[Senate Report 113-135]
[From the U.S. Government Publishing Office]
Calendar No. 280
113th Congress Report
SENATE
2d Session 113-135
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TO AMEND TITLE XVIII OF THE SOCIAL SECURITY ACT TO REPEAL THE MEDICARE
SUSTAINABLE GROWTH RATE FORMULA AND TO IMPROVE BENEFICIARY ACCESS UNDER
THE MEDICARE PROGRAM, AND FOR OTHER PURPOSES
_______
January 16, 2014.--Ordered to be printed
_______
Mr. Baucus, from the Committee on Finance,
submitted the following
R E P O R T
[To accompany S. 1871]
[Including cost estimate of the Congressional Budget Office]
The Committee on Finance, having considered an original
bill, S. 1871, to amend title XVIII of the Social Security Act
to repeal the Medicare sustainable growth rate formula and to
improve beneficiary access under the Medicare program, and for
other purposes, reports favorably thereon and recommends that
the bill do pass.
I. BACKGROUND AND NEED FOR LEGISLATIVE ACTION
The Sustainable Growth Rate (SGR) formula--the mechanism
that dictates Medicare payment updates for physicians and other
practitioners, referred to as professionals--is fundamentally
broken and must be repealed. Congress has spent nearly $150
billion since 2003 on short-term overrides of payment cuts
stipulated by the SGR. These overrides or ``patches'' have
frustrated providers, threatened access for beneficiaries, and
created a budgetary dilemma from which Congress has struggled
to emerge.
The physician fee schedule can limit the amount Medicare
pays for each service but it does not directly impact the
volume of services provided. When the fee schedule was
implemented in 1992, a Medicare volume performance standard
(MVPS) was included, but it was not very effective in limiting
total professional expenditures. The Balanced Budget Act of
1997 (BBA, P.L. 105-33) established the SGR to replace the MVPS
and created a target rate of growth for Medicare professional
expenditures. The intent was to adjust payments under the fee
schedule according to how overall Medicare professional
spending compares to an SGR ``target.''
Generally, under the SGR formula, comparisons of actual
versus target spending for both the current year as well as
cumulatively (going back to 1996, the base year) will determine
the magnitude and direction (positive or negative) of the
update adjustment factor. For example, if current year
comparisons as well as cumulative expenditures from the current
period going back to 1996 are less than the cumulative spending
target over the same period, the annual update is increased
according to a statutory formula. If, however, spending exceeds
the cumulative spending target over the same period, the SGR
methodology necessitates fee schedule update reductions to
bring spending back in line with the target growth rate.
Since 2002, professional spending has routinely exceeded
the target set by the SGR, resulting in payment cuts under the
formula. In 2002, Medicare professional payments were cut by
4.8%. In subsequent years, however, Congress approved overrides
of the payment reductions required by the SGR without changing
the underlying formula. The most recent override was approved
in December of 2013 as part of the Bipartisan Budget Act of
2013 (BPBA, P.L. 113-67) and replaced the SGR-dictated payment
reduction with a 0.5 percent update for three months, until
March 31, 2014. If Congress does not act by this date, Medicare
professional payment rates will be cut by over 20%.
Congress has implemented several initiatives to address the
perverse incentives created by the Medicare fee-for-service
(FFS) system. The Tax Relief and Health Care Act of 2006
(TRHCA, P.L. 109-432) established the physician quality
reporting system (PQRS) that provides incentive payments to
eligible professionals who report quality data to Medicare. The
Affordable Care Act (ACA, P.L. 111-148) extended the PQRS
incentive payment program and created the value-based payment
modifier (VBM), a separate, budget-neutral payment modifier
that adjusts payments under the Medicare physician fee schedule
based on the relative quality and cost of care provided. The
implementation of the VBM shifted Medicare from paying for
reporting to paying for value.
Congress has also advanced the objectives of delivery
system reform in multiple ways. The American Recovery and
Reinvestment Act of 2009 (ARRA, P.L. 111-5) authorized
incentive payments to physicians who are meaningful users of
certified electronic health record (EHR) technology. Meaningful
users must demonstrate the ability to exchange electronic
health information to improve health care quality and use EHR
technology to report clinical quality measures. Additionally,
the ACA established the Center for Medicare and Medicaid
Innovation (CMMI) to test alternative payment models (APMs)
like accountable care organizations, bundled payments, and
patient-centered medical homes.
The Committee Bill would permanently repeal the SGR update
mechanism and provide zero percent updates until 2023. It also
would reform the physician fee schedule by consolidating
existing quality programs to place greater focus on value over
volume, and encourage participation in APMs being tested by
CMMI. After 2023, health care professionals in APMs would
receive an annual payment update of two percent; all other
professionals would receive an update of one percent.
The Bill would also consolidate the three existing
incentive programs into a budget-neutral value-based
performance (VBP) incentive program. Under this program,
professionals would receive annual payment increases or
decreases based on their performance. By combining the existing
quality incentive programs into a comprehensive VBP program,
the Committee Bill would further value-based purchasing within
the Medicare program while maintaining and improving the
efficiency of the underlying structure with which professionals
are already familiar.
Professionals who receive a significant portion of their
revenue from an APM(s) that involves a quality measurement
component, use of certified EHR technology and involves either
two-sided financial risk or is a Medicare or Medicaid medical
home certified by the Chief Actuary of the Centers for Medicare
& Medicaid Services (CMS) as reducing Medicare spending would
receive a bonus payment starting in 2017 and be exempted from
the VBP program.
The Committee Bill would fund measure development
priorities for professionals to address the current gaps in
quality programs and ensure meaningful measures on which to
assess professionals. It would also involve the health care
professional community in furthering the measurement of
resource use.
The Committee Bill would encourage care management services
for individuals with complex chronic care needs through the
development of new payment codes for such services. It would
also leverage physician-developed standard of care guidelines
to avoid the provision of unnecessary services. The Bill would
also improve the accuracy of the physician fee schedule by
setting a target for correcting misvalued services.
Recognizing the role of quality and resource use data in
helping consumers make informed purchasing decisions and
helping professionals improve their performance, the Bill would
expand the data available to qualified entities (QEs) for
quality improvement activities as well as the information
available on the Physician Compare website.
In addition to ending the cycle of temporary SGR patches,
the Committee Bill addresses so-called health extenders that
Congress addresses temporarily year after year. The Bill makes
permanent policies to support rural and small hospitals, the
floor on geographic adjustments to the component of
professional payments that reflect the time and intensity
associated with furnishing a service, the authority for special
needs plans (SNPs) for patients in institutionalized settings,
and funding for outreach and assistance to low-income Medicare
beneficiaries. The Bill also temporarily extends payment
increases for ground ambulance transportation, the authority
for SNPs for patients who are eligible for Medicare and
Medicaid and patients with specific, disabling chronic
conditions, funding for states to pay Medicare Part B premiums
for low-income qualifying individuals, additional funding for
the transitional medical assistance program, a temporary
extension of ``Express Lane'' eligibility determination,
redirected funding to temporarily extend pediatric quality
measures, and funding for the special diabetes programs
authorized under the BBA. Finally, the Bill replaces some
existing extender policies with new policies. Medicare cost
contract plans would be required to convert to Medicare
Advantage (MA) plans or contracts will be terminated.
Additionally, the existing cap on therapy services would be
eliminated and replaced with a medical review program for
outpatient therapy services.
The Committee Bill also temporarily extends funding for
several human services programs including abstinence education
grants, the personal responsibility education program, family-
to-family health information centers, and the health workforce
demonstration project for low-income individuals.
LEGISLATIVE HISTORY AND COMMITTEE ACTION
The 113th Congress brought renewed commitment by the Senate
Finance Committee to repeal and replace the flawed SGR update
mechanism. Two factors reinvigorated the debate on replacing
the SGR: the significantly reduced Congressional Budget Office
score for repealing the SGR over ten years ($116.5 billion
compared to over $300 two years earlier) and a bipartisan
proposal reported out by the House Energy & Commerce Committee
in July of 2013.
The Senate Finance Committee began working on professional
payment reform in the spring of 2012. The Committee held three
roundtable discussions to ask three important questions. First,
the Committee invited former CMS Administrators Gail Wilensky,
Bruce Vladeck, Thomas Scully, and Mark McClellan to explain the
history of the SGR and why it did not work as intended. Second,
the Committee invited senior leaders from commercial insurance
plans to discuss what professional payment reforms are being
used in the private sector. Third, the Committee invited
leaders from the American Medical Association and diverse
physician specialty groups to ask them what an ideal payment
system would look like for professionals.
