERVICES UNDER THE
MEDICARE PROGRAM FOR INDIVIDUALS DIAGNOSED WITH
AMYOTROPHIC LATERAL SCLEROSIS.
(a) In General.--Subtitle E of title XVIII of the Social Security
Act (42 U.S.C. 1395 et. seq.) is amended by inserting after section
1881A the following new section:
``SEC. 1881B. MEDICARE COVERAGE OF ALS-RELATED SERVICES FOR INDIVIDUALS
DIAGNOSED WITH AMYOTROPHIC LATERAL SCLEROSIS.
``(a) In General.--In the case of a covered ALS individual, the
Secretary shall establish a supplemental facility-based payment system
described in subsection (d) for ALS-related services provided to such
an individual.
``(b) Covered ALS Individual.--For purposes of this section, the
term `covered ALS individual' means an individual who is medically
determined to have amyotrophic lateral sclerosis (as described in
section 226(h)).
``(c) ALS-Related Services.--For purposes of this section, the term
`ALS-related services' means items and services that are ordinarily
furnished to a covered ALS individual in an outpatient setting by a
qualified provider (or by others under arrangements with them made by
the qualified provider) consistent with a multidisciplinary approach
(as determined by the Secretary) for the care and treatment of such an
individual with respect to the progression of amyotrophic lateral
sclerosis.
``(d) Payment System.--
``(1) Authority.--The Secretary shall establish a facility-
based payment system under which a single payment determined in
accordance with the succeeding paragraphs is made to a
qualified provider for ALS-related services furnished to a
covered ALS individual during a visit beginning on and after
January 1, 2024.
``(2) Base payment amount.--
``(A) 2024.--For coverage year 2024, the Secretary
shall establish a single payment amount for ALS-related
services equal to $800 for such services furnished for
each visit during such year.
``(B) 2025.--
``(i) In general.--For coverage year 2025,
the Secretary shall establish a single payment
amount for ALS-related services furnished for
each visit during such year that is the greater
of--
``(I) taking into account the
payment amount recommended by the
Comptroller General in the report
described in clause (ii), the amount
specified by the Secretary; or
``(II) the amount specified in
subparagraph (A).
``(ii) Report by the comptroller general.--
Not later than January 1, 2024, the Comptroller
General shall, in consultation with qualified
providers submit to the Secretary of Health and
Human Services a report that recommends a
single payment amount for ALS-related services
that takes into account the average amount of
payment for each item or service included in
ALS-related services that the Comptroller
General estimates would have been payable--
``(I) under this title for such a
service based on per patient
utilization data from whichever single
coverage year from 2020 through 2022
has the highest per patient utilization
of ALS-related services, even if such
service is not payable for a particular
ALS individual because of the
application of section 1862(a)(1)(A)
with respect to an item or service
provided to such individual;
``(II) in the case an estimate is
unable to be determined pursuant to
subclause (I), by health insurance
issuers and group health plans (as such
terms are defined in section 2791 of
the Public Health Service Act) and MA
plans under part C for such a service,
based on such data from whichever
single coverage year from 2020 through
2022 has the highest per patient
utilization of ALS-related services;
and
``(III) in the case an estimate is
unable to be determined pursuant to
subclause (II), based on the
recommendation of the Specialty Society
Relative Value Scale Update Committee
of the American Medical Association or
the estimate of the Comptroller General
for such a service.
``(C) 2026 and subsequent years.--For each coverage
year beginning with coverage year 2026, the Secretary
shall annually increase the payment amount for each
visit determined under this paragraph by an ALS
services market basket percentage increase (as
determined by the Secretary) that reflects changes over
time in the prices of an appropriate mix of goods and
services that are ALS-related services.
``(3) Payment adjustments.--The payment system under this
subsection--
``(A) shall include a payment adjustment based on
case mix that may take into account comorbidities,
length of time from diagnosis, age, race, ethnicity,
and other appropriate factors;
``(B) shall include a payment adjustment for high-
cost outliers due to unusual variations in the type or
amount of medically necessary care;
``(C) shall include a payment adjustment that
reflects the extent to which costs incurred by low-
volume facilities (as defined by the Secretary) in
furnishing ALS-related services exceed the costs
incurred by other facilities in furnishing such
services, and such payment adjustment may not be less
than 10 percent;
``(D) shall include a payment adjustment for a
medical service or technology which is furnished as a
part of ALS-related services for which, as determined
by the Secretary--
``(i) payment for the service or technology
as part of ALS-related services under this
section was not being made in the preceding
coverage year; and
``(ii) the cost of the service or
technology is not insignificant in relation the
payment amount (as determined under this
subsection) payable for ALS-related services;
and
``(E) may include such other payment adjustments as
the Secretary deems appropriate, including a payment
adjustment for--
``(i) a geographic index, such as the index
referred to in section 1886(d)(3)(E);
``(ii) the status of the facility as
provider-based or free-standing (as such terms
are defined in section 413.65(a)(2), title 42,
Code of Federal Regulations); and
``(iii) qualified providers located in
rural areas (as defined in section
1886(d)(2)(D)).
``(4) Mechanism for payments.--For purposes of making
payments for ALS-related services, the Secretary shall
establish a mechanism under the payment system under this
subsection which makes payment when a qualified provider
submits a claim for reimbursement which includes, with respect
to a covered ALS individual, an alphanumeric code issued under
the International Classification of Diseases, 10th Revision,
Clinical Modification (`ICD-10-CM') and its subsequent
revisions that is for the treatment of a diagnosis of
amyotrophic lateral sclerosis.
``(5) No cost sharing.--Payment under this subsection shall
be made only on an assignment-related basis without any cost
sharing.
``(6) Qualified provider defined.--In this section, the
term `qualified provider' means a provider of services which
meets requirements as the Secretary prescribes by regulation.
``(e) Clarification.--Payment under subsection (d) shall be in
addition to, and shall not supplant, any payment that would be
otherwise made to a provider of services, physician, practitioner,
supplier, or laboratory under any other provision of this title for an
item or service furnished to a covered ALS individual.
``(f) Implementation.--
``(1) In general.--Except as provided under paragraph (2),
the Secretary may implement the provisions of this section by
program instruction or otherwise.
``(2) Rulemaking.--The Secretary shall implement
subsections (c) and (d)(6) through notice and comment
rulemaking.
``(g) Funding.--For purposes of carrying out this section, subject
to subsection (e), payment under this section shall be made from the
Federal Supplementary Medical Insurance Trust Fund under section 1841
or from the Federal Hospital Insurance Trust Fund under section
1817.''.
(b) Conforming Amendments.--
(1) Section 1833(t) of the Social Security Act (42 U.S.C.
1395(t) is amended by adding at the end the following new
paragraph:
``(23) Ensuring supplemental payments for als-related
services.--Any covered OPD service furnished to a covered ALS
individual (as defined in section 1881B(b)) that is otherwise
payable to a qualified provider (as defined in section
1881B(d)(6)) pursuant to paragraph (4) shall be payable under
such paragraph notwithstanding any payment made under section
1881B(d).''.
(2) Section 1861(w)(1) of the Social Security Act (42
U.S.C. 1395x(w)(1)) is amended by inserting ``qualified
provider (as defined in section 1881B(d)(6)(A)) with respect to
ALS-related services (as defined in section 1881B(c)),'' before
``or hospice program''.
SEC. 3. EFFECTIVE DATE.
The amendments made by this Act shall take effect on the date of
the enactment of this Act.
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