[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4302 Received in Senate (RDS)]
113th CONGRESS
2d Session
H. R. 4302
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
March 27, 2014
Received
_______________________________________________________________________
AN ACT
To amend the Social Security Act to extend Medicare payments to
physicians and other provisions of the Medicare and Medicaid programs,
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 ``Protecting Access
to Medicare Act of 2014''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--MEDICARE EXTENDERS
Sec. 101. Physician payment update.
Sec. 102. Extension of work GPCI floor.
Sec. 103. Extension of therapy cap exceptions process.
Sec. 104. Extension of ambulance add-ons.
Sec. 105. Extension of increased inpatient hospital payment adjustment
for certain low-volume hospitals.
Sec. 106. Extension of the Medicare-dependent hospital (MDH) program.
Sec. 107. Extension for specialized Medicare Advantage plans for
special needs individuals.
Sec. 108. Extension of Medicare reasonable cost contracts.
Sec. 109. Extension of funding for quality measure endorsement, input,
and selection.
Sec. 110. Extension of funding outreach and assistance for low-income
programs.
Sec. 111. Extension of two-midnight rule.
Sec. 112. Technical changes to Medicare LTCH amendments.
TITLE II--OTHER HEALTH PROVISIONS
Sec. 201. Extension of the qualifying individual (QI) program.
Sec. 202. Temporary extension of transitional medical assistance (TMA).
Sec. 203. Extension of Medicaid and CHIP express lane option.
Sec. 204. Extension of special diabetes program for type I diabetes and
for Indians.
Sec. 205. Extension of abstinence education.
Sec. 206. Extension of personal responsibility education program
(PREP).
Sec. 207. Extension of funding for family-to-family health information
centers.
Sec. 208. Extension of health workforce demonstration project for low-
income individuals.
Sec. 209. Extension of maternal, infant, and early childhood home
visiting programs.
Sec. 210. Pediatric quality measures.
Sec. 211. Delay of effective date for Medicaid amendments relating to
beneficiary liability settlements.
Sec. 212. Delay in transition from ICD-9 TO ICD-10 code sets.
Sec. 213. Elimination of limitation on deductibles for employer-
sponsored health plans.
Sec. 214. GAO report on the Children's Hospital Graduate Medical
Education Program.
Sec. 215. Skilled nursing facility value-based purchasing.
Sec. 216. Improving Medicare policies for clinical diagnostic
laboratory tests.
Sec. 217. Revisions under the Medicare ESRD prospective payment system.
Sec. 218. Quality incentives for computed tomography diagnostic imaging
and promoting evidence-based care.
Sec. 219. Using funding from Transitional Fund for Sustainable Growth
Rate (SGR) Reform.
Sec. 220. Ensuring accurate valuation of services under the physician
fee schedule.
Sec. 221. Medicaid DSH.
Sec. 222. Realignment of the Medicare sequester for fiscal year 2024.
Sec. 223. Demonstration programs to improve community mental health
services.
Sec. 224. Assisted outpatient treatment grant program for individuals
with serious mental illness.
Sec. 225. Exclusion from PAYGO scorecards.
TITLE I--MEDICARE EXTENDERS
SEC. 101. PHYSICIAN PAYMENT UPDATE.
Section 1848(d) of the Social Security Act (42 U.S.C. 1395w-4(d))
is amended--
(1) in paragraph (15)--
(A) in the heading, by striking ``January through
march of'';
(B) in subparagraph (A), by striking ``for the
period beginning on January 1, 2014, and ending on
March 31, 2014''; and
(C) in subparagraph (B)--
(i) in the heading, by striking ``remaining
portion of 2014 and''; and
(ii) by striking ``the period beginning on
April 1, 2014, and ending on December 31, 2014,
and for''; and
(2) by adding at the end the following new paragraph:
``(16) Update for january through march of 2015.--
``(A) In general.--Subject to paragraphs (7)(B),
(8)(B), (9)(B), (10)(B), (11)(B), (12)(B), (13)(B),
(14)(B), and (15)(B), in lieu of the update to the
single conversion factor established in paragraph
(1)(C) that would otherwise apply for 2015 for the
period beginning on January 1, 2015, and ending on
March 31, 2015, the update to the single conversion
factor shall be 0.0 percent.
``(B) No effect on computation of conversion factor
for remaining portion of 2015 and subsequent years.--
The conversion factor under this subsection shall be
computed under paragraph (1)(A) for the period
beginning on April 1, 2015, and ending on December 31,
2015, and for 2016 and subsequent years as if
subparagraph (A) had never applied.''.
SEC. 102. EXTENSION OF WORK GPCI FLOOR.
Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)(E)) is amended by striking ``April 1, 2014'' and inserting
``April 1, 2015''.
SEC. 103. EXTENSION OF THERAPY CAP EXCEPTIONS PROCESS.
Section 1833(g) of the Social Security Act (42 U.S.C. 1395l(g)) is
amended--
(1) in paragraph (5)(A), in the first sentence, by striking
``March 31, 2014'' and inserting ``March 31, 2015''; and
(2) in paragraph (6)(A)--
(A) by striking ``March 31, 2014'' and inserting
``March 31, 2015''; and
(B) by striking ``2012, 2013, or the first three
months of 2014'' and inserting ``2012, 2013, 2014, or
the first three months of 2015''.
SEC. 104. EXTENSION OF AMBULANCE ADD-ONS.
(a) Ground Ambulance.--Section 1834(l)(13)(A) of the Social
Security Act (42 U.S.C. 1395m(l)(13)(A)) is amended by striking ``April
1, 2014'' and inserting ``April 1, 2015'' each place it appears.
(b) Super Rural Ground 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 ``April 1, 2014'' and inserting ``April 1,
2015''.
SEC. 105. EXTENSION OF INCREASED INPATIENT HOSPITAL PAYMENT ADJUSTMENT
FOR CERTAIN LOW-VOLUME HOSPITALS.
Section 1886(d)(12) of the Social Security Act (42 U.S.C.
1395ww(d)(12)) is amended--
(1) in subparagraph (B), in the matter preceding clause
(i), by striking ``in the portion of fiscal year 2014 beginning
on April 1, 2014, fiscal year 2015, and subsequent fiscal
years'' and inserting ``in fiscal year 2015 (beginning on April
1, 2015), fiscal year 2016, and subsequent fiscal years'';
(2) in subparagraph (C)(i), by striking ``fiscal years
2011, 2012, and 2013, and the portion of fiscal year 2014
before'' and inserting ``fiscal years 2011 through 2014 and
fiscal year 2015 (before April 1, 2015),'' each place it
appears; and
(3) in subparagraph (D), by striking ``fiscal years 2011,
2012, and 2013, and the portion of fiscal year 2014 before
April 1, 2014,'' and inserting ``fiscal years 2011 through 2014
and fiscal year 2015 (before April 1, 2015),''.
SEC. 106. EXTENSION OF THE MEDICARE-DEPENDENT HOSPITAL (MDH) PROGRAM.
(a) In General.--Section 1886(d)(5)(G) of the Social Security Act
(42 U.S.C. 1395ww(d)(5)(G)) is amended--
(1) in clause (i), by striking ``April 1, 2014'' and
inserting ``April 1, 2015''; and
(2) in clause (ii)(II), by striking ``April 1, 2014'' and
inserting ``April 1, 2015''.
(b) Conforming Amendments.--
(1) Extension of target amount.--Section 1886(b)(3)(D) of
the Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is
amended--
(A) in the matter preceding clause (i), by striking
``April 1, 2014'' and inserting ``April 1, 2015''; and
(B) in clause (iv), by striking ``through fiscal
year 2013 and the portion of fiscal year 2014 before
April 1, 2014'' and inserting ``through fiscal year
2014 and the portion of fiscal year 2015 before April
1, 2015''.
(2) 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 ``through
the first 2 quarters of fiscal year 2014'' and inserting
``through the first 2 quarters of fiscal year 2015''.
SEC. 107. EXTENSION FOR SPECIALIZED MEDICARE ADVANTAGE PLANS FOR
SPECIAL NEEDS INDIVIDUALS.
Section 1859(f)(1) of the Social Security Act (42 U.S.C. 1395w-
28(f)(1)) is amended by striking ``2016'' and inserting ``2017''.
SEC. 108. EXTENSION OF MEDICARE REASONABLE COST CONTRACTS.
Section 1876(h)(5)(C)(ii) of the Social Security Act (42 U.S.C.
1395mm(h)(5)(C)(ii)) is amended, in the matter preceding subclause (I),
by striking ``January 1, 2015'' and inserting ``January 1, 2016''.
SEC. 109. EXTENSION OF FUNDING FOR QUALITY MEASURE ENDORSEMENT, INPUT,
AND SELECTION.
Section 1890(d) of the Social Security Act (42 U.S.C. 1395aaa(d))
is amended--
(1) by inserting ``(1)'' before ``For purposes''; and
(2) by adding at the end the following new paragraph:
``(2) For purposes of carrying out this section 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 $5,000,000 for fiscal year 2014 and $15,000,000
for the first 6 months of fiscal year 2015. Amounts transferred under
the preceding sentence shall remain available until expended.''.
SEC. 110. EXTENSION OF FUNDING OUTREACH AND ASSISTANCE FOR LOW-INCOME
PROGRAMS.
(a) Additional Funding for State Health Insurance Programs.--
Subsection (a)(1)(B) 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), section 610 of the American Taxpayer Relief Act of
2012 (Public Law 112-240), and section 1110 of the Pathway for SGR
Reform Act of 2013 (Public Law 113-67), is amended--
(1) in clause (iii), by striking ``and'' at the end;
(2) by striking clause (iv); and
(3) by adding at the end the following new clauses:
``(iv) for fiscal year 2014, of $7,500,000;
and
``(v) for the portion of fiscal year 2015
before April 1, 2015, of $3,750,000.''.
(b) Additional Funding for Area Agencies on Aging.--Subsection
(b)(1)(B) of such section 119, as so amended, is amended--
(1) in clause (iii), by striking ``and'' at the end;
(2) by striking clause (iv); and
(3) by inserting after clause (iii) the following new
clauses:
``(iv) for fiscal year 2014, of $7,500,000;
and
``(v) for the portion of fiscal year 2015
before April 1, 2015, of $3,750,000.''.
(c) Additional Funding for Aging and Disability Resource Centers.--
Subsection (c)(1)(B) of such section 119, as so amended, is amended--
(1) in clause (iii), by striking ``and'' at the end;
(2) by striking clause (iv); and
(3) by inserting after clause (iii) the following new
clauses:
``(iv) for fiscal year 2014, of $5,000,000;
and
``(v) for the portion of fiscal year 2015
before April 1, 2015, of $2,500,000.''.