A key finding of the roundtable discussions was that
Congress should improve the existing FFS payment system while
seeking to implement APMs that reward value over volume. To
this end, the Finance Committee held a hearing in May of 2013
with the Executive Director of the Medicare Payment Advisory
Commission (MedPAC) and other experts to discuss possible
improvements to the FFS professional payment system. Witnesses
emphasized that, while APMs would provide better incentives to
help professionals improve quality and contain resource use,
policies including a focus on care coordination, harmonizing
current payment adjustments, and providing feedback to
professionals on resource use would help improve the existing
FFS system. Two months later, the Committee held a hearing with
Jon Blum, Deputy Administrator of CMS, to discuss quality
improvement programs that CMS is already implementing within
the FFS system and APMs being tested by the CMMI.
During this time, Chairman Baucus and Ranking Member Hatch
sent a letter to the professional community. The Senators asked
for recommendations on policies that would improve the
valuation of professional services under the physician fee
schedule, identify and reduce unnecessary utilization to
improve health and reduce Medicare spending growth, and
incentivize practices to undertake the structural and
behavioral changes needed to participate in APMs. Committee
staff reviewed over 130 responses from stakeholders.
Building on that effort, the bipartisan, bicameral staffs
of the House Ways & Means and Senate Finance Committees
developed a discussion draft of a policy to replace the SGR and
shared it with stakeholders on October 31, 2013. The Committees
collected feedback for two weeks; holding town hall meetings
with stakeholders and reviewing over 200 comment letters. Based
on this feedback, the Committees made several modifications to
the policy. These changes adjusted the timeline for
implementation of several provisions within the legislation to
reflect professionals' readiness for practice transformation.
By December, the Finance Committee was ready to act. The
Chairman's Mark was released on December 10, 2013, two days
prior to the Executive Session to consider what became the
Committee Bill.
During the markup the Committee recognized that market
consolidation among providers, hospitals, and payers is a
pressing issue facing the US health care system. Market
consolidation could, through unintended consequences, raise the
cost of care and, potentially even decrease access for Medicare
beneficiaries. Creating a comprehensive, systematic ongoing
mechanism for collecting information about health care markets
so that they may be monitored in a timely fashion should be a
key priority for policymakers. The Committee expressed support
for efforts by the Government Accountability Office (GAO) to
analyze market trends in health care consolidation, along with
any common contributing factors, and evaluate the availability
and quality of current public and private data sources on
hospital, physician practice, and health plan ownership,
transactions, and commercial pricing. The Committee may
consider the GAO's report in future policy discussions.
Members submitted 137 amendments to the Mark. A total of 26
amendments was accepted and incorporated into the Mark before
the Executive Session began and another seven amendments were
approved by voice vote during the markup. No roll call votes
were conducted. The final vote to report the bill was approved
by voice vote.
II. EXPLANATION OF THE BILL
TITLE I--MEDICARE PAYMENT FOR PHYSICIANS' SERVICES
SEC. 101. REPEALING THE SUSTAINABLE GROWTH RATE AND IMPROVING MEDICARE
PAYMENT FOR PHYSICIANS' SERVICES
Present Law
Medicare payments for items and services furnished by
physicians and other professionals are made on the basis of a
fee schedule. The fee schedule assigns relative value units
(RVUs) to each of the over 7,000 service codes that reflect
professional work (i.e., time, skill, and intensity it takes to
provide the service), practice expenses, and malpractice costs.
The relative value for a service compares the RVUs for
professional work, practice expense and malpractice expense
with the corresponding RVUs for other services. The scale used
to compare the value of one service with another is known as a
resource-based relative value scale (RBRVS). These RVUs are
adjusted for geographic variation in input costs. The adjusted
relative values are then converted into a dollar payment amount
by a conversion factor.
CMS, which is responsible for maintaining and updating the
fee schedule, continually modifies and refines the methodology
for estimating RVUs. The American Medical Association/Specialty
Society Relative Value Scale Update Committee (RUC) has
historically provided advice and recommendations to CMS to
assist in the assessments. CMS is required to review the RVUs
at least every five years.
In determining adjustments to the RVUs, the Secretary of
Health and Human Services (herein after ``the Secretary'') has
authority to adjust the number of RVUs for any service code to
take into account changes in medical practice, coding changes,
new data on relative value components, or the addition of new
procedures. The Secretary is required to publish an explanation
of the basis for such adjustments. These adjustments are
subject to budget neutrality. With the exception of certain
expenditures that are exempt by statute, the adjustments may
not cause the amount of expenditures made under the Medicare
physician fee schedule to differ from year to year by more than
$20,000,000 from the expenditures that would have been incurred
without such an adjustment.
The SGR, is a statutory method for determining the annual
updates to the Medicare physician fee schedule. The SGR
methodology was established because of the concern that the
Medicare fee schedule itself would not adequately constrain
overall increases in spending for physicians' services.
Generally, under the SGR formula, comparisons of actual
versus target spending for both the current year as well as
cumulatively (going back to 1996, the base year) will determine
the magnitude and direction (positive or negative) of the
update adjustment factor. For example, if current year
comparisons as well as cumulative expenditures from the current
period going back to 1996 are less than the cumulative spending
target over the same period, the annual update is increased
according to a statutory formula. If, however, spending exceeds
the cumulative spending target over the same period, the SGR
methodology necessitates fee schedule update reductions to
bring spending back in line with the target growth rate.
In the first few years of the SGR system, the actual
expenditures did not exceed the targets and the updates to the
physician fee schedule were positive. Beginning in 2002, the
cumulative actual expenditures exceeded allowed targets,
resulting in SGR--mandated reductions in the update adjustment
factor, and the discrepancy has grown each year. With the
exception of 2002, when a 4.8 percent decrease was applied,
Congress has enacted a series of laws to override the
reductions.
Most recently, in December of 2013, the BPBA included a
Congressional override of the SGR-dictated payment reduction,
instead providing for a 0.5 percent update for three months,
until March 31, 2014. If Congress does not act by this date,
Medicare professional payment rates will be cut by over 20%.
Over time, Congress has added provisions to the physician
fee schedule intended to improve the quality of care delivered
to Medicare beneficiaries and constrain the growth of Medicare
spending for professional services. The TRHCA required the
establishment of a PQRS that would include an incentive payment
to eligible professionals who satisfactorily report data on
quality measures, based on a percentage of the allowed Medicare
charges for all such covered professional services. The
Medicare Improvements for Patients and Providers Act of 2008
(MIPPA, P.L. 110-275) made this program permanent and extended
the bonuses through 2010; the incentive payment was increased
from 1.5 percent of total allowable charges under the physician
fee schedule in 2007 and 2008, and to two percent in 2009 and
2010.
The ACA extended the PQRS incentive payments through 2014
and put in place a penalty for providers who do not report
quality measures beginning in 2015. Eligible professionals who
successfully reported received a one percent bonus in 2011;
those who successfully reported will receive a 0.5 percent
bonus in 2012, 2013, and 2014. By contrast, eligible
professionals who fail to participate successfully in the
program face a 1.5 percent payment penalty in 2015, and a two
percent payment penalty in 2016 and subsequent years. The
incentive payments and penalties are based on the allowed
charges for all covered services furnished by the eligible
professional.
Both MedPAC and the GAO have suggested that CMS provide
information to physicians on their resource use with the
expectation that physicians who are outliers would alter their
practice patterns in response. To that end, section 131 of the
MIPPA established a physician feedback program. The physician
feedback program uses Medicare claims data and other data to
provide confidential feedback reports to physicians (and as
determined appropriate by the Secretary, to groups of
physicians) that measure the resources involved in furnishing
care to Medicare beneficiaries. CMS initially called this
effort the Physician Resource Use Feedback Program, but has
renamed this initiative the ``Physician Resource Use
Measurement and Reporting Program.''
The ARRA authorized Medicare incentive payments over a
five-year period to physicians who are determined to be
``meaningful users'' of certified EHR technology. Meaningful
use is defined as (1) demonstrating to the satisfaction of the
Secretary the use of certified EHR technology in a meaningful
manner (including e-prescribing), including for the purpose of
exchanging electronic health information to improve health care
quality; and (2) using such certified EHR technology to report
clinical quality measures, as selected by the Secretary. The
incentive payments equal 75 percent of the allowed Part B
charges during the reporting year. The total amount that a
physician could receive was capped and decreased over time.
