I 112th CONGRESS 1st Session H. R. 3315 IN THE HOUSE OF REPRESENTATIVES November 2, 2011 Mr. Cassidy introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, 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 establish a pilot program providing for monthly fee-based payments for direct primary care medical homes for Medicare-Medicaid dual eligibles and other Medicare beneficiaries.
1.
Short title
This Act may be cited as the Direct M.D. Care Act of 2011.
2.
Qualified direct primary care medical home pilot for Medicare part B beneficiaries
(a)
In general
The Secretary of Health and Human Services (in this section referred to as the Secretary) shall establish a program of pilot projects (each in this section referred to as the pilot project) under part B of title XVIII of the Social Security Act under which the Secretary reimburses a qualified direct primary care medical home practice, as described in section 1301(a)(3) of the Patient Protection and Affordable Care Act (as amended by section 10104(a) of such Act), using a monthly fee-based payment methodology. (b)
Affordable primary care
No pilot project may be established under this section with respect to a medical home if the monthly fee under this section for an enrolled individual exceeds $100 (or $125 in the case of a dual eligible individual (as defined in subsection (i)). The Secretary shall adjust from time to time the dollar amounts specified in the previous sentence for inflation. (c)
Scope of services
Each pilot project shall employ the following activities and functions associated with direct primary care medical homes: (1)Provision of preventive care. (2)Wellness counseling. (3)Primary care. (4)Coordination of primary care with specialty and hospital care. (5)Urgent care services. (6)Availability of office appointments 7 days per week. (7)E-mail and telephone consultation. (8)Availability of telephone access for urgent care consultation on a 7-day per week, 24-hour per day basis. (9)Use of a primary care provider panel size that promotes the ability of participating providers to appropriately provide the scope of services described in this subparagraph. (d)
Priorities
(1)
Qualified state
At least one such pilot project shall be conducted in a State that— (A)has enacted legislation to enable direct primary care practices to deliver monthly fee-based primary care without being regulated as an insurer or health maintenance organization; and (B)has direct primary care practices which enroll, in the aggregate as of September 1, 2011, at least 3,000 individuals using the monthly fee-based primary care model. (2)
Projects including dual eligibles
Subject to paragraph (1), the Secretary shall provide priority to pilot projects that seek to enroll individuals who are dual eligible individuals. (e)
No insurance
Care provided under a pilot project shall not be considered an insurance product and shall not be subject to regulation as insurance product or health maintenance organization by State insurance commissioners. (f)
Application of provisions
The provisions of subsections (b)(3) and (d) of section 1115A of the Social Security Act (42 U.S.C. 1315a) shall apply in carrying out the program of pilot projects under this section in the same manner as such provisions apply to testing models under subsection (b)(1) of such section and, notwithstanding any other provision of law, funds appropriated under subsection (f)(1)(B) of such section for activities under such section shall be available to carry out pilot projects under this section. (g)
Reporting to Secretary
An entity that establishes a pilot project shall submit to the Secretary an annual report that measures the progress, of patients enrolled in the project with one or more chronic conditions, on the following: (1)Emergency room visits. (2)Hospitalizations. (3)Surgeries (including type of surgery). (4)Specialist visits. (5)Use of advanced radiology (other than mammograms and DEXA scans). (h)
Provision of data
The Secretary shall provide the entities operating pilot projects with all necessary and relevant patient data, including any prior claims data, needed for clinical purposes and for the purpose of providing an evaluation of such projects. (i)
Dual eligible individual defined
In this section, the term dual eligible individual means a Medicare beneficiary who is described in subparagraph (A)(ii) of section 1935(c)(6) of the Social Security Act (42 U.S.C. 1396u–5(c)(6)), taking into account the application of subparagraph (B) of such section.