(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--
(1) in clause (iii), by striking ``and'' at the end;
(2) by striking clause (iv); and
(3) by inserting after clause (iii) the following new
clauses:
``(iv) for fiscal year 2014, of $5,000,000;
and
``(v) for the portion of fiscal year 2015
before April 1, 2015, of $2,500,000.''.
SEC. 111. EXTENSION OF TWO-MIDNIGHT RULE.
(a) Continuation of Certain Medical Review Activities.--The
Secretary of Health and Human Services may continue medical review
activities described in the notice entitled ``Selecting Hospital Claims
for Patient Status Reviews: Admissions On or After October 1, 2013'',
posted on the Internet website of the Centers for Medicare & Medicaid
Services, through the first 6 months of fiscal year 2015 for such
additional hospital claims as the Secretary determines appropriate.
(b) Limitation.--The Secretary of Health and Human Services shall
not conduct patient status reviews (as described in such notice) on a
post-payment review basis through recovery audit contractors under
section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)) for
inpatient claims with dates of admission October 1, 2013, through March
31, 2015, unless there is evidence of systematic gaming, fraud, abuse,
or delays in the provision of care by a provider of services (as
defined in section 1861(u) of such Act (42 U.S.C. 1395x(u))).
SEC. 112. TECHNICAL CHANGES TO MEDICARE LTCH AMENDMENTS.
(a) In General.--Subclauses (I) and (II) of section
1886(m)(6)(C)(iv) of the Social Security Act (42 U.S.C.
1395ww(m)(6)(C)(iv)) are each amended by striking ``discharges'' and
inserting ``Medicare fee-for-service discharges''.
(b) MMSEA Correction.--Section 114(d) of the Medicare, Medicaid,
and SCHIP Extension Act of 2007 (42 U.S.C. 1395ww note), as amended by
sections 3106(b) and 10312(b) of Public Law 111-148 and by section
1206(b)(2) of the Pathway for SGR Reform Act of 2013 (division B of
Public Law 113-67), is amended--
(1) in paragraph (1), in the matter preceding subparagraph
(A), by striking ``January 1, 2015,'' and inserting ``on the
date of the enactment of paragraph (7) of this subsection'';
(2) in paragraph (6), by striking ``January 1, 2015,'' and
inserting ``on the date of the enactment of paragraph (7) of
this subsection''; and
(3) by adding at the end the following new paragraph:
``(7) Additional exception for certain long-term care
hospitals.--The moratorium under paragraph (1)(A) shall not
apply to a long-term care hospital that--
``(A) began its qualifying period for payment as a
long-term care hospital under section 412.23(e) of
title 42, Code of Federal Regulations, on or before the
date of enactment of this paragraph;
``(B) has a binding written agreement as of the
date of the enactment of this paragraph with an
outside, unrelated party for the actual construction,
renovation, lease, or demolition for a long-term care
hospital, and has expended, before such date of
enactment, at least 10 percent of the estimated cost of
the project (or, if less, $2,500,000); or
``(C) has obtained an approved certificate of need
in a State where one is required on or before such date
of enactment.''.
(c) Additional Amendments.--Section 1206(a) of the Pathway for SGR
Reform Act of 2013 (division B of Public Law 113-67) is amended--
(1) in paragraph (2)(A), by striking ``Assessment'' and
inserting ``Advisory''; and
(2) in paragraph (3)(B), by striking ``shall not apply to a
hospital that is classified as of December 10, 2013, as a
subsection (d) hospital (as defined in section 1886(d)(1)(B) of
the Social Security Act, 42 U.S.C. 1395ww(d)(1)(B))'' and
inserting ``shall only apply to a hospital that is classified
as of December 10, 2013, as a long-term care hospital (as
defined in section 1861(ccc) of the Social Security Act, 42
U.S.C. 1395x(ccc))''.
(d) Effective Date.--The amendments made by this section are
effective as of the date of the enactment of this Act.
TITLE II--OTHER HEALTH PROVISIONS
SEC. 201. EXTENSION OF THE QUALIFYING INDIVIDUAL (QI) 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 ``March
2014'' and inserting ``March 2015''.
(b) Extending Total Amount Available for Allocation.--Section
1933(g) of the Social Security Act (42 U.S.C. 1396u-3(g)) is amended--
(1) in paragraph (2)--
(A) in subparagraph (T), by striking ``and'' at the
end;
(B) in subparagraph (U)--
(i) by striking ``March 31, 2014'' and
inserting ``September 30, 2014''; and
(ii) by striking ``$200,000,000.'' and
inserting ``$485,000,000;''; and
(C) by adding at the end the following new
subparagraphs:
``(V) for the period that begins on October 1,
2014, and ends on December 31, 2014, the total
allocation amount is $300,000,000; and
``(W) for the period that begins on January 1,
2015, and ends on March 31, 2015, the total allocation
amount is $250,000,000.''; and
(2) in paragraph (3), in the matter preceding subparagraph
(A), by striking ``or (T)'' and inserting ``(T), or (V)''.
SEC. 202. TEMPORARY EXTENSION OF TRANSITIONAL MEDICAL ASSISTANCE (TMA).
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 ``March
31, 2014'' and inserting ``March 31, 2015''.
SEC. 203. EXTENSION OF MEDICAID AND CHIP EXPRESS LANE OPTION.
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. 204. EXTENSION OF SPECIAL DIABETES PROGRAM FOR TYPE I DIABETES AND
FOR INDIANS.
(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 ``2015''.
(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 ``2015''.
SEC. 205. EXTENSION OF ABSTINENCE EDUCATION.
Subsections (a) and (d) of section 510 of the Social Security Act
(42 U.S.C. 710) are each amended by striking ``2014'' and inserting
``2015''.
SEC. 206. EXTENSION OF PERSONAL RESPONSIBILITY EDUCATION PROGRAM
(PREP).
Section 513 of the Social Security Act (42 U.S.C. 713) is amended--
(1) in paragraphs (1)(A) and (4)(A) of subsection (a), by
striking ``2014'' and inserting ``2015'' each place it appears;
(2) in subsection (a)(4)(B)(i), by striking ``and 2014''
and inserting ``2014, and 2015''; and
(3) in subsection (f), by striking ``2014'' and inserting
``2015''.
SEC. 207. EXTENSION OF FUNDING FOR FAMILY-TO-FAMILY HEALTH INFORMATION
CENTERS.
Section 501(c)(1)(A) of the Social Security Act (42 U.S.C.
701(c)(1)(A)) is amended--
(1) in clause (iii), by striking at the end ``and'';
(2) in clause (iv), by striking the period at the end and
inserting a semicolon and by moving the margin to align with
the margin for clause (iii); and
(3) by adding at the end the following new clauses:
``(v) $2,500,000 for the portion of fiscal year 2014 on or
after April 1, 2014; and
``(vi) $2,500,000 for the portion of fiscal year 2015
before April 1, 2015.''.
SEC. 208. EXTENSION OF 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 ``2014'' and inserting ``2015''.
SEC. 209. EXTENSION OF MATERNAL, INFANT, AND EARLY CHILDHOOD HOME
VISITING PROGRAMS.
Section 511(j) of the Social Security Act (42 U.S.C. 711(j)) is
amended--
(1) in paragraph (1)--
(A) by striking ``and'' at the end of subparagraph
(D);
(B) by striking the period at the end of
subparagraph (E) and inserting ``; and''; and
(C) by adding at the end the following new
subparagraph:
``(F) for the period beginning on October 1, 2014,
and ending on March 31, 2015, an amount equal to the
amount provided in subparagraph (E).''; and
(2) in paragraphs (2) and (3), by inserting ``(or portion
of a fiscal year)'' after ``for a fiscal year'' each place it
appears.
SEC. 210. 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. 211. DELAY OF EFFECTIVE DATE FOR MEDICAID AMENDMENTS RELATING TO
BENEFICIARY LIABILITY SETTLEMENTS.
Effective as if included in the enactment of the Bipartisan Budget
Act of 2013 (Public Law 113-67), section 202(c) of such Act is amended
by striking ``October 1, 2014'' and inserting ``October 1, 2016''.
SEC. 212. DELAY IN TRANSITION FROM ICD-9 TO ICD-10 CODE SETS.
The Secretary of Health and Human Services may not, prior to
October 1, 2015, adopt ICD-10 code sets as the standard for code sets
under section 1173(c) of the Social Security Act (42 U.S.C. 1320d-2(c))
and section 162.1002 of title 45, Code of Federal Regulations.
SEC. 213. ELIMINATION OF LIMITATION ON DEDUCTIBLES FOR EMPLOYER-
SPONSORED HEALTH PLANS.
(a) In General.--Section 1302(c) of the Patient Protection and
Affordable Care Act (Public Law 111-148; 42 U.S.C. 18022(c)) is
amended--
(1) by striking paragraph (2); and
(2) in paragraph (4)(A), by striking ``paragraphs (1)(B)(i)
and (2)(B)(i)'' and inserting ``paragraph (1)(B)(i)''.
(b) Conforming Amendment.--Section 2707(b) of the Public Health
Service Act (42 U.S.C. 300gg-6(b)) is amended by striking ``paragraphs
(1) and (2)'' and inserting ``paragraph (1)''.
(c) Effective Date.--The amendments made by this Act shall be
effective as if included in the enactment of the Patient Protection and
Affordable Care Act (Public Law 111-148).
SEC. 214. GAO REPORT ON THE CHILDREN'S HOSPITAL GRADUATE MEDICAL
EDUCATION PROGRAM.
(a) In General.--In the case that the Children's Hospital GME
Support Reauthorization Act of 2013 is enacted into law, the
Comptroller General of the United States shall, not later than November
30, 2017, conduct an independent evaluation, and submit to the
appropriate committees of Congress a report, concerning the
implementation of section 340E(h) of the Public Health Service Act, as
added by section 3 of the Children's Hospital GME Support
Reauthorization Act of 2013.
(b) Content.--The report described in subsection (a) shall review
and assess each of the following, with respect to hospitals receiving
payments under such section 340E(h) during the period of fiscal years
2015 through 2017:
(1) The number and type of such hospitals that applied for
such payments.
(2) The number and type of such hospitals receiving such
payments.
(3) The amount of such payments awarded to such hospitals.
(4) How such hospitals used such payments.