Beginning in 2011, eligible physicians received up to $15,000
in the first payment year, $12,000 in the second year, $8,000
in the third year, $4,000 in the fourth year, and $2,000 in the
fifth, and final, year. Early EHR adopters whose first payment
year was 2011 or 2012 received up to $18,000 (instead of
$15,000) for that year.
Eligible physicians who become meaningful EHR users for the
first time after 2013 will receive fewer payments and those who
do not adopt EHRs until after 2014 will receive no bonus. No
incentive payments will be made after 2016. Eligible physicians
who are not meaningful EHR users by 2015 will see their
Medicare payments reduced by the following amounts: one percent
in 2015, two percent in 2016, three percent in 2017 and each
subsequent year. For 2018 and each subsequent year, if the
proportion of eligible physicians who are meaningful EHR users
is less than 75 percent, the payment will be further decreased
by one percentage point from the applicable amount in the
previous year, though the reduction cannot exceed five percent.
The Secretary may, on a case-by-case basis, exempt eligible
physicians (e.g., rural physicians who lack sufficient Internet
access) from the payment reduction for up to five years if it
is determined that being a meaningful EHR user would result in
significant hardship.
The ACA required the Secretary to establish a VBM, which is
a budget-neutral payment modifier that adjusts payments under
the Medicare physician fee schedule based on the relative
quality and cost of the care provided. Quality of care is to be
evaluated on a composite of risk-adjusted measures of quality
established by the Secretary, such as measures that reflect
health outcomes. Costs, defined as expenditures per individual,
are to be evaluated based on a composite of appropriate
measures of costs established by the Secretary that eliminate
the effect of geographic adjustments in payment rates and take
into account risk factors (such as socioeconomic and
demographic characteristics, ethnicity, and the health status
of individuals) and other factors determined appropriate by the
Secretary.
Beginning January 1, 2015, the value-based payment modifier
will apply for items and services furnished for physicians in
groups of 100 or more eligible professionals who submit claims
to Medicare under a single tax identification number (TIN)
based on performance in CY2013. In CY2015 one percent of
payment will be at risk. This will increase to two percent in
CY2016. By 2017, the value-based payment modifier will apply to
all physicians who participate in FFS Medicare. The Secretary
is to apply the payment modifier in a manner that promotes
systems-based care and takes into account the special
circumstances of physicians or groups of physicians in rural
areas and other underserved communities.
Committee Bill
The Committee Bill would repeal the SGR methodology for
determining updates to the Medicare physician fee schedule. In
addition, it would: (1) provide a 10-year period of zero
percent updates; (2) establish a value-based performance
program that consolidates and enhances existing incentive
payment programs; (3) incentivize the development of, and
participation in, APMs; and (4) make other changes to Medicare
physician payment policies.
The update to the conversion factor for the Medicare
physician fee schedule would be zero percent for each year from
2014 through 2023. Beginning in 2024 and in subsequent years,
the update would vary, depending on whether the provider is a
participant in a qualifying APM. For services furnished by a
qualifying APM participant, the update would be two percent,
while the update for all other services provided by all other
professionals would be one percent.
By July 1, 2016, MedPAC would be required to submit a
report to Congress on the relationship between (1) physician
and other health professional utilization and expenditures, and
the rate of increase of such utilization and expenditures of
items and services paid for under Part B of the Medicare
program, and (2) total utilization and expenditures and their
rates of increase under Medicare Parts A, B, and D. The report
would include a methodology to describe this relationship and
the impact of changes in practice and service ordering patterns
of physician and other health professionals on total
utilization and expenditures, of health care services in
Medicare Parts A, B, and D. Another report, applying the
methodology developed, would be due to Congress by July 1,
2020.
The Committee Bill would create a new incentive payment
system, which would be called the VBP incentive program. This
program would extend key components of three existing programs
and would sunset their payment incentives and separate
application by consolidating and incorporating them into the
new VBP program beginning on January 1, 2017 (the payment
incentives for these programs would continue to be in effect
for CY2015 and CY2016). These three programs are: (1) the
Medicare EHR incentive program for meaningful use of certified
EHR technology, (2) the quality reporting incentive program
(currently called the PQRS), and (3) the value-based payment
modifier. The VBP would continue to use the provisions and
processes of these programs including meaningful use
determinations already carried out by the Medicare program,
PQRS quality metrics already being reported by professionals,
and requirements for quality and resource use measurement under
the VBM. Adjustments in the application of these provisions
would be made to ensure consistency with the new VBP program to
avoid duplicative requirements.
The VBP program would develop a methodology for assessing
the total performance of each VBP eligible professional,
provide for a composite performance score for each eligible
professional for each performance period; and use the composite
performance score of the VBP eligible professional to make VBP
program incentive payments.
The VBP program would apply to payments for items and
services furnished on or after January 1, 2017.
The types of health care professionals eligible for the VBP
incentive payments would expand over time. Subject to the
exclusions described below, physicians (as defined under
section 1861(r) of the Social Security Act (SSA, P.L. 74-271)),
physician assistants, nurse practitioners, and clinical nurse
specialists (defined under section 1861(aa)(5) of the SSA), and
certified clinical nurse specialists (defined under section
1861(bb)(2) of the SSA), and certified registered nurse
anesthetists (defined under section 1861(bb)(2) of the SSA)
would be eligible for the VBP program in 2017 and 2018. The
Secretary would have the authority to expand the VBP program to
additional eligible professionals described under section
1848(k)(3)(B) of the SSA, in 2019 and subsequent years.
Health care professionals excluded from the VBP program
would include otherwise eligible professionals who are
qualifying APM participants, partial qualifying APM
participants who do not report on the applicable measures and
activities (partial qualifying APM participants, who chose to
report under the VBP program despite this exclusion, would be
eligible for VBP incentive payments) and professionals who do
not exceed the low-volume threshold.
The Secretary would select one of three low-volume
thresholds to determine exclusion from the VBP program: (1) a
minimum number of Medicare beneficiaries who are treated by the
eligible professional, (2) a minimum number of items and
services furnished by the professional to Medicare
beneficiaries, or (3) a minimum amount of Medicare allowed
charges billed by the professional. In each case, the minimum
number would be determined by the Secretary.
A new VBP-eligible professional who had not previously
submitted Medicare claims as a person, an entity, or as a part
of a physician group or under a different billing number or tax
identifier, would be eligible for the VBP incentive program
beginning in the subsequent year and performance period for
such year.
Payments to professionals who are not VBP eligible
professionals would not be affected by any reduction in
payments for establishment of the funding pool for VBP
incentive payments or by any VBP program incentive payments.
The Secretary would encourage the use of qualified clinical
data registries (as specified in current law) in carrying out
this program.
The VBP program would be based on measures and activities
under four categories. A composite performance score would be
calculated for each VBP eligible professional, which would be
used to determine the VBP program incentive payment amounts.
The Secretary would use the following performance categories to
determine the composite performance score and the measures and
activities specified for each category:
1. Quality--The quality performance category would use
quality measures established under current law for the PQRS
program and the value--based payment modifier. The Secretary
would, as feasible, emphasize the application of outcome
measures, and could use measures used for a payment system
other than for physicians or use global measures, such as
global outcome measures, and population-based measures.
Analysis of measures used under the quality performance
category could include data submitted by VBP eligible
professionals from multiple payers.
2. Resource use--The resource use performance category
would use measures of resource use established under current
law for the value--based payment modifier. To the extent
feasible, resource use measures would account for the cost of
Part D drugs. As appropriate, the Secretary would employ
resource use measurements developed through the process for
collaborating with the physician, practitioner, and other
stakeholder communities to improve resource use measurement
described below.
3. Clinical practice improvement activities--The clinical
practice improvement activities performance category would use
activities specified by the Secretary, including at least the
following subcategories:
(a) expanded practice access, which would include
activities such as same-day appointments for urgent
needs and after-hours access to clinician advice;
(b) population management, which would include
activities such as monitoring health conditions of
individuals to provide timely health care interventions
or participation in a qualified clinical data registry;
(c) care coordination, which would include activities
such as timely communication of test results, timely
exchange of clinical information to patients and other
providers, and use of remote monitoring or telehealth;
(d) beneficiary engagement, which would include
activities such as the establishment of care plans for
individuals with complex care needs, beneficiary self-
management training, and using shared decision-making
mechanisms;
(e) patient safety and practice assessment, which
would include activities such as the use of clinical or
surgical checklists and practice assessments related to
maintaining certification; and
(f) participation in an APM, as defined below.