(5) The impact of such payments on--
(A) the number of pediatric providers; and
(B) health care needs of children.
SEC. 215. SKILLED NURSING FACILITY VALUE-BASED PURCHASING.
(a) In General.--Section 1888 of the Social Security Act (42 U.S.C.
1395yy) is amended by adding at the end the following new subsection:
``(g) Skilled Nursing Facility Readmission Measure.--
``(1) Readmission measure.--Not later than October 1, 2015,
the Secretary shall specify a skilled nursing facility all-
cause all-condition hospital readmission measure (or any
successor to such a measure).
``(2) Resource use measure.--Not later than October 1,
2016, the Secretary shall specify a measure to reflect an all-
condition risk-adjusted potentially preventable hospital
readmission rate for skilled nursing facilities.
``(3) Measure adjustments.--When specifying the measures
under paragraphs (1) and (2), the Secretary shall devise a
methodology to achieve a high level of reliability and
validity, especially for skilled nursing facilities with a low
volume of readmissions.
``(4) Pre-rulemaking process (measure application
partnership process).--The application of the provisions of
section 1890A shall be optional in the case of a measure
specified under paragraph (1) and a measure specified under
paragraph (2).
``(5) Feedback reports to skilled nursing facilities.--
Beginning October 1, 2016, and every quarter thereafter, the
Secretary shall provide confidential feedback reports to
skilled nursing facilities on the performance of such
facilities with respect to a measure specified under paragraph
(1) or (2).
``(6) Public reporting of skilled nursing facilities.--
``(A) In general.--Subject to subparagraphs (B) and
(C), the Secretary shall establish procedures for
making available to the public by posting on the
Nursing Home Compare Medicare website (or a successor
website) described in section 1819(i) information on
the performance of skilled nursing facilities with
respect to a measure specified under paragraph (1) and
a measure specified under paragraph (2).
``(B) Opportunity to review.--The procedures under
subparagraph (A) shall ensure that a skilled nursing
facility has the opportunity to review and submit
corrections to the information that is to be made
public with respect to the facility prior to such
information being made public.
``(C) Timing.--Such procedures shall provide that
the information described in subparagraph (A) is made
publicly available beginning not later than October 1,
2017.
``(7) Non-application of paperwork reduction act.--Chapter
35 of title 44, United States Code (commonly referred to as the
`Paperwork Reduction Act of 1995') shall not apply to this
subsection.''.
(b) Value-Based Purchasing Program for Skilled Nursing
Facilities.--Section 1888 of the Social Security Act (42 U.S.C.
1395yy), as amended by subsection (a), is further amended by adding at
the end the following new subsection:
``(h) Skilled Nursing Facility Value-Based Purchasing Program.--
``(1) Establishment.--
``(A) In general.--Subject to the succeeding
provisions of this subsection, the Secretary shall
establish a skilled nursing facility value-based
purchasing program (in this subsection referred to as
the `SNF VBP Program') under which value-based
incentive payments are made in a fiscal year to skilled
nursing facilities.
``(B) Program to begin in fiscal year 2019.--The
SNF VBP Program shall apply to payments for services
furnished on or after October 1, 2018.
``(2) Application of measures.--
``(A) In general.--The Secretary shall apply the
measure specified under subsection (g)(1) for purposes
of the SNF VBP Program.
``(B) Replacement.--For purposes of the SNF VBP
Program, the Secretary shall apply the measure
specified under (g)(2) instead of the measure specified
under (g)(1) as soon as practicable.
``(3) Performance standards.--
``(A) Establishment.--The Secretary shall establish
performance standards with respect to the measure
applied under paragraph (2) for a performance period
for a fiscal year.
``(B) Higher of achievement and improvement.--The
performance standards established under subparagraph
(A) shall include levels of achievement and
improvement. In calculating the SNF performance score
under paragraph (4), the Secretary shall use the higher
of either improvement or achievement.
``(C) Timing.--The Secretary shall establish and
announce the performance standards established under
subparagraph (A) not later than 60 days prior to the
beginning of the performance period for the fiscal year
involved.
``(4) SNF performance score.--
``(A) In general.--The Secretary shall develop a
methodology for assessing the total performance of each
skilled nursing facility based on performance standards
established under paragraph (3) with respect to the
measure applied under paragraph (2). Using such
methodology, the Secretary shall provide for an
assessment (in this subsection referred to as the `SNF
performance score') for each skilled nursing facility
for each such performance period.
``(B) Ranking of snf performance scores.--The
Secretary shall, for the performance period for each
fiscal year, rank the SNF performance scores determined
under subparagraph (A) from low to high.
``(5) Calculation of value-based incentive payments.--
``(A) In general.--With respect to a skilled
nursing facility, based on the ranking under paragraph
(4)(B) for a performance period for a fiscal year, the
Secretary shall increase the adjusted Federal per diem
rate determined under subsection (e)(4)(G) otherwise
applicable to such skilled nursing facility (and after
application of paragraph (6)) for services furnished by
such facility during such fiscal year by the value-
based incentive payment amount under subparagraph (B).
``(B) Value-based incentive payment amount.--The
value-based incentive payment amount for services
furnished by a skilled nursing facility in a fiscal
year shall be equal to the product of--
``(i) the adjusted Federal per diem rate
determined under subsection (e)(4)(G) otherwise
applicable to such skilled nursing facility for
such services furnished by the skilled nursing
facility during such fiscal year; and
``(ii) the value-based incentive payment
percentage specified under subparagraph (C) for
the skilled nursing facility for such fiscal
year.
``(C) Value-based incentive payment percentage.--
``(i) In general.--The Secretary shall
specify a value-based incentive payment
percentage for a skilled nursing facility for a
fiscal year which may include a zero
percentage.
``(ii) Requirements.--In specifying the
value-based incentive payment percentage for
each skilled nursing facility for a fiscal year
under clause (i), the Secretary shall ensure
that--
``(I) such percentage is based on
the SNF performance score of the
skilled nursing facility provided under
paragraph (4) for the performance
period for such fiscal year;
``(II) the application of all such
percentages in such fiscal year results
in an appropriate distribution of
value-based incentive payments under
subparagraph (B) such that--
``(aa) skilled nursing
facilities with the highest
rankings under paragraph (4)(B)
receive the highest value-based
incentive payment amounts under
subparagraph (B);
``(bb) skilled nursing
facilities with the lowest
rankings under paragraph (4)(B)
receive the lowest value-based
incentive payment amounts under
subparagraph (B); and
``(cc) in the case of
skilled nursing facilities in
the lowest 40 percent of the
ranking under paragraph (4)(B),
the payment rate under
subparagraph (A) for services
furnished by such facility
during such fiscal year shall
be less than the payment rate
for such services for such
fiscal year that would
otherwise apply under
subsection (e)(4)(G) without
application of this subsection;
and
``(III) the total amount of value-
based incentive payments under this
paragraph for all skilled nursing
facilities in such fiscal year shall be
greater than or equal to 50 percent,
but not greater than 70 percent, of the
total amount of the reductions to
payments for such fiscal year under
paragraph (6), as estimated by the
Secretary.
``(6) Funding for value-based incentive payments.--
``(A) In general.--The Secretary shall reduce the
adjusted Federal per diem rate determined under
subsection (e)(4)(G) otherwise applicable to a skilled
nursing facility for services furnished by such
facility during a fiscal year (beginning with fiscal
year 2019) by the applicable percent (as defined in
subparagraph (B)). The Secretary shall make such
reductions for all skilled nursing facilities in the
fiscal year involved, regardless of whether or not the
skilled nursing facility has been determined by the
Secretary to have earned a value-based incentive
payment under paragraph (5) for such fiscal year.
``(B) Applicable percent.--For purposes of
subparagraph (A), the term `applicable percent' means,
with respect to fiscal year 2019 and succeeding fiscal
years, 2 percent.
``(7) Announcement of net result of adjustments.--Under the
SNF VBP Program, the Secretary shall, not later than 60 days
prior to the fiscal year involved, inform each skilled nursing
facility of the adjustments to payments to the skilled nursing
facility for services furnished by such facility during the
fiscal year under paragraphs (5) and (6).
``(8) No effect in subsequent fiscal years.--The value-
based incentive payment under paragraph (5) and the payment
reduction under paragraph (6) shall each apply only with
respect to the fiscal year involved, and the Secretary shall
not take into account such value-based incentive payment or
payment reduction in making payments to a skilled nursing
facility under this section in a subsequent fiscal year.
``(9) Public reporting.--
``(A) SNF specific information.--The Secretary
shall make available to the public, by posting on the
Nursing Home Compare Medicare website (or a successor
website) described in section 1819(i) in an easily
understandable format, information regarding the
performance of individual skilled nursing facilities
under the SNF VBP Program, with respect to a fiscal
year, including--
``(i) the SNF performance score of the
skilled nursing facility for such fiscal year;
and
``(ii) the ranking of the skilled nursing
facility under paragraph (4)(B) for the
performance period for such fiscal year.
``(B) Aggregate information.--The Secretary shall
periodically post on the Nursing Home Compare Medicare
website (or a successor website) described in section
1819(i) aggregate information on the SNF VBP Program,
including--
``(i) the range of SNF performance scores
provided under paragraph (4)(A); and
``(ii) the number of skilled nursing
facilities receiving value-based incentive
payments under paragraph (5) and the range and
total amount of such value-based incentive
payments.
``(10) Limitation on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of the following:
``(A) The methodology used to determine the value-
based incentive payment percentage and the amount of
the value-based incentive payment under paragraph (5).
``(B) The determination of the amount of funding
available for such value-based incentive payments under
paragraph (5)(C)(ii)(III) and the payment reduction
under paragraph (6).
``(C) The establishment of the performance
standards under paragraph (3) and the performance
period.
``(D) The methodology developed under paragraph (4)
that is used to calculate SNF performance scores and
the calculation of such scores.
``(E) The ranking determinations under paragraph
(4)(B).
``(11) Funding for program management.--The Secretary shall
provide for the one time transfer from the Federal Hospital
Insurance Trust Fund established under section 1817 to the
Centers for Medicare & Medicaid Services Program Management
Account of--
``(A) for purposes of subsection (g)(2),
$2,000,000; and
``(B) for purposes of implementing this subsection,
$10,000,000.
Such funds shall remain available until expended.''.
(c) MedPAC Study.--Not later than June 30, 2021, the Medicare
Payment Advisory Commission shall submit to Congress a report that
reviews the progress of the skilled nursing facility value-based
purchasing program established under section 1888(h) of the Social
Security Act, as added by subsection (b), and makes recommendations, as
appropriate, on any improvements that should be made to such program.
For purposes of the previous sentence, the Medicare Payment Advisory
Commission shall consider any unintended consequences with respect to
such skilled nursing facility value-based purchasing program and any
potential adjustments to the readmission measure specified under
section 1888(g)(1) of such Act, as added by subsection (a), for
purposes of determining the effect of the socio-economic status of a
beneficiary under the Medicare program under title XVIII of the Social
Security Act for the SNF performance score of a skilled nursing
facility provided under section 1888(h)(4) of such Act, as added by
subsection (b).
SEC. 216. IMPROVING MEDICARE POLICIES FOR CLINICAL DIAGNOSTIC
LABORATORY TESTS.
(a) In General.--Title XVIII of the Social Security Act is amended
by inserting after section 1834 (42 U.S.C. 1395m) the following new
section:
``SEC. 1834A. IMPROVING POLICIES FOR CLINICAL DIAGNOSTIC LABORATORY
TESTS.
``(a) Reporting of Private Sector Payment Rates for Establishment
of Medicare Payment Rates.--
``(1) In general.--Beginning January 1, 2016, and every 3
years thereafter (or, annually, in the case of reporting with
respect to an advanced diagnostic laboratory test, as defined
in subsection (d)(5)), an applicable laboratory (as defined in
paragraph (2)) shall report to the Secretary, at a time
specified by the Secretary, applicable information (as defined
in paragraph (3)) for a data collection period (as defined in
paragraph (4)) for each clinical diagnostic laboratory test
that the laboratory furnishes during such period for which
payment is made under this part.
``(2) Definition of applicable laboratory.--In this
section, the term `applicable laboratory' means a laboratory
that, with respect to its revenues under this title, a majority
of such revenues are from this section, section 1833(h), or
section 1848. The Secretary may establish a low volume or low
expenditure threshold for excluding a laboratory from the
definition of applicable laboratory under this paragraph, as
the Secretary determines appropriate.
``(3) Applicable information defined.--
``(A) In general.--In this section, subject to
subparagraph (B), the term `applicable information'
means, with respect to a laboratory test for a data
collection period, the following:
``(i) The payment rate (as determined in
accordance with paragraph (5)) that was paid by
each private payor for the test during the
period.
``(ii) The volume of such tests for each
such payor for the period.
``(B) Exception for certain contractual
arrangements.--Such term shall not include information
with respect to a laboratory test for which payment is
made on a capitated basis or other similar payment
basis during the data collection period.
``(4) Data collection period defined.--In this section, the
term `data collection period' means a period of time, such as a
previous 12 month period, specified by the Secretary.
``(5) Treatment of discounts.--The payment rate reported by
a laboratory under this subsection shall reflect all discounts,
rebates, coupons, and other price concessions, including those
described in section 1847A(c)(3).
``(6) Ensuring complete reporting.--In the case where an
applicable laboratory has more than one payment rate for the
same payor for the same test or more than one payment rate for
different payors for the same test, the applicable laboratory
shall report each such payment rate and the volume for the test
at each such rate under this subsection. Beginning with January
1, 2019, the Secretary may establish rules to aggregate
reporting with respect to the situations described in the
preceding sentence.
``(7) Certification.--An officer of the laboratory shall
certify the accuracy and completeness of the information
reported under this subsection.
``(8) Private payor defined.--In this section, the term
`private payor' means the following:
``(A) A health insurance issuer and a group health
plan (as such terms are defined in section 2791 of the
Public Health Service Act).
``(B) A Medicare Advantage plan under part C.
``(C) A medicaid managed care organization (as
defined in section 1903(m)).
``(9) Civil money penalty.--
``(A) In general.--If the Secretary determines that
an applicable laboratory has failed to report or made a
misrepresentation or omission in reporting information
under this subsection with respect to a clinical
diagnostic laboratory test, the Secretary may apply a
civil money penalty in an amount of up to $10,000 per
day for each failure to report or each such
misrepresentation or omission.
``(B) Application.--The provisions of section 1128A
(other than subsections (a) and (b)) shall apply to a
civil money penalty under this paragraph in the same
manner as they apply to a civil money penalty or
proceeding under section 1128A(a).
``(10) Confidentiality of information.--Notwithstanding any
other provision of law, information disclosed by a laboratory
under this subsection is confidential and shall not be
disclosed by the Secretary or a Medicare contractor in a form
that discloses the identity of a specific payor or laboratory,
or prices charged or payments made to any such laboratory,
except--
``(A) as the Secretary determines to be necessary
to carry out this section;
``(B) to permit the Comptroller General to review
the information provided;
``(C) to permit the Director of the Congressional
Budget Office to review the information provided; and
``(D) to permit the Medicare Payment Advisory
Commission to review the information provided.
``(11) Protection from public disclosure.--A payor shall
not be identified on information reported under this
subsection. The name of an applicable laboratory under this
subsection shall be exempt from disclosure under section
552(b)(3) of title 5, United States Code.
``(12) Regulations.--Not later than June 30, 2015, the
Secretary shall establish through notice and comment rulemaking
parameters for data collection under this subsection.
``(b) Payment for Clinical Diagnostic Laboratory Tests.--
``(1) Use of private payor rate information to determine
medicare payment rates.--
``(A) In general.--Subject to paragraph (3) and
subsections (c) and (d), in the case of a clinical
diagnostic laboratory test furnished on or after
January 1, 2017, the payment amount under this section
shall be equal to the weighted median determined for
the test under paragraph (2) for the most recent data
collection period.
``(B) Application of payment amounts to hospital
laboratories.--The payment amounts established under
this section shall apply to a clinical diagnostic
laboratory test furnished by a hospital laboratory if
such test is paid for separately, and not as part of a
bundled payment under section 1833(t).
``(2) Calculation of weighted median.--For each laboratory
test with respect to which information is reported under
subsection (a) for a data collection period, the Secretary
shall calculate a weighted median for the test for the period,
by arraying the distribution of all payment rates reported for
the period for each test weighted by volume for each payor and
each laboratory.
``(3) Phase-in of reductions from private payor rate
implementation.--
``(A) In general.--Payment amounts determined under
this subsection for a clinical diagnostic laboratory
test for each of 2017 through 2022 shall not result in
a reduction in payments for a clinical diagnostic
laboratory test for the year of greater than the
applicable percent (as defined in subparagraph (B)) of
the amount of payment for the test for the preceding
year.
``(B) Applicable percent defined.--In this
paragraph, the term `applicable percent' means--
``(i) for each of 2017 through 2019, 10
percent; and
``(ii) for each of 2020 through 2022, 15
percent.
``(C) No application to new tests.--This paragraph
shall not apply to payment amounts determined under
this section for either of the following.
``(i) A new test under subsection (c).
``(ii) A new advanced diagnostic test (as
defined in subsection (d)(5)) under subsection
(d).
``(4) Application of market rates.--
``(A) In general.--Subject to paragraph (3), once
established for a year following a data collection
period, the payment amounts under this subsection shall
continue to apply until the year following the next
data collection period.
``(B) Other adjustments not applicable.--The
payment amounts under this section shall not be subject
to any adjustment (including any geographic adjustment,
budget neutrality adjustment, annual update, or other
adjustment).
``(5) Sample collection fee.--In the case of a sample
collected from an individual in a skilled nursing facility or
by a laboratory on behalf of a home health agency, the nominal
fee that would otherwise apply under section 1833(h)(3)(A)
shall be increased by $2.
``(c) Payment for New Tests That Are Not Advanced Diagnostic
Laboratory Tests.--
``(1) Payment during initial period.--In the case of a
clinical diagnostic laboratory test that is assigned a new or
substantially revised HCPCS code on or after the date of
enactment of this section, and which is not an advanced
diagnostic laboratory test (as defined in subsection (d)(5)),
during an initial period until payment rates under subsection
(b) are established for the test, payment for the test shall be
determined--
``(A) using cross-walking (as described in section
414.508(a) of title 42, Code of Federal Regulations, or
any successor regulation) to the most appropriate
existing test under the fee schedule under this section
during that period; or
``(B) if no existing test is comparable to the new
test, according to the gapfilling process described in
paragraph (2).
``(2) Gapfilling process described.--The gapfilling process
described in this paragraph shall take into account the
following sources of information to determine gapfill amounts,
if available:
``(A) Charges for the test and routine discounts to
charges.
``(B) Resources required to perform the test.
``(C) Payment amounts determined by other payors.
``(D) Charges, payment amounts, and resources
required for other tests that may be comparable or
otherwise relevant.
``(E) Other criteria the Secretary determines
appropriate.
``(3) Additional consideration.--In determining the payment
amount under crosswalking or gapfilling processes under this
subsection, the Secretary shall consider recommendations from
the panel established under subsection (f)(1).
``(4) Explanation of payment rates.--In the case of a
clinical diagnostic laboratory test for which payment is made
under this subsection, the Secretary shall make available to
the public an explanation of the payment rate for the test,
including an explanation of how the criteria described in
paragraph (2) and paragraph (3) are applied.
``(d) Payment for New Advanced Diagnostic Laboratory Tests.--
``(1) Payment during initial period.--
``(A) In general.--In the case of an advanced
diagnostic laboratory test for which payment has not
been made under the fee schedule under section 1833(h)
prior to the date of enactment of this section, during
an initial period of three quarters, the payment amount
for the test for such period shall be based on the
actual list charge for the laboratory test.
``(B) Actual list charge.--For purposes of
subparagraph (A), the term `actual list charge', with
respect to a laboratory test furnished during such
period, means the publicly available rate on the first
day at which the test is available for purchase by a
private payor.
``(2) Special rule for timing of initial reporting.--With
respect to an advanced diagnostic laboratory test described in
paragraph (1)(A), an applicable laboratory shall initially be
required to report under subsection (a) not later than the last
day of the second quarter of the initial period under such
paragraph.
``(3) Application of market rates after initial period.--
Subject to paragraph (4), data reported under paragraph (2)
shall be used to establish the payment amount for an advanced
diagnostic laboratory test after the initial period under
paragraph (1)(A) using the methodology described in subsection
(b). Such payment amount shall continue to apply until the year
following the next data collection period.
``(4) Recoupment if actual list charge exceeds market
rate.--With respect to the initial period described in
paragraph (1)(A), if, after such period, the Secretary
determines that the payment amount for an advanced diagnostic
laboratory test under paragraph (1)(A) that was applicable
during the period was greater than 130 percent of the payment
amount for the test established using the methodology described
in subsection (b) that is applicable after such period, the
Secretary shall recoup the difference between such payment
amounts for tests furnished during such period.
``(5) Advanced diagnostic laboratory test defined.--In this
subsection, the term `advanced diagnostic laboratory test'
means a clinical diagnostic laboratory test covered under this
part that is offered and furnished only by a single laboratory
and not sold for use by a laboratory other than the original
developing laboratory (or a successor owner) and meets one of
the following criteria:
``(A) The test is an analysis of multiple
biomarkers of DNA, RNA, or proteins combined with a
unique algorithm to yield a single patient-specific
result.
``(B) The test is cleared or approved by the Food
and Drug Administration.
``(C) The test meets other similar criteria
established by the Secretary.
``(e) Coding.--
``(1) Temporary codes for certain new tests.--
``(A) In general.--The Secretary shall adopt
temporary HCPCS codes to identify new advanced
diagnostic laboratory tests (as defined in subsection
(d)(5)) and new laboratory tests that are cleared or
approved by the Food and Drug Administration.
``(B) Duration.--
``(i) In general.--Subject to clause (ii),
the temporary code shall be effective until a
permanent HCPCS code is established (but not to
exceed 2 years).
``(ii) Exception.--The Secretary may extend
the temporary code or establish a permanent
HCPCS code, as the Secretary determines
appropriate.
``(2) Existing tests.--Not later than January 1, 2016, for
each existing advanced diagnostic laboratory test (as so
defined) and each existing clinical diagnostic laboratory test
that is cleared or approved by the Food and Drug Administration
for which payment is made under this part as of the date of
enactment of this section, if such test has not already been
assigned a unique HCPCS code, the Secretary shall--
``(A) assign a unique HCPCS code for the test; and
``(B) publicly report the payment rate for the
test.
``(3) Establishment of unique identifier for certain
tests.--For purposes of tracking and monitoring, if a
laboratory or a manufacturer requests a unique identifier for
an advanced diagnostic laboratory test (as so defined) or a
laboratory test that is cleared or approved by the Food and
Drug Administration, the Secretary shall utilize a means to
uniquely track such test through a mechanism such as a HCPCS
code or modifier.
``(f) Input From Clinicians and Technical Experts.--
``(1) In general.--The Secretary shall consult with an
expert outside advisory panel, established by the Secretary not
later than July 1, 2015, composed of an appropriate selection
of individuals with expertise, which may include molecular
pathologists, researchers, and individuals with expertise in
laboratory science or health economics, in issues related to
clinical diagnostic laboratory tests, which may include the
development, validation, performance, and application of such
tests, to provide--
``(A) input on--
``(i) the establishment of payment rates
under this section for new clinical diagnostic
laboratory tests, including whether to use
crosswalking or gapfilling processes to
determine payment for a specific new test; and
``(ii) the factors used in determining
coverage and payment processes for new clinical
diagnostic laboratory tests; and
``(B) recommendations to the Secretary under this
section.
``(2) Compliance with faca.--The panel shall be subject to
the Federal Advisory Committee Act (5 U.S.C. App.).
``(3) Continuation of annual meeting.--The Secretary shall
continue to convene the annual meeting described in section
1833(h)(8)(B)(iii) after the implementation of this section for
purposes of receiving comments and recommendations (and data on
which the recommendations are based) as described in such
section on the establishment of payment amounts under this
section.
``(g) Coverage.--
``(1) Issuance of coverage policies.--
``(A) In general.--A medicare administrative
contractor shall only issue a coverage policy with
respect to a clinical diagnostic laboratory test in
accordance with the process for making a local coverage
determination (as defined in section 1869(f)(2)(B)),
including the appeals and review process for local
coverage determinations under part 426 of title 42,
Code of Federal Regulations (or successor regulations).
``(B) No effect on national coverage determination
process.--This paragraph shall not apply to the
national coverage determination process (as defined in
section 1869(f)(1)(B)).
``(C) Effective date.--This paragraph shall apply
to coverage policies issued on or after January 1,
2015.
``(2) Designation of one or more medicare administrative
contractors for clinical diagnostic laboratory tests.--The
Secretary may designate one or more (not to exceed 4) medicare
administrative contractors to either establish coverage
policies or establish coverage policies and process claims for
payment for clinical diagnostic laboratory tests, as determined
appropriate by the Secretary.
``(h) Implementation.--
``(1) Implementation.--There shall be no administrative or
judicial review under section 1869, section 1878, or otherwise,
of the establishment of payment amounts under this section.
``(2) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to information collected under
this section.
``(3) Funding.--For purposes of implementing this section,
the Secretary shall provide for the transfer, from the Federal
Supplementary Medical Insurance Trust Fund under section 1841,
to the Centers for Medicare & Medicaid Services Program
Management Account, for each of fiscal years 2014 through 2018,
$4,000,000, and for each of fiscal years 2019 through 2023,
$3,000,000. Amounts transferred under the preceding sentence
shall remain available until expended.
``(i) Transitional Rule.--During the period beginning on the date
of enactment of this section and ending on December 31, 2016, with
respect to advanced diagnostic laboratory tests under this part, the
Secretary shall use the methodologies for pricing, coding, and coverage
in effect on the day before such date of enactment, which may include
cross-walking or gapfilling methods.''.
(b) Conforming Amendments.--
(1) Section 1833(a) of the Social Security Act (42 U.S.C.
1395l(a)) is amended--
(A) in paragraph (1)(D)--
(i) by striking ``(i) on the basis'' and
inserting ``(i)(I) on the basis'';
(ii) in subclause (I), as added by clause
(i), by striking ``subsection (h)(1)'' and
inserting ``subsection (h)(1) (for tests
furnished before January 1, 2017)'';
(iii) by striking ``or (ii)'' and inserting
``or (II) under section 1834A (for tests
furnished on or after January 1, 2017), the
amount paid shall be equal to 80 percent (or
100 percent, in the case of such tests for
which payment is made on an assignment-related
basis) of the lesser of the amount determined
under such section or the amount of the charges
billed for the tests, or (ii)''; and
(iv) in clause (ii), by striking ``on the
basis'' and inserting ``for tests furnished
before January 1, 2017, on the basis'';
(B) in paragraph (2)(D)--
(i) by striking ``(i) on the basis'' and
inserting ``(i)(I) on the basis'';
(ii) in subclause (I), as added by clause
(i), by striking ``subsection (h)(1)'' and
inserting ``subsection (h)(1) (for tests
furnished before January 1, 2017)'';
(iii) by striking ``or (ii)'' and inserting
``or (II) under section 1834A (for tests
furnished on or after January 1, 2017), the
amount paid shall be equal to 80 percent (or
100 percent, in the case of such tests for
which payment is made on an assignment-related
basis or to a provider having an agreement
under section 1866) of the lesser of the amount
determined under such section or the amount of
the charges billed for the tests, or (ii)'';
and
(iv) in clause (ii), by striking ``on the
basis'' and inserting ``for tests furnished
before January 1, 2017, on the basis'';
(C) in subsection (b)(3)(B), by striking ``on the
basis'' and inserting ``for tests furnished before
January 1, 2017, on the basis'';
(D) in subsection (h)(2)(A)(i), by striking ``and
subject to'' and inserting ``and, for tests furnished
before the date of enactment of section 1834A, subject
to'';
(E) in subsection (h)(3), in the matter preceding
subparagraph (A), by striking ``fee schedules'' and
inserting ``fee schedules (for tests furnished before
January 1, 2017) or under section 1834A (for tests
furnished on or after January 1, 2017), subject to
subsection (b)(5) of such section'';
(F) in subsection (h)(6), by striking ``In the
case'' and inserting ``For tests furnished before
January 1, 2017, in the case''; and
(G) in subsection (h)(7), in the first sentence--
(i) by striking ``and (4)'' and inserting
``and (4) and section 1834A''; and
(ii) by striking ``under this subsection''
and inserting ``under this part''.
(2) Section 1869(f)(2) of the Social Security Act (42
U.S.C. 1395ff(f)(2)) is amended by adding at the end the
following new subparagraph:
``(C) Local coverage determinations for clinical
diagnostic laboratory tests.--For provisions relating
to local coverage determinations for clinical
diagnostic laboratory tests, see section 1834A(g).''.
(c) GAO Study and Report; Monitoring of Medicare Expenditures and
Implementation of New Payment System for Laboratory Tests.--
(1) GAO study and report on implementation of new payment
rates for clinical diagnostic laboratory tests.--
(A) Study.--The Comptroller General of the United
States (in this subsection referred to as the
``Comptroller General'') shall conduct a study on the
implementation of section 1834A of the Social Security
Act, as added by subsection (a). The study shall
include an analysis of--
(i) payment rates paid by private payors
for laboratory tests furnished in various
settings, including--
(I) how such payment rates compare
across settings;
(II) the trend in payment rates
over time; and
(III) trends by private payors to
move to alternative payment
methodologies for laboratory tests;
(ii) the conversion to the new payment rate
for laboratory tests under such section;
(iii) the impact of such implementation on
beneficiary access under title XVIII of the
Social Security Act;
(iv) the impact of the new payment system
on laboratories that furnish a low volume of
services and laboratories that specialize in a
small number of tests;
(v) the number of new Healthcare Common
Procedure Coding System (HCPCS) codes issued
for laboratory tests;
(vi) the spending trend for laboratory
tests under such title;
(vii) whether the information reported by
laboratories and the new payment rates for
laboratory tests under such section accurately
reflect market prices;
(viii) the initial list price for new
laboratory tests and the subsequent reported
rates for such tests under such section;
(ix) changes in the number of advanced
diagnostic laboratory tests and laboratory
tests cleared or approved by the Food and Drug
Administration for which payment is made under
such section; and
(x) healthcare economic information on
downstream cost impacts for such tests and
decision making based on accepted
methodologies.
(B) Report.--Not later than October 1, 2018, the
Comptroller General shall submit to the Committee on
Ways and Means and the Committee on Energy and Commerce
of the House of Representatives and the Committee on
Finance of the Senate a report on the study under
subparagraph (A), including recommendations for such
legislation and administrative action as the
Comptroller General determines appropriate.
(2) Monitoring of medicare expenditures and implementation
of new payment system for laboratory tests.--The Inspector
General of the Department of Health and Human Services shall--
(A) publicly release an annual analysis of the top
25 laboratory tests by expenditures under title XVIII
of the Social Security Act; and
(B) conduct analyses the Inspector General
determines appropriate with respect to the
implementation and effect of the new payment system for
laboratory tests under section 1834A of the Social
Security Act, as added by subsection (a).
SEC. 217. REVISIONS UNDER THE MEDICARE ESRD PROSPECTIVE PAYMENT SYSTEM.
(a) Delay of Implementation of Oral-Only Policy.--Section 632(b)(1)
of the American Taxpayer Relief Act of 2012 (42 U.S.C. 1395rr note) is
amended--
(1) by striking ``2016'' and inserting ``2024''; and
(2) by adding at the end the following new sentence:
``Notwithstanding section 1881(b)(14)(A)(ii) of the Social
Security Act (42 U.S.C. 1395rr(b)(14)(A)(ii)), implementation
of the policy described in the previous sentence shall be based
on data from the most recent year available.''.
(b) Mitigation of the Application of Adjustment to ESRD Bundled
Payment Rate To Account for Changes in the Utilization of Certain Drugs
and Biologicals.--
(1) In general.--Section 1881(b)(14)(I) of the Social
Security Act (42 U.S.C. 1395rr(b)(14)(I)) is amended by
inserting ``and before January 1, 2015,'' after ``January 1,
2014,''.
(2) Market basket.--Section 1881(b)(14)(F)(i) of the Social
Security Act (42 U.S.C. 1395rr(b)(14)(F)(i)) is amended--
(A) in subclause (I)--
(i) by striking ``subclause (II)'' and
inserting ``subclauses (II) and (III)''; and
(ii) by adding at the end the following new
sentence: ``In order to accomplish the purposes
of subparagraph (I) with respect to 2016, 2017,
and 2018, after determining the increase factor
described in the preceding sentence for each of
2016, 2017, and 2018, the Secretary shall
reduce such increase factor by 1.25 percentage
points for each of 2016 and 2017 and by 1
percentage point for 2018.'';
(B) in subclause (II), by striking ``For 2012'' and
inserting ``Subject to subclause (III), for 2012''; and
(C) by adding at the end the following new
subclause:
``(III) Notwithstanding subclauses (I) and (II), in order
to accomplish the purposes of subparagraph (I) with respect to
2015, the increase factor described in subclause (I) for 2015
shall be 0.0 percent pursuant to the regulation issued by the
Secretary on December 2, 2013, entitled `Medicare Program; End-
Stage Renal Disease Prospective Payment System, Quality
Incentive Program, and Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies; Final Rule' (78 Fed. Reg. 72156).''.
(c) Drug Designations.--As part of the promulgation of annual rule
for the Medicare end stage renal disease prospective payment system
under section 1881(b)(14) of the Social Security Act (42 U.S.C.
1395rr(b)(14)) for calendar year 2016, the Secretary of Health and
Human Services (in this subsection referred to as the ``Secretary'')
shall establish a process for--
(1) determining when a product is no longer an oral-only
drug; and
(2) including new injectable and intravenous products into
the bundled payment under such system.
(d) Quality Measures Related to Conditions Treated by Oral-Only
Drugs Under the ESRD Quality Incentive Program.--Section 1881(h)(2) of
the Social Security Act (42 U.S.C. 1395rr(h)(2)) is amended--
(1) in subparagraph (A)--
(A) in clause (ii), by striking ``and'' at the end;
(B) by redesignating clause (iii) as clause (iv);
and
(C) by inserting after clause (ii) the following
new clause:
``(iii) for 2016 and subsequent years,
measures described in subparagraph (E)(i);
and'';
(2) in subparagraph (B)(i), by striking ``(A)(iii)'' and
inserting ``(A)(iv)''; and
(3) by adding at the end the following new subparagraph:
``(E) Measures specific to the conditions treated
with oral-only drugs.--
``(i) In general.--The measures described
in this subparagraph are measures specified by
the Secretary that are specific to the
conditions treated with oral-only drugs. To the
extent feasible, such measures shall be
outcomes-based measures.
``(ii) Consultation.--In specifying the
measures under clause (i), the Secretary shall
consult with interested stakeholders.
``(iii) Use of endorsed measures.--
``(I) In general.--Subject to
subclause (I), any measures specified
under clause (i) must have been
endorsed by the entity with a contract
under section 1890(a).
``(II) Exception.--If the entity
with a contract under section 1890(a)
has not endorsed a measure for a
specified area or topic related to
measures described in clause (i) that
the Secretary determines appropriate,
the Secretary may specify a measure
that is endorsed or adopted by a
consensus organization recognized by
the Secretary that has expertise in
clinical guidelines for kidney
disease.''.
(e) Audits of Cost Reports of ESRD Providers as Recommended by
MedPAC.--
(1) In general.--The Secretary of Health and Human Services
shall conduct audits of Medicare cost reports beginning during
2012 for a representative sample of providers of services and
renal dialysis facilities furnishing renal dialysis services.
(2) Funding.--For purposes of carrying out paragraph (1),
the Secretary of Health and Human Services shall provide for
the transfer from the Federal 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 Services Program Management Account of $18,000,000 for
fiscal year 2014. Amounts transferred under this paragraph for
a fiscal year shall be available until expended.
SEC. 218. QUALITY INCENTIVES FOR COMPUTED TOMOGRAPHY DIAGNOSTIC IMAGING
AND PROMOTING EVIDENCE-BASED CARE.
(a) Quality Incentives To Promote Patient Safety and Public Health
in Computed Tomography Diagnostic Imaging.--
(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) Quality Incentives To Promote Patient Safety and Public
Health in Computed Tomography.--
``(1) Quality incentives.--In the case of an applicable
computed tomography service (as defined in paragraph (2)) for
which payment is made under an applicable payment system (as
defined in paragraph (3)) and that is furnished on or after
January 1, 2016, using equipment that is not consistent with
the CT equipment standard (described in paragraph (4)), the
payment amount for such service shall be reduced by the
applicable percentage (as defined in paragraph (5)).
``(2) Applicable computed tomography services defined.--In
this subsection, the term `applicable computed tomography
service' means a service billed using diagnostic radiological
imaging codes for computed tomography (identified as of January
1, 2014, by HCPCS codes 70450-70498, 71250-71275, 72125-72133,
72191-72194, 73200-73206, 73700-73706, 74150-74178, 74261-
74263, and 75571-75574 (and any succeeding codes).
``(3) Applicable payment system defined.--In this
subsection, the term `applicable payment system' means the
following:
``(A) The technical component and the technical
component of the global fee under the fee schedule
established under section 1848(b).
``(B) The prospective payment system for hospital
outpatient department services under section 1833(t).
``(4) Consistency with ct equipment standard.--In this
subsection, the term `not consistent with the CT equipment
standard' means, with respect to an applicable computed
tomography service, that the service was furnished using
equipment that does not meet each of the attributes of the
National Electrical Manufacturers Association (NEMA) Standard
XR-29-2013, entitled `Standard Attributes on CT Equipment
Related to Dose Optimization and Management'. Through
rulemaking, the Secretary may apply successor standards.
``(5) Applicable percentage defined.--In this subsection,
the term `applicable percentage' means--
``(A) for 2016, 5 percent; and
``(B) for 2017 and subsequent years, 15 percent.
``(6) Implementation.--
``(A) Information.--The Secretary shall require
that information be provided and attested to by a
supplier and a hospital outpatient department that
indicates whether an applicable computed tomography
service was furnished that was not consistent with the
CT equipment standard (described in paragraph (4)).
Such information may be included on a claim and may be
a modifier. Such information shall be verified, as
appropriate, as part of the periodic accreditation of
suppliers under section 1834(e) and hospitals under
section 1865(a).
``(B) Administration.--Chapter 35 of title 44,
United States Code, shall not apply to information
described in subparagraph (A).''.
(2) Conforming amendments.--
(A) Prospective payment system for hospital
outpatient department services.--Section 1833(t) of the
Social Security Act (42 1395l(t)) is amended by adding
at the end the following new paragraph:
``(20) Not budget neutral application of reduced
expenditures resulting from quality incentives for computed
tomography.--The Secretary shall not take into account the
reduced expenditures that result from the application of
section 1834(p) in making any budget neutrality adjustments
this subsection.''.
(B) Physician fee schedule.--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) Reduced expenditures
attributable to application of quality
incentives for computed tomography.--
Effective for fee schedules established
beginning with 2016, reduced
expenditures attributable to the
application of the quality incentives
for computed tomography under section
1834(p)''.
(b) Promoting Evidence-Based Care.--
(1) In general.--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) 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 for an individual. 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.
``(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.
``(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) are scientifically valid and
evidence based; and
``(iii) are based on studies that are
published and reviewable by stakeholders.
``(C) Revisions.--The Secretary shall review, on an
annual basis, the specified applicable appropriate use
criteria to determine if there is a need to update or
revise (as appropriate) such specification of
applicable appropriate use criteria and make such
updates or revisions through rulemaking.
``(D) Treatment of multiple applicable appropriate
use criteria.--In the case where the Secretary
determines that more than one appropriate use criterion
applies with respect to an applicable imaging service,
the Secretary shall apply 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 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, health
care technology experts, 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 is
more than one applicable appropriate
use criterion 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 identify on an annual basis 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) 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 an annual basis, no more
than five percent of the total number of 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) Process.--The Secretary shall establish a
process for determining when an outlier ordering
professional is no longer an outlier ordering
professional.
``(E) 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) Appropriate use criteria in prior
authorization.--In applying prior authorization under
subparagraph (A), the Secretary shall utilize only the
applicable appropriate use criteria specified under
this subsection.
``(C) 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.
``(7) Construction.--Nothing in this subsection shall be
construed as granting the Secretary the authority to develop or
initiate the development of clinical practice guidelines or
appropriate use criteria.''.
(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(q).''.
(3) Report on experience of imaging appropriate use
criteria program.--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 includes a
description of the extent to which appropriate use criteria
could be used for other services under part B of title XVIII of
the Social Security Act (42 U.S.C. 1395j et seq.), such as
radiation therapy and clinical diagnostic laboratory services.
SEC. 219. USING FUNDING FROM TRANSITIONAL FUND FOR SUSTAINABLE GROWTH
RATE (SGR) REFORM.
Section 1898(b)(1) of the Social Security Act (42 U.S.C.
1395iii(b)(1)) is amended by striking ``$2,300,000,000'' and inserting
``$0''.
SEC. 220. 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 2017 through 2020, 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
2017.
``(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 2017,
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 2017, for services that are not new or revised codes, 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).
(h) Adjustment to Medicare Payment Localities.--
(1) In general.--Section 1848(e) of the Social Security Act
(42 U.S.C. 1395w-4(e)) is amended by adding at the end the
following new paragraph:
``(6) Use of msas as fee schedule areas in california.--
``(A) In general.--Subject to the succeeding
provisions of this paragraph and notwithstanding the
previous provisions of this subsection, for services
furnished on or after January 1, 2017, the fee schedule
areas used for payment under this section applicable to
California shall be the following:
``(i) Each Metropolitan Statistical Area
(each in this paragraph referred to as an
`MSA'), as defined by the Director of the
Office of Management and Budget as of December
31 of the previous year, shall be a fee
schedule area.
``(ii) All areas not included in an MSA
shall be treated as a single rest-of-State fee
schedule area.
``(B) Transition for msas previously in rest-of-
state payment locality or in locality 3.--
``(i) In general.--For services furnished
in California during a year beginning with 2017
and ending with 2021 in an MSA in a transition
area (as defined in subparagraph (D)), subject
to subparagraph (C), the geographic index
values to be applied under this subsection for
such year shall be equal to the sum of the
following:
``(I) Current law component.--The
old weighting factor (described in
clause (ii)) for such year multiplied
by the geographic index values under
this subsection for the fee schedule
area that included such MSA that would
have applied in such area (as estimated
by the Secretary) if this paragraph did
not apply.
``(II) MSA-based component.--The
MSA-based weighting factor (described
in clause (iii)) for such year
multiplied by the geographic index
values computed for the fee schedule
area under subparagraph (A) for the
year (determined without regard to this
subparagraph).
``(ii) Old weighting factor.--The old
weighting factor described in this clause--
``(I) for 2017, is \5/6\; and
``(II) for each succeeding year, is
the old weighting factor described in
this clause for the previous year minus
\1/6\.
``(iii) MSA-based weighting factor.--The
MSA-based weighting factor described in this
clause for a year is 1 minus the old weighting
factor under clause (ii) for that year.
``(C) Hold harmless.--For services furnished in a
transition area in California during a year beginning
with 2017, the geographic index values to be applied
under this subsection for such year shall not be less
than the corresponding geographic index values that
would have applied in such transition area (as
estimated by the Secretary) if this paragraph did not
apply.
``(D) Transition area defined.--In this paragraph,
the term `transition area' means each of the following
fee schedule areas for 2013:
``(i) The rest-of-State payment locality.
``(ii) Payment locality 3.
``(E) References to fee schedule areas.--Effective
for services furnished on or after January 1, 2017, for
California, any reference in this section to a fee
schedule area shall be deemed a reference to a fee
schedule area established in accordance with this
paragraph.''.
(2) Conforming amendment to definition of fee schedule
area.--Section 1848(j)(2) of the Social Security Act (42 U.S.C.
1395w-4(j)(2)) is amended by striking ``The term'' and
inserting ``Except as provided in subsection (e)(6)(D), the
term''.
(i) Disclosure of Data Used To Establish Multiple Procedure Payment
Reduction Policy.--The Secretary of Health and Human Services shall
make publicly available the information used to establish the multiple
procedure payment reduction policy to the professional component of
imaging services in the final rule published in the Federal Register,
v. 77, n. 222, November 16, 2012, pages 68891-69380 under the physician
fee schedule under section 1848 of the Social Security Act (42 U.S.C.
1395w-4).
SEC. 221. MEDICAID DSH.
(a) Modifications of Reductions to Allotments.--Section 1923(f) of
the Social Security Act (42 U.S.C. 1396r-4(f)) is amended--
(1) in paragraph (7)(A)--
(A) in clause (i), by striking ``2016 through
2020'' and inserting ``2017 through 2024''; and
(B) in clause (ii), by striking subclauses (I)
through (IV), and inserting the following:
``(I) $1,800,000,000 for fiscal
year 2017;
``(II) $4,700,000,000 for fiscal
year 2018;
``(III) $4,700,000,000 for fiscal
year 2019;
``(IV) $4,700,000,000 for fiscal
year 2020;
``(V) $4,800,000,000 for fiscal
year 2021;
``(VI) $5,000,000,000 for fiscal
year 2022;
``(VII) $5,000,000,000 for fiscal
year 2023; and
``(VIII) $4,400,000,000 for fiscal
year 2024.''; and
(2) by striking paragraph (8) and inserting the following:
``(8) Calculation of DSH allotments after reductions
period.--The DSH allotment for a State for fiscal years after
fiscal year 2024 shall be calculated under paragraph (3)
without regard to paragraph (7).''.
(b) MACPAC Review and Report.--Section 1900(b)(6) of the Social
Security Act (42 U.S.C. 1396(b)(6)) is amended--
(1) by striking ``MACPAC shall consult'' and inserting the
following:
``(A) In general.--MACPAC shall consult''; and
(2) by adding at the end the following:
``(B) Review and reports regarding medicaid dsh.--
``(i) In general.--MACPAC shall review and
submit an annual report to Congress on
disproportionate share hospital payments under
section 1923. Each report shall include the
information specified in clause (ii).
``(ii) Required report information.--Each
report required under this subparagraph shall
include the following:
``(I) Data relating to changes in
the number of uninsured individuals.
``(II) Data relating to the amount
and sources of hospitals' uncompensated
care costs, including the amount of
such costs that are the result of
providing unreimbursed or under-
reimbursed services, charity care, or
bad debt.
``(III) Data identifying hospitals
with high levels of uncompensated care
that also provide access to essential
community services for low-income,
uninsured, and vulnerable populations,
such as graduate medical education, and
the continuum of primary through
quarternary care, including the
provision of trauma care and public
health services.
``(IV) State-specific analyses
regarding the relationship between the
most recent State DSH allotment and the
projected State DSH allotment for the
succeeding year and the data reported
under subclauses (I), (II), and (III)
for the State.
``(iii) Data.--Notwithstanding any other
provision of law, the Secretary regularly shall
provide MACPAC with the most recent State
reports and most recent independent certified
audits submitted under section 1923(j), cost
reports submitted under title XVIII, and such
other data as MACPAC may request for purposes
of conducting the reviews and preparing and
submitting the annual reports required under
this subparagraph.
``(iv) Submission deadlines.--The first
report required under this subparagraph shall
be submitted to Congress not later than
February 1, 2016. Subsequent reports shall be
submitted as part of, or with, each annual
report required under paragraph (1)(C) during
the period of fiscal years 2017 through
2024.''.
SEC. 222. REALIGNMENT OF THE MEDICARE SEQUESTER FOR FISCAL YEAR 2024.
Paragraph (6) (relating to implementing direct spending reductions)
of section 251A of the Balanced Budget and Emergency Deficit Control
Act of 1985 (2 U.S.C. 901a) is amended by adding at the end the
following new subparagraph:
``(D) Notwithstanding the 2 percent limit specified in
subparagraph (A) for payments for the Medicare programs
specified in section 256(d), the sequestration order of the
President under such subparagraph for fiscal year 2024 shall be
applied to such payments so that--
``(i) with respect to the first 6 months in which
such order is effective for such fiscal year, the
payment reduction shall be 4.0 percent; and
``(ii) with respect to the second 6 months in which
such order is so effective for such fiscal year, the
payment reduction shall be 0.0 percent.''.
SEC. 223. DEMONSTRATION PROGRAMS TO IMPROVE COMMUNITY MENTAL HEALTH
SERVICES.
(a) Criteria for Certified Community Behavioral Health Clinics To
Participate in Demonstration Programs.--
(1) Publication.--Not later than September 1, 2015, the
Secretary shall publish criteria for a clinic to be certified
by a State as a certified community behavioral health clinic
for purposes of participating in a demonstration program
conducted under subsection (d).
(2) Requirements.--The criteria published under this
subsection shall include criteria with respect to the
following:
(A) Staffing.--Staffing requirements, including
criteria that staff have diverse disciplinary
backgrounds, have necessary State-required license and
accreditation, and are culturally and linguistically
trained to serve the needs of the clinic's patient
population.
(B) Availability and accessibility of services.--
Availability and accessibility of services, including
crisis management services that are available and
accessible 24 hours a day, the use of a sliding scale
for payment, and no rejection for services or limiting
of services on the basis of a patient's ability to pay
or a place of residence.
(C) Care coordination.--Care coordination,
including requirements to coordinate care across
settings and providers to ensure seamless transitions
for patients across the full spectrum of health
services including acute, chronic, and behavioral
health needs. Care coordination requirements shall
include partnerships or formal contracts with the
following:
(i) Federally-qualified health centers (and
as applicable, rural health clinics) to provide
Federally-qualified health center services (and
as applicable, rural health clinic services) to
the extent such services are not provided
directly through the certified community
behavioral health clinic.
(ii) Inpatient psychiatric facilities and
substance use detoxification, post-
detoxification step-down services, and
residential programs.
(iii) 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, State
licensed and nationally accredited child
placing agencies for therapeutic foster care
service, and other social and human services.
(iv) 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.
(v) Inpatient acute care hospitals and
hospital outpatient clinics.
(D) Scope of services.--Provision (in a manner
reflecting person-centered care) of the following
services which, if not available directly through the
certified community behavioral health clinic, are
provided or referred through formal relationships with
other providers:
(i) Crisis mental health services,
including 24-hour mobile crisis teams,
emergency crisis intervention services, and
crisis stabilization.
(ii) Screening, assessment, and diagnosis,
including risk assessment.
(iii) Patient-centered treatment planning
or similar processes, including risk assessment
and crisis planning.
(iv) Outpatient mental health and substance
use services.
(v) Outpatient clinic primary care
screening and monitoring of key health
indicators and health risk.
(vi) Targeted case management.
(vii) Psychiatric rehabilitation services.
(viii) Peer support and counselor services
and family supports.
(ix) Intensive, community-based mental
health care for members of the armed forces and
veterans, particularly those members and
veterans located in rural areas, provided the
care is 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.
(E) Quality and other reporting.--Reporting of
encounter data, clinical outcomes data, quality data,
and such other data as the Secretary requires.
(F) Organizational authority.--Criteria that a
clinic be a non-profit or part of a local government
behavioral health authority or operated under the
authority of the Indian Health Service, an Indian tribe
or tribal organization pursuant to a contract, grant,
cooperative agreement, or compact with the Indian
Health Service pursuant to the Indian Self-
Determination Act (25 U.S.C. 450 et seq.), or an urban
Indian organization pursuant to a grant or contract
with the Indian Health Service under title V of the
Indian Health Care Improvement Act (25 U.S.C. 1601 et
seq.).
(b) Guidance on Development of Prospective Payment System for
Testing Under Demonstration Programs.--
(1) In general.--Not later than September 1, 2015, the
Secretary, through the Administrator of the Centers for
Medicare & Medicaid Services, shall issue guidance for the
establishment of a prospective payment system that shall only
apply to medical assistance for mental health services
furnished by a certified community behavioral health clinic
participating in a demonstration program under subsection (d).
(2) Requirements.--The guidance issued by the Secretary
under paragraph (1) shall provide that--
(A) 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
(B) no payment shall be made to satellite
facilities of certified community behavioral health
clinics if such facilities are established after the
date of enactment of this Act.
(c) Planning Grants.--
(1) In general.--Not later than January 1, 2016, the
Secretary shall award planning grants to States for the purpose
of developing proposals to participate in time-limited
demonstration programs described in subsection (d).
(2) Use of funds.--A State awarded a planning grant under
this subsection shall--
(A) solicit input with respect to the development
of such a demonstration program from patients,
providers, and other stakeholders;
(B) certify clinics as certified community
behavioral health clinics for purposes of participating
in a demonstration program conducted under subsection
(d); and
(C) establish a prospective payment system for
mental health services furnished by a certified
community behavioral health clinic participating in a
demonstration program under subsection (d) in
accordance with the guidance issued under subsection
(b).
(d) Demonstration Programs.--
(1) In general.--Not later than September 1, 2017, the
Secretary shall select States to participate in demonstration
programs that are developed through planning grants awarded
under subsection (c), meet the requirements of this subsection,
and represent a diverse selection of geographic areas,
including rural and underserved areas.
(2) Application requirements.--
(A) In general.--The Secretary shall solicit
applications to participate in demonstration programs
under this subsection solely from States awarded
planning grants under subsection (c).
(B) Required information.--An application for a
demonstration program under this subsection shall
include the following:
(i) The target Medicaid population to be
served under the demonstration program.
(ii) A list of participating certified
community behavioral health clinics.
(iii) Verification that the State has
certified a participating clinic as a certified
community behavioral health clinic in
accordance with the requirements of subsection
(b).
(iv) A description of the scope of the
mental health services available under the
State Medicaid program that will be paid for
under the prospective payment system tested in
the demonstration program.
(v) Verification that the State has agreed
to pay for such services at the rate
established under the prospective payment
system.
(vi) Such other information as the
Secretary may require relating to the
demonstration program including with respect to
determining the soundness of the proposed
prospective payment system.
(3) Number and length of demonstration programs.--Not more
than 8 States shall be selected for 2-year demonstration
programs under this subsection.
(4) Requirements for selecting demonstration programs.--
(A) In general.--The Secretary shall give
preference to selecting demonstration programs where
participating certified community behavioral health
clinics--
(i) provide the most complete scope of
services described in subsection (a)(2)(D) to
individuals eligible for medical assistance
under the State Medicaid program;
(ii) will improve availability of, access
to, and participation in, services described in
subsection (a)(2)(D) to individuals eligible
for medical assistance under the State Medicaid
program;
(iii) will improve availability of, access
to, and participation in assisted outpatient
mental health treatment in the State; or
(iv) demonstrate the potential to expand
available mental health services in a
demonstration area and increase the quality of
such services without increasing net Federal
spending.
(5) Payment for medical assistance for mental health
services provided by certified community behavioral health
clinics.--
(A) In general.--The Secretary shall pay a State
participating in a demonstration program under this
subsection the Federal matching percentage specified in
subparagraph (B) for amounts expended by the State to
provide medical assistance for mental health services
described in the demonstration program application in
accordance with paragraph (2)(B)(iv) that are provided
by certified community behavioral health clinics to
individuals who are enrolled in the State Medicaid
program. Payments to States made under this paragraph
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).
(B) Federal matching percentage.--The Federal
matching percentage specified in this subparagraph is
with respect to medical assistance described in
subparagraph (A) that is furnished--
(i) to a newly eligible individual
described in paragraph (2) of section 1905(y)
of the Social Security Act (42 U.S.C.
1396d(y)), the matching rate applicable under
paragraph (1) of that section; and
(ii) to an individual who is not a newly
eligible individual (as so described) but who
is eligible for medical assistance under the
State Medicaid program, the enhanced FMAP
applicable to the State.
(C) Limitations.--
(i) In general.--Payments shall be made
under this paragraph to a State only for mental
health services--
(I) that are described in the
demonstration program application in
accordance with paragraph (2)(iv);
(II) for which payment is available
under the State Medicaid program; and
(III) that are provided to an
individual who is eligible for medical
assistance under the State Medicaid
program.
(ii) Prohibited payments.--No payment shall
be made under this paragraph--
(I) for inpatient care, residential
treatment, room and board expenses, or
any other non-ambulatory services, as
determined by the Secretary; or
(II) with respect to payments made
to satellite facilities of certified
community behavioral health clinics if
such facilities are established after
the date of enactment of this Act.
(6) Waiver of statewideness requirement.--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 demonstration programs in accordance with
the requirements of this subsection.
(7) Annual reports.--
(A) In general.--Not later than 1 year after the
date on which the first State is selected for a
demonstration program under this subsection, and
annually thereafter, the Secretary shall submit to
Congress an annual report on the use of funds provided
under all demonstration programs conducted under this
subsection. Each such report shall include--
(i) an assessment of access to community-
based mental health services under the Medicaid
program in the area or areas of a State
targeted by a demonstration program compared to
other areas of the State;
(ii) an assessment of the quality and scope
of services provided by certified community
behavioral health clinics compared to
community-based mental health services provided
in States not participating in a demonstration
program under this subsection and in areas of a
demonstration State that are not participating
in the demonstration program; and
(iii) an assessment of the impact of the
demonstration programs on the Federal and State
costs of a full range of mental health services
(including inpatient, emergency and ambulatory
services).
(B) Recommendations.--Not later than December 31,
2021, the Secretary shall submit to Congress
recommendations concerning whether the demonstration
programs under this section should be continued,
expanded, modified, or terminated.
(e) Definitions.--In this section:
(1) Federally-qualified health center services; federally-
qualified health center; rural health clinic services; rural
health clinic.--The terms ``Federally-qualified health center
services'', ``Federally-qualified health center'', ``rural
health clinic services'', and ``rural health clinic'' have the
meanings given those terms in section 1905(l) of the Social
Security Act (42 U.S.C. 1396d(l)).
(2) Enhanced fmap.--The term ``enhanced FMAP'' has the
meaning given that term 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.
(3) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(4) 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.).
(f) Funding.--
(1) In general.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to the
Secretary--
(A) for purposes of carrying out subsections (a),
(b), and (d)(7), $2,000,000 for fiscal year 2014; and
(B) for purposes of awarding planning grants under
subsection (c), $25,000,000 for fiscal year 2016.
(2) Availability.--Funds appropriated under paragraph (1)
shall remain available until expended.
SEC. 224. ASSISTED OUTPATIENT TREATMENT GRANT PROGRAM FOR INDIVIDUALS
WITH SERIOUS MENTAL ILLNESS.
(a) In General.--The Secretary shall establish a 4-year pilot
program to award not more than 50 grants each year to eligible entities
for assisted outpatient treatment programs for individuals with serious
mental illness.
(b) Consultation.--The Secretary shall carry out this section in
consultation with the Director of the National Institute of Mental
Health, the Attorney General of the United States, the Administrator of
the Administration for Community Living, and the Administrator of the
Substance Abuse and Mental Health Services Administration.
(c) Selecting Among Applicants.--The Secretary--
(1) may only award grants under this section to applicants
that have not previously implemented an assisted outpatient
treatment program; and
(2) shall evaluate applicants based on their potential to
reduce hospitalization, homelessness, incarceration, and
interaction with the criminal justice system while improving
the health and social outcomes of the patient.
(d) Use of Grant.--An assisted outpatient treatment program funded
with a grant awarded under this section shall include--
(1) evaluating the medical and social needs of the patients
who are participating in the program;
(2) preparing and executing treatment plans for such
patients that--
(A) include criteria for completion of court-
ordered treatment; and
(B) provide for monitoring of the patient's
compliance with the treatment plan, including
compliance with medication and other treatment
regimens;
(3) providing for such patients case management services
that support the treatment plan;
(4) ensuring appropriate referrals to medical and social
service providers;
(5) evaluating the process for implementing the program to
ensure consistency with the patient's needs and State law; and
(6) measuring treatment outcomes, including health and
social outcomes such as rates of incarceration, health care
utilization, and homelessness.
(e) Report.--Not later than the end of each of fiscal years 2016,
2017, and 2018, the Secretary shall submit a report to the appropriate
congressional committees on the grant program under this section. Each
such report shall include an evaluation of the following:
(1) Cost savings and public health outcomes such as
mortality, suicide, substance abuse, hospitalization, and use
of services.
(2) Rates of incarceration by patients.
(3) Rates of homelessness among patients.
(4) Patient and family satisfaction with program
participation.
(f) Definitions.--In this section:
(1) The term ``assisted outpatient treatment'' means
medically prescribed mental health treatment that a patient
receives while living in a community under the terms of a law
authorizing a State or local court to order such treatment.
(2) The term ``eligible entity'' means a county, city,
mental health system, mental health court, or any other entity
with authority under the law of the State in which the grantee
is located to implement, monitor, and oversee assisted
outpatient treatment programs.
(3) The term ``Secretary'' means the Secretary of Health
and Human Services.
(g) Funding.--
(1) Amount of grants.--A grant under this section shall be
in an amount that is not more than $1,000,000 for each of
fiscal years 2015 through 2018. Subject to the preceding
sentence, the Secretary shall determine the amount of each
grant based on the population of the area, including estimated
patients, to be served under the grant.
(2) Authorization of appropriations.--There is authorized
to be appropriated to carry out this section $15,000,000 for
each of fiscal years 2015 through 2018.
SEC. 225. EXCLUSION FROM PAYGO SCORECARDS.
(a) Statutory Pay-As-You-Go Scorecards.--The budgetary effects of
this Act shall not be entered on either PAYGO scorecard maintained
pursuant to section 4(d) of the Statutory Pay-As-You-Go Act of 2010.
(b) Senate PAYGO Scorecards.--The budgetary effects of this Act
shall not be entered on any PAYGO scorecard maintained for purposes of
section 201 of S. Con. Res. 21 (110th Congress).
Passed the House of Representatives March 27, 2014.
Attest:
KAREN L. HAAS,
Clerk.