In establishing the clinical practice improvement
activities, the Secretary would give consideration to the
circumstances of small practices consisting of ten or fewer
professionals and practices located in rural areas and in
health professional shortage areas (HPSA). The Secretary could
contract with entities to assist in identifying the activities,
specifying criteria for such activities, and determining
whether a VBP eligible professional meets such criteria.
Additionally, the Secretary would use a request-for-information
process to solicit recommendations from stakeholders for
identifying other activities not expressly listed above, and
specifying criteria for such activities.
4. Meaningful use of certified EHR technology--The EHR
Meaningful Use performance category would use requirements
established for purposes of section 1848(o) of the SSA for
determining whether an eligible professional is a meaningful
EHR user for such period.
The Secretary would establish performance standards with
respect to the measures and activities under each of the four
VBP performance categories. The performance standards would
take into account historical performance standards, improvement
rates, and the opportunity for continued improvement.
The Secretary would establish a performance period (or
periods) for each year in which incentive payments would be
made under the VBP program, beginning with 2017. The
performance period would begin and end prior to the beginning
of the year in which the incentive payments would be paid and
be as close as possible to the payment year.
With respect to assessing performance in the quality
performance category, the Secretary would be required to
establish and apply a process for applying the VBP program to
group practices, which would include features of provisions
that currently apply to group practices in the PQRS. With
respect to assessing performance of group practices in the
remaining three performance categories described above, the
Secretary could also apply such a process for groups. In
determining these processes, the Secretary would reflect the
full range of items and services furnished by the VBP eligible
professionals in the group practice involved, to the extent
practicable. VBP eligible professionals electing to be a
virtual group (as described below) would not be considered VBP
eligible professionals in a group practice.
The Secretary would develop a methodology for assessing the
total performance of each VBP eligible professional according
to the performance standards and the applicable measures and
activities specified above with respect to each performance
category applicable to an eligible professional for a
performance period. Using the methodology developed, the
Secretary would determine a composite performance score for
each such professional for each performance period.
In weighting the performance categories, measures, and
activities to determine the composite performance score, the
Secretary may assign different scoring weights (including a
weight of zero) for each performance category based on the
extent to which the category is applicable to the type of
eligible professional involved, and each measure and activity
based on the extent to which the measure or activity is
applicable to the type of eligible professional involved. With
respect to the quality performance category, the Secretary
would assign a higher scoring weight to outcomes measures than
to other measures and increase the scoring weight for outcome
measures over time. The Secretary could also assign a higher
scoring weight to patient experience measures.
To incentivize reporting of activities and measures used to
determine the composite performance score, a VBP eligible
professional who failed to report on an applicable measure or
activity that is required for such professional would be
treated as having achieved the lowest potential score
applicable. To encourage the use of certified EHR technology
for reporting quality measures, the Secretary would encourage
VBP eligible professionals to report on applicable quality
measures through the use of certified EHR technology, and treat
any VBP eligible professional who reports the applicable
quality measures through the use of such EHR technology as
having satisfied the clinical quality measures reporting
requirement to be a meaningful EHR user under section
1848(o)(2)(A)(iii) of the SSA.
For the performance category of clinical practice
improvement activities, a VBP eligible professional who is in a
practice that is certified as a patient--centered medical home
or comparable specialty practice by an organization that is
recognized by the Secretary for purposes of certifying medical
homes and specialty practices would be given the highest
potential score for the clinical practice improvement
activities performance subcategory. A VBP eligible professional
in an APM, as defined below, would earn one--half of the
highest potential score for the clinical practice improvement
activity performance category. Such professional could also
earn more than one-half of the highest potential score for this
performance period by performing additional activities with
respect to the same performance category. A VBP eligible
professional would not be required to perform activities in
each subcategory of the clinical practice improvement activity
performance category to achieve the highest potential score for
this performance category.
The Secretary would ensure that the application of the
methodology developed to determine the composite performance
score would result in a continuous distribution of performance
scores, which would subsequently result in differential
incentive payments for VBP eligible professionals.
Beginning with the second year of the VBP program, in
addition to the achievement score of a VBP eligible
professional, the composite score methodology would take into
account improvement in the quality performance and the resource
use performance categories, and could take into account
improvement in the other performance categories. Beginning with
the fourth year of the VBP program, the composite score
methodology would assign a higher scoring weight with respect
to the achievement score than to any improvement score with
respect to a measure or activity, or a performance category or
both.
In general, subject to the adjustment noted below, the
composite performance score would be determined based on the
following weights: quality (30 percent), resource use (30
percent), clinical practice improvement activities (15
percent), and meaningful use of EHR technology (25 percent). In
any year in which the Secretary estimates that the proportion
of eligible professionals who are meaningful EHR users is 75
percent or greater, the Secretary could reduce the percent
applicable from 25 percent, but not below 15 percent. If the
Secretary were to make such a reduction, the weights of the
other categories would be increased such that the total
percentage points of the increase would equal the total number
of percentage points by which the EHR category was to be
reduced.
The weights for the quality and resource use performance
categories would always be equal, even after the application of
the above EHR adjustment, with the following exception. For the
first two years of the VBP program, after any EHR adjustment,
the Secretary could increase the weight for either the quality
or the resource use performance category, as long as the
Secretary were to decrease the weight under the other category
by an equal number of percentage points and so long as neither
weight is less than 15 percent.
The Secretary would provide a process to allow an
individual VBP eligible professional or a group practice
consisting of not more than ten VBP eligible professionals to
elect to be a virtual group with at least one other individual
VBP eligible professional or group of VBP eligible
professionals. For VBP eligible professionals who elect to be a
virtual group, the assessment on the quality and resource use
performance categories applied to each professional in such
group would be with respect to the combined performance of all
such professionals in such group, and the composite score under
the VBP program for each VBP eligible professional in the
virtual group would be based on the assessment of the combined
performance for the performance category and performance
period.
VBP eligible professionals who elect to become a virtual
group would be required to do so before the beginning of a
performance period and would not be allowed to change status
during the performance period. Each practice and each VBP
eligible professional in such a practice could elect to be in
no more than one virtual group for a performance period.
VBP incentive payments would be distributed in a budget
neutral manner. The total amount for VBP program incentive
payments for all VBP eligible professionals for a year would be
equal to the total amount of the performance funding pool for
all VBP eligible professionals (described below).
For items and services furnished by a VBP eligible
professional, the Secretary would conduct two concurrent
calculations to determine the amount paid: (1) a reduction of
the otherwise applicable fee schedule amount for that year (see
the applicable percent for the performance funding pool
described below); and (2) a calculation of the VBP incentive
payment amount (also described below). Eligible professionals
would be notified of their payment adjustment prior to the year
in which payments are made. The process to calculate the VBP
incentive payment amount would not authorize or create an
upfront withhold of reimbursements to eligible professionals.
The pool for paying VBP incentive payments would be created
by reducing the otherwise applicable fee schedule amount, which
is defined as the fee schedule amount for items and services
furnished by an eligible professional that would otherwise
apply. Beginning with 2017, the fee schedule amount for items
and services provided by a VBP eligible professional would be
reduced by the specified percentage described below (called the
`applicable percent'). The cumulative amount of such reductions
for a year across all VBP eligible professionals would
constitute the `performance funding pool' for the year. The
applicable percent reduction would be 4 percent for 2017, 6
percent for 2018, 8 percent for 2019, 10 percent for 2020, and
in subsequent years, a percentage to be specified by the
Secretary, but no less than 10 percent and no more than 12
percent.
The Secretary would specify a VBP program incentive payment
adjustment factor for each VBP eligible professional for a
year, which would be determined by the composite performance
score of the eligible professional for the year. The adjustment
factors would result in differential payments reflecting the
full range of distribution of composite performance scores of
VBP eligible professionals with professionals having higher
composite performance scores receiving higher payments. The
adjustment factors in a year could not result in a payment
reduction that exceeds the applicable percent for a year, and
could not result in a payment increase that exceeds the
applicable percent for such year.
The VBP program incentive payment amount for items and
services furnished by a VBP eligible professional during a year
would be equal to the difference between:
1. the product of (a) the VBP program incentive
payment adjustment factor and (b) the otherwise
applicable fee schedule amount; and
2. the otherwise applicable fee schedule amount, as
reduced by the applicable percent above, with respect
to such items and services, eligible professional, and
year.
No later than 60 days prior to the year involved, the
Secretary would make available to each VBP eligible
professional the VBP program incentive payment adjustment
factor and the percentage payment reduction for the performance
funding pool applicable to the eligible professional for items
and services furnished by the professional as described above
for the year. The Secretary could include such information in
confidential feedback reports.
The VBP program incentive payment and the payment reduction
would each apply only with respect to the year involved. The
Secretary would not take VBP program incentive payments or
payment reductions into account in making payments to a VBP
eligible professional in a subsequent year.
The Secretary would make information regarding the
performance of VBP eligible professionals under the VBP program
available to the public, in an easily understandable format on
the Physician Compare website. This information would include
the composite score for each VBP eligible professional, the
performance of each VBP eligible professional with respect to
each performance category, and the names of eligible
professionals in qualifying APMs and, to the extent feasible,
the name of the APM. The information could also include the
performance of each VBP eligible professional with respect to
each performance category measure or activity. The Secretary
would provide an opportunity for an eligible professional to
review, and submit corrections to, the individual's information
to be made public prior to such information being made public.
The Secretary would periodically post aggregate information
on the VBP program on the Physician Compare website, including
the range of composite scores for all VBP eligible
professionals, and the range of the performance of all VBP
eligible professionals with respect to each performance
category.
The Secretary would consult with stakeholders in carrying
out the VBP program, including for the identification of
performance category measures and activities and the
methodologies for developing the composite score and the VBP
program incentive payment adjustment factors. These
consultations would include the use of a request for
information or other mechanisms determined appropriate.
The Secretary would enter into contracts or agreements with
appropriate entities (such as quality improvement
organizations, regional extension centers, or regional health
collaboratives) to offer guidance and assistance to VBP
eligible professionals in practices of ten or fewer
professionals (with priority given to practices in rural areas,
in HPSAs, in medically underserved areas, or with low composite
scores). The guidance and assistance would help professionals
comply with the VBP program, and transition to an APM.
For purposes of implementing the guidance and assistance
described above, the Secretary would provide for the transfer
of $25 million from the Supplementary Medical Insurance (SMI)
Trust Fund to the CMS Program Management Account for each of
fiscal years 2014 through 2018. Not less than $10 million would
be available for technical assistance to practices of ten or
fewer professionals in HPSAs. These amounts would be available
until expended.
Beginning July 1, 2015, the Secretary would make available
timely (such as quarterly) confidential feedback to each VBP
eligible professional on the individual's performance with
respect to the quality and resource use performance categories.
The Secretary could also make available confidential feedback
on the individual's performance with respect to the clinical
practice improvement activities performance category and the
meaningful use of certified EHR technology category. The
Secretary could use one or more mechanisms to provide this
feedback, including use of a web-based portal or other
mechanisms determined appropriate by the Secretary. The
Secretary would encourage provision of feedback through
qualified clinical data registries under the existing PQRS
program, as implemented by American Taxpayer Relief Act (ATRA,
P.L. 112-240). The Secretary could also use such mechanisms to
receive information from professionals.
To facilitate timely feedback, the Secretary could use
data, with respect to VBP eligible professionals, from periods
prior to the current performance period and could use rolling
periods in order to make illustrative calculations about the
performance of these professionals. This feedback would be
exempt from disclosure under the Freedom of Information Act
(FOIA, P.L. 104-231).
Beginning July 1, 2016, the Secretary would make available,
to each VBP eligible professional, information about selected
items and services (as determined appropriate by the Secretary)
furnished to the professional's patients by other suppliers and
providers of services for which Medicare payment is made.
Information on selected items and services furnished to
patients of a VBP eligible professional by another supplier or
provider of services during the most recent period for which
data are available (such as the most recent three-month
period), would include the name of such providers furnishing
items and services to such patients during the period, the
types of items and services so furnished, and the dates on
which these items and services were furnished. The Secretary
would also make available historical averages (and other
measures of the distribution if appropriate) of the total, and
components of, allowed charges (and other figures as determined
appropriate by the Secretary) for care episode codes for such
period. Such information would be made available to VBP
eligible professionals by mechanisms determined appropriate by
the Secretary, which may include use of a web-based portal.
Such information would be made available on the same or similar
terms as data are made available to accountable care
organizations under section 1899 of the SSA, including a
beneficiary opt-out.
The Secretary would establish a process under which a VBP
eligible professional could seek an informal review of the
calculation of the individual's VBP program incentive payment
adjustment factor. The results of such a review would not be
taken into account for purposes of determining the VPB program
incentive payment adjustment factors with respect to a year
(other than with respect to the calculation of such eligible
professional's VBP program incentive payment adjustment factor
for such year).
When considering how to implement the Committee Bill, the
Secretary should consider the administrative impact on eligible
professionals. Implementation of the Bill should not create any
undue or complicated administrative burdens for eligible
professionals.
There would be no administrative or judicial review of the
following: (1) the methodology used to determine the amount of
the VBP program incentive payment adjustment factor and the
determination of such amount; (2) the determination of the
amount of funding available for such VBP program incentive
payments and the payment reduction described above; (3) the
establishment of the performance standards and the performance
period; (4) the identification of performance category measures
and activities and information made public or posted on the
Physician Compare website; and (5) the methodology developed
and used to calculate performance scores and the calculation of
such scores, including the weighting of measures and activities
under such methodology.
The GAO would submit two VBP program evaluation reports to
Congress, due October 1, 2018 and October 1, 2021. These
reports would include an examination of the distribution of the
performance and incentive payments for VBP eligible
professionals and patterns relating to the performance and
incentive payments, including an analysis based on the type of
provider, practice size, geographic location, and patient mix.
The reports would also provide recommendations for improving
the program. Finally, the reports would evaluate the impact of
technical assistance funding on the ability of providers
(especially physicians in rural areas or HPSAs, and physicians
treating other underserved populations) to improve within the
VBP or successfully transition to APMs and provide
recommendations for maximizing use of these technical
assistance funds.
The GAO would submit reports to Congress on October 1, 2019
and October 1, 2021 on the transition of physicians in rural
areas and HPSAs and physicians treating other underserved
populations to APMs. The studies would make recommendations on
changes that could be made to overcome barriers for rural
providers and those in HPSAs to participate in APMs.
The GAO would also submit a report to Congress, not later
than 18 months after enactment, which would compare the
similarities and differences in the use of quality measures
under the Medicare FFS program, the MA program, selected state
Medicaid programs, and private payer arrangements. The report
would consider those measures applicable to Medicare enrollees
under the age of 65 and would focus on measures that comprise
the most significant component of the quality performance
category of the VBP program. The report would also make
recommendations on how to reduce the administrative burden
involved in applying such quality measures.
For purposes of implementing the VBP program, the Secretary
would provide for the transfer from the SMI Trust Fund to the
CMS Program Management Account of $50 million for each fiscal
year from 2014 through 2017. Amounts transferred would remain
available until expended.
The Committee Bill includes several modifications to
improve quality reporting for the VBP program. The Bill
clarifies and allows group practices to meet satisfactory
reporting requirements for group practices by reporting to
qualified clinical data registries beginning in 2015 and
subsequent years. Similarly, current requirements for
satisfactory reporting under the PQRS program are simplified,
beginning in 2014 and in subsequent years, by allowing (but not
requiring) the Secretary to establish alternative criteria for
satisfactorily reporting such as reporting groups of measures
under the PQRS program and to establish an alternative
reporting period. The satisfactory reporting of measures for
group practices would be modified for 2014 and subsequent years
by allowing for, but not requiring, the use of a statistical
sampling model to submit data on measures.
Reports under the physician feedback program would not be
provided after December 31, 2016 and instead would be provided
under the requirements of the VBP program (described above).
The Committee Bill establishes incentive payments for
eligible professionals who become qualifying participants in an
eligible APM. For covered professional services furnished by a
qualifying APM participant from 2017 through 2022, such
professionals would be paid an amount equal to five percent of
the payment amount for the Medicare--covered professional
services for the preceding year (which may be an estimate for
the full preceding year based on a period that is less than the
full year). The Secretary would establish policies to implement
the additional payment in cases where payment for covered
professional services furnished by a qualifying APM participant
in an APM is made to an entity participating in the APM rather
than directly to the participant. Payment would be made in a
lump sum, on an annual basis, as soon as practicable. APM
incentive payments would not be taken into account for purposes
of determining actual expenditures or rebasing any benchmarks
used under the APM.
The amount of the additional payment for an item or service
made to a qualifying APM participant would be determined
without regard to additional payments for items and services
furnished to professionals in HPSAs (under section 1833(m) of
the SSA), additional incentive payments for primary care
services (under section 1833(x) of the SSA), or additional
incentive payments for major surgical procedures furnished in
HPSAs (under section 1833(y) of the SSA).
The term ``APM'' would be defined to mean any of the
following:
(a) A model under the CMMI defined under section 1115A of
the SSA (other than a health care innovation award).
(b) A Medicare Shared Savings Program accountable care
organization (defined under section1899 of the SSA).
(c) A demonstration under section 1866(C) of the SSA.
(d) A demonstration required by federal law.
The term ``eligible APM'' would mean, with respect to a
year, an APM that uses certified EHR technology (defined under
section 1848(o)(4) of the SSA), provides for payment for
covered professional services based on quality measures
comparable to the VBP quality performance category, and
satisfies the requirement that the APM (1) bears financial risk
for monetary losses under such model that are in excess of a
nominal amount or (2) is a medical home expanded under the CMMI
(under section 1115A(c) of the SSA).
The term ``qualifying APM participant'' would mean the
following:
(1) in 2017 and 2018, an eligible professional for whom the
Secretary determines that at least 25 percent of payments for
Medicare-covered professional services furnished by the
professional during the most recent period for which data are
available (which may be less than a year) were attributable to
services furnished to individuals who receive services under
Medicare Part B through an entity that participates in an
eligible APM;
(2) in 2019 and 2020, an eligible professional for whom the
Secretary determines that:
a. Medicare-only revenue threshold option--at least
50 percent of payments under Medicare Part B for
covered professional services furnished by such
professional during the most recent period for which
data are available (which may be less than a year) were
attributable to services furnished to individuals who
receive services under Medicare Part B through an
entity that participates in an eligible APM; or
b. Medicare and all-payer revenue threshold option--
i. at least 25 percent of payments under this
part were for covered professional services
furnished by such professional during the most
recent period for which data are available
(which may be less than a year) were
attributable to service furnished to
individuals who receive services under Medicare
Part B through an entity that participates in
an eligible APM;
ii. at least 50 percent of the sum of
payments made under Medicare Part B, and all
other payments regardless of payer (other than
payments made by the Veterans Administration,
TRICARE, or payments made under title XIX in
the case where no medical home or APM is
available under the State program under that
title) for items and services furnished by such
professional during the most recent period for
which data are available (which may be less
than a year) were attributable to such items
and services for which such professional uses
certified EHR technology (as defined under
section 1848(o)(4) of the SSA), is paid based
on quality measures comparable to the VBP
quality performance category, and satisfies the
requirement that the APM (1) bears more than
nominal financial risk if aggregate
expenditures exceeds expected aggregate
expenditures or (2) is a title XIX medical home
meeting criteria comparable to medical homes
expanded under section 1115A(c); and
iii. who provides the Secretary such
information as is necessary for the Secretary
to make a determination regarding the percent
of revenue received under (ii) above.
(3) in 2021 and subsequent years, an eligible professional
for whom the Secretary determines that:
a. Medicare only revenue threshold option--at least
75 percent of payments under Medicare Part B for
covered professional services furnished by such
professional during the most recent period for which
data are available (which may be less than a year) were
attributable to services furnished to individuals who
receive services under Medicare Part B through an
entity that participates in an eligible APM;
b. Medicare and all-payer revenue threshold option--
i. at least 25 percent of payments under this
part were for covered professional services
furnished by such professional during the most
recent period for which data are available
(which may be less than a year) were
attributable to items and services furnished to
individuals who receive services under Medicare
Part B through an entity that participates in
an eligible APM;
ii. at least 75 percent of the sum of
payments made under Medicare Part B, and all
other payments regardless of payer (other than
payments made by the Veterans Administration,
TRICARE, or payments made under title XIX in
the case where no medical home or APM is
available under the State program under that
title) for items and services furnished by such
professional during the most recent period for
which data are available (which may be less
than a year) were attributable to such items
and services for which such professional uses
certified EHR technology (as defined under
section 1848(o)(4) of the SSA), is paid based
on quality measures comparable to the VBP
quality performance category, and satisfies the
requirement that the APM (1) bears more than
nominal financial risk if aggregate
expenditures exceeds expected aggregate
expenditures or (2) is a title XIX medical home
meeting criteria comparable to medical homes
expanded under section 1115A(c); and
iii. who provides the Secretary such
information as is necessary for the Secretary
to make a determination regarding the percent
of revenue received under (ii) above.
A ``partial qualifying APM participant'' would be defined
as an eligible professional who would fail to meet the
appropriate revenue threshold to achieve a bonus payment under
the qualified APM program but who met the thresholds defined
below. Although a partial qualifying APM participant could
choose to participate in the VBP program for a year (and
receive VBP incentive payments for that year), the eligible
professional would be held harmless for lack of participation
in the VBP program if the appropriate revenue thresholds were
met, as follows:
1. for 2017 and 2018, the partial qualifying APM
threshold would be set at 20 percent of Medicare
revenue;
2. for 2019 and 2020, the partial qualifying APM
threshold would be set at 40 percent of Medicare
revenue; or 40 percent of all-payer revenue and 20
percent of Medicare revenue; and
3. for 2021 and subsequent years, the partial
qualifying APM threshold would be set at 50 percent of
Medicare revenue or 50 percent of all-payer revenue and
20 percent of Medicare revenue.
The term ``eligible professional'' would have the same
meaning as defined for purposes of the PQRS program (under
section 1848(k)(3)(B) of the SSA).
There would be no administrative or judicial review of the
following: (1) the determination that an eligible professional
is a qualifying APM participant as described above and the
determination that an APM is an eligible APM; and (2) the
determination of the amount of the five percent payment
incentive including any estimation as part of this
determination.
The Committee Bill would not prevent an APM or qualifying
APM participant from furnishing a telehealth service for which
Medicare payment is not made.
To encourage the development and testing of additional
APMs, section 1115A(b)(2) would be amended to encourage CMMI to
test models focusing primarily on physicians' services (as
defined under section 1848(j)(3) of the SSA), with particular
focus on services furnished by physicians who are not primary
care practitioners, practices of ten or fewer professionals,
statewide payment models, in addition to other public sector or
private sector payers, and models that focus primarily on
Medicaid, working in conjunction with the Center for Medicaid
and CHIP Services.
In designing APMs under this section of the Committee Bill,
to the extent an APM includes a product covered under Medicare
Part D, the Secretary would take into consideration the
successful Part D competitive bidding system.
The Secretary would propose to Congress a plan to integrate
MA APMs that take into account a budget neutral VBM.
The Secretary would also conduct a study that examines the
applicability of the federal fraud prevention laws to items and
services furnished under the Medicare program for which payment
is made under an APM. The study would identify aspects of APMs
that are vulnerable to fraudulent activities and examine the
implications of waivers of federal fraud prevention laws
granted by the Secretary in support of APMs (including any
expansion of APMs).
Not later than two years after the date of enactment, the
Secretary would report to Congress on the results of the study.
The report would be required to include recommendations for
actions to be taken to reduce vulnerability of APMs to
fraudulent activities (including, as appropriate,
recommendations of the Inspector General for changes in federal
fraud prevention laws).
The Secretary would also conduct a study that examines the
effect of individuals' socioeconomic status on quality and
resource use outcome measures for individuals under the
Medicare program. The study would collect information on
factors such as urban and rural location, eligibility for
Medicaid (recognizing and accounting for varying Medicaid
eligibility across states), and eligibility for benefits under
the Supplemental Security Income program. Not later than two
years after the date of enactment, the Secretary would report
to Congress on the results of the study.
The Secretary would also conduct another study examining
the impact of risk factors described under the VBM established
under the SSA, as well as other factors such as health
literacy, limited English proficiency, patient activation, and
race, on quality and resource use outcome measures under the
Medicare program. In conducting the study, the Secretary could
use existing federal data and collect additional data that may
be necessary to complete the study. Not later than five years
after the date of enactment, the Secretary would report to
Congress on the results of the study.
In conducting the studies, the Secretary would examine
other useful non-Medicare data sets such as data from the
American Community Survey. The Secretary would also consider
how such data sets can be coordinated with Medicare
administrative data, in order to improve the overall data set
available to complete the studies and for the administration of
the Medicare program.
If the studies find a relationship between the factors
examined and quality and resource use outcome measures, then
the Secretary would also provide recommendations on how CMS
should obtain access to the necessary data (and how to address
barriers to data collection). The Secretary would also provide
recommendations on how CMS should account for such factors in
determining payment adjustments based on quality and resource
use outcome measures under the VBP program and other similar
provisions under the Medicare program.
To conduct these studies, $6 million would be appropriated
from the SMI Trust Fund to the Secretary. These funds would
remain available until expended.
Taking into account the studies conducted and
recommendations made, the Secretary, on an ongoing basis, would
estimate how an individual's health status and other risk
factors affect quality and resource use outcome measures and,
as feasible, would incorporate information from quality and
resource use outcome measurement (including care episode and
patient condition groups) into the VBP program and, as the
Secretary determines appropriate other similar provisions of
the Medicare program.
Taking into account the studies conducted and
recommendations made, the Secretary would account for factors
identified with an effect on quality and resource use outcome
measures when determining payment adjustments under the
eligible professional VBP program and, as the Secretary
determines appropriate, other similar Medicare provisions.
The Secretary would collect or obtain data necessary to
account for factors besides health status. The Secretary would
carry out periodic analyses, at least every three years, based
on factors other than health status so as to monitor possible
changes in relationships between factors examined and quality
and resource use outcome measures.
To conduct these activities, $10 million would be
appropriated from the SMI Trust Fund to the Secretary. These
funds would remain available until expended.
Not later than 18 months after the date of the enactment of
the Committee Bill, the Secretary would develop and report to
Congress on a strategic plan for collecting or otherwise
accessing data on race and ethnicity for purposes of carrying
out the Medicare program.
The Secretary would engage in a process, collaborating with
physician, practitioner, and other stakeholder communities, to
improve resource use measurement. The Secretary would be
required to develop a classification system and codes in order
to classify similar patients into distinct care episode and
patient condition groups for purposes of measuring resource
use. No later than 60 days after enactment, the Secretary would
post a list on the CMS website of the episode groups and a
related description of the grouping criteria developed pursuant
to the episode grouper required under section 1848(n)(9)(A) of
the SSA. The Secretary would accept suggestions from physician
specialty societies, applicable practitioner organizations, and
other stakeholders for additional episode groups as well as
specific clinical criteria and patient characteristics to
classify similar patients into distinct care episode groups,
and distinct patient condition groups after the Secretary posts
the list to the CMS website for 60 days.
To develop the proposed classification codes, the Secretary
would establish distinct care episode groups and distinct
patient condition groups which account for at least an
estimated two-thirds of expenditures under Medicare Parts A and
B, and assign codes to these groups.
In establishing the care episode groups, the Secretary
would base the groups on the patient's clinical problems at the
time items and services are furnished during an episode of
care, such as the clinical conditions or diagnoses, whether or
not inpatient hospitalization is anticipated or occurs, the
principal procedures or services planned or furnished, and
other factors determined appropriate by the Secretary.
In establishing the patient condition groups, the Secretary
would base the groups on the patient's clinical history at the
time of each medical visit, such as the patient's combination
of chronic conditions, current health status, and recent
significant history (such as hospitalization and major surgery
during the previous three months), and other factors determined
appropriate by the Secretary (such as Medicare eligibility
status and dual eligibility under Medicare and Medicaid).
The Secretary would be required to post a draft list of the
care episode and patient condition codes (and the criteria and
characteristics assigned to the codes) on the CMS website
within 120 days after the stakeholder comment deadline. The
Secretary would then seek comments from physician specialty
societies, applicable practitioner organizations, and other
stakeholders regarding the draft list and use one or more
mechanisms that could include use of open door forums, town
hall meetings, or other appropriate mechanisms.
Not later than 120 days after the end of the comment
period, the Secretary would post an operational list of care
episode and patient condition codes (and the criteria and
characteristics assigned to the code) on the CMS website,
taking into account the comments received.
Beginning with 2016, the Secretary would formalize the
update process and make appropriate revisions to the
operational lists of care episode and patient condition codes
by November 1 of each year, through rulemaking. Such revisions
could be based on experience, new information developed
pursuant to the development of the episode grouper required
under section 1848(n)(9)(A) of the SSA, and input from
physician specialty societies, applicable practitioner
organizations, and other stakeholders.
To facilitate the attribution of patients and episodes (in
whole or in part) to one or more physicians or applicable
practitioners who provided their care, the Secretary would
undertake the following:
1. Develop patient relationship categories and codes that
define and distinguish the relationship and responsibility of a
physician or applicable practitioner with a patient at the time
of providing an item or service. These patient relationship
categories would include different relationships of the
physician or applicable practitioner to the patient (and the
codes could reflect combinations of such categories), such as a
physician or applicable practitioner who:
a. considers themself to have the primary
responsibility for the general and ongoing care for the
patient over extended periods of time;
b. considers themself to be the lead physician or
practitioner and who furnishes items and services and
coordinates care furnished by other physicians or
practitioners for the patient during an acute episode;
c. furnishes items and services to the patient on a
continuing basis during an acute episode of care, but
in a supportive rather than a lead role;
d. furnishes items and services to the patient on an
occasional basis, usually at the request of another
physician or practitioner; or
e. furnishes items and services only as ordered by
another physician or practitioner.
2. Post the draft list of patient relationship categories
and codes on the CMS website within 180 days after the date of
enactment.
3. Seek comments, through the date that is 60 days after
the Secretary posts the list of draft patient relationship
categories and codes, from physician specialty societies,
applicable practitioner organizations, and other stakeholders
regarding the patient relationship categories and codes as
posted. In seeking such comments, the Secretary would use one
or more mechanisms that may include open door forums, town hall
meetings, or other appropriate mechanisms.
4. Post an operational list of patient relationship
categories and codes on the CMS website not later than 120 days
after the end of the comment period, taking into account the
comments received.
5. Make revisions to the operational list of patient
relationship categories and codes as appropriate not later than
November 1 of each year (beginning with 2016), through
rulemaking. Such revisions could be based on experience, new
information developed pursuant to the development of the
episode grouper required under section 1848(n)(9)(A) of the
SSA, and input from physician specialty societies, applicable
practitioner organizations, and other stakeholders.
Beginning on January 1, 2016, any claim for payment for
items or services furnished by a physician or applicable
practitioner would have to include, as determined appropriate
by the Secretary, care episode and patient condition codes and
patient relationship codes, and the national provider
identifier (NPI) of the ordering physician or applicable
practitioner (if different from the billing physician or
applicable practitioner).
In order to evaluate the resources used to treat patients
with respect to care episode and patient condition groups, the
Secretary would conduct an analysis using the patient
relationship codes reported on claims to attribute patients (in
whole or in part) to one or more physicians and applicable
practitioners, and using the care episode and patient condition
codes reported on claims as a basis to compare similar patients
and care episodes and patient condition groups.
This resource use analysis would, as feasible, use the
claims data experience of patients during a common period, such
as 12 months, for patient condition codes. In addition, the
analysis would use the claims data experience by care episode
codes for defined periods of time as determined appropriate by
the Secretary. For non-hospitalization services, the defined
period could be the number of days of care, while the period
for episodes with a hospitalization could be the number of days
before, during, and after the hospitalization.
In measuring the resource use, the Secretary would use per
patient total allowed charges for all services under Medicare
Part A, Part B and, if the Secretary determines appropriate,
Part D, for the analysis of patient resource use, by care
episode codes and by patient condition codes. The Secretary
could use other measures of allowed charges (such as subtotals
for categories of items and services) and measures of
utilization of items and services (such as frequency of
specific items and services and the ratio of specific items and
services among attributed patients or episodes), as
appropriate.
The Secretary would seek comments from physician specialty
societies, applicable practitioner organizations, and other
stakeholders regarding the resource use methodology established
above. In seeking comments, the Secretary would use one or more
mechanisms (other than notice and comment rulemaking) that
could include open door forums, town hall meetings, or other
appropriate mechanisms.
There would be no administrative or judicial review of the
care episode and patient condition groups and codes, patient
relationship categories and codes, or measurement of, and
analyses of resource use with respect to, the care episode and
patient condition codes and patient relationship codes.
CMS would not penalize any professional who fails to report
information for the development of care episode, patient
condition, and patient relationship codes with non-payment of a
claim.
Requirements under current law (Chapter 35 of title 44,
United States Code) regarding coordination of federal
information, including the Paperwork Reduction Act, would not
apply to this section.
For purposes of the resource use program described in this
section, the term `physician' would have the same meaning as
under current Medicare law, while the term `applicable
practitioner' would mean (1) a physician assistant, nurse
practitioner, or clinical nurse specialist (as such terms are
defined under current law), and (2) beginning January 1, 2017,
other eligible professionals as specified by the Secretary.
The Committee Bill process for collaborating with the
physician, practitioner, and other stakeholder communities to
measure resource use falls outside of the process of multi-
stakeholder input for measure development.
SEC. 102. PRIORITIES AND FUNDING FOR QUALITY MEASURE DEVELOPMENT
Present Law
Currently, measures for physicians and practitioners are
concentrated in certain specialties and services while other
services and specialties have few or no measures. In addition,
many current measures are process measures rather than the
preferred type of measures such as for outcomes, functional
status, patient experience, care coordination and measures of
appropriate use of services.
Committee Bill
The Committee Bill would amend section 1848 of the SSA to
add a new subsection (s), ``Priorities and Funding for Quality
Measure Development.'' The Secretary would be required, not
later than October 1, 2014, to develop a draft plan for the
development of professional quality measures for application in
the quality performance category under the new VBP program and
comparable quality measures used by an APM. Such plan would be
required to address how measures used in integrated delivery
systems and by private payers could be incorporated under this
subsection. In developing the plan, the Secretary would be
required to consider gap analyses conducted by the entity with
a contract under Section 1890(a) of the SSA or other
contractors or entities and whether measures are applicable
across health care settings. In addition, the Secretary would
be required to prioritize, among other things, outcome
measures, including patient-reported outcome and functional
status measures, patient experience measures, care coordination
measures, and measures of appropriate use of services
(including measures of overuse).
The Secretary would be required to accept stakeholder
comments on the draft plan, through December 1, 2014, and would
be required to, not later than February 1, 2015, post on the
CMS website an operational plan for the development of quality
measures for use under the VBP.
Under the Committee Bill, the Secretary would also be
required to enter into contracts or other arrangements with
entities (such as physician specialty societies and other
practitioner organizations) to develop, improve, update, or
expand quality measures. In entering into contracts, the
Secretary would be required to give priority to measures that
are prioritized in the draft plan. In addition, the Secretary
must consider whether measures developed would be
electronically specified.
The Secretary would be required, not later than February 1,
2016 and annually thereafter, to post on the CMS website a
report on the progress made in developing quality measures for
application as specified. The reports would be required to
include the following: (1) a description of the Secretary's
efforts to implement the subsection; (2) for the measures
developed over the previous year, including information on the
total and type of measures developed, the name of each measure
developed, the name of the developer and steward for each
measure, and an estimate of the total amount expended to
develop the measures (this information must also be provided
for measures in development, as well as a timeline for
development completion); (3) an update on the progress in
developing measures of outcome, patient experience of care,
care coordination, and appropriate use; (4) a list of topics
and concepts that are being considered for development and the
rationale for the selection of topics and concepts, including
their relationship to gaps analyses; (5) a description of
updates to the plan and the inventory of applicable measures
maintained by CMS; and (6) other information the Secretary
determines appropriate.
The Secretary would be required to seek stakeholder input
with respect to: (1) the identification of gaps where no
measures exist, and specifically with respect to measures of
outcomes, patient experience of care, care coordination, and
appropriate use; (2) prioritization of quality measure
development to address such gaps; and other quality measure
development areas, as determined by the Secretary.
To carry out these activities, the Secretary would provide
for the transfer of $15 million, for each of FY2014 through
FY2018, from the SMI Trust Fund to the CMS Program Management
Account. The funds would remain available through FY2021.
SEC. 103. ENCOURAGING CARE MANAGEMENT FOR INDIVIDUALS WITH CHRONIC CARE
NEEDS
Present Law
Physicians are paid under the physician fee schedule for
services provided to Medicare beneficiaries. The most common
services are for evaluation and management (E/M), which are
often associated with a typical physician office visit.
Generally, to receive payment, there must be a face-to-face
visit with the patient. Beneficiaries with chronic care needs
often require care management services. Payments for E/M visits
are calculated to include some non-face-to-face care
management. However, these codes do not reflect all of the
services and resources required to furnish comprehensive
coordinated care management services for beneficiaries with
chronic needs.
In the 2014 Medicare physician fee schedule final rule, CMS
established a new payment for professionals for managing
Medicare patients' chronic conditions in addition to payments
professionals already receive for treating the patient's
presenting condition. These new payments are separately payable
for non-face-to-face chronic care management services. The
chronic care management payment would apply to Medicare FFS
beneficiaries with multiple chronic conditions expected to
persist for at least 12 months or until the patient's death.
The conditions must put patients at significant risk of death,
acute exacerbation/decomposition, or functional decline. The
new payment would be for 20-minutes of management services that
physicians can deliver over a 30-day period.
Committee Bill
The Committee Bill directs the Secretary to establish one
or more Healthcare Common Procedure Coding System (HCPCS) codes
for chronic care management services for individuals with
chronic care needs. The Secretary would make payment for such
management services furnished on or after January 1, 2015 by an
applicable provider.
The term applicable provider would refer to providers who
furnish services as part of a patient-centered medical home or
comparable specialty practice that is certified by an
organization recognized by the Secretary, or who meet other
comparable qualifications that the Secretary determines
appropriate. Applicable providers eligible to receive care
management payments include a doctor of medicine or osteopathy.
The Committee Bill also defines an applicable provider as a
physician assistant or nurse practitioner who performs such
services as are legally authorized by the state. Finally, the
Committee Bill recognizes clinical nurse specialists licensed
to practice nursing in the state in which clinical nurse
specialist services are performed as an applicable provider.
In establishing new HCPCS codes for chronic care management
services, the budget neutrality provision of the physician fee
schedule would still apply.
Payment for chronic care management services would only be
made to one applicable provider during a period on behalf of
each beneficiary. Payments for such management services could
not be duplicative of payments for other services, such as
hospice or home health services. Finally, payments for chronic
care management would not require that an annual wellness visit
or an initial preventive physician examination be furnished as
a condition of payment.
The Bill directs the Secretary to conduct an education and
outreach campaign to inform providers and individuals enrolled
under Medicare Part B of the benefits of chronic care
management. The campaign would encourage enrollees with chronic
conditions to receive chronic care management services. The
Secretary would work through the Office of Rural Health Policy
of the Department of Health and Human Services and the Office
of Minority Health of CMS and would focus on encouraging
participation by underserved rural populations and racial and
ethnic minority populations. The Secretary would report to
Congress no later than December 31, 2017 on the use of chronic
care management services by individuals living in rural areas
and by racial and ethnic minority populations. The report would
identify barriers to receiving chronic care management services
and make recommendations for increasing the appropriate use of
chronic care management services.
SEC. 104. ENSURING ACCURATE VALUATION OF SERVICES UNDER THE PHYSICIAN
FEE SCHEDULE
Present Law
Payment is made under the Medicare physician fee schedule
for more than 7,000 services. Payment is equal to the sum of
the RVUs--adjusted for geographic differences in costs--for
physician work, practice expense, and malpractice for each
service. A RVU reflects the relative resources of one physician
fee schedule service compared to another.
The Secretary is responsible for establishing the fee
schedule, including the modification and refinement of the
methodology for establishing RVUs. In establishing RVUs, the
Secretary receives recommendations from the public including
the RUC. Modifications to RVUs for a service are done in a
budget neutral manner. Thus, payment increases from changes to
the RVUs for some services must be offset by reductions in
payment for all other physicians' services. The Secretary is
required to review the RVUs no less than every five years.
Currently, when the Secretary calculates RVUs, the results
can be very minor relative value differences that do not
reflect material differences in the work, practice expense and
malpractice relative value difference. For example, the
difference between 18.61 and 18.62 does not reflect a material
difference between services.
Section 1848(c)(2)(K) of the SSA requires the Secretary to
periodically identify physicians' services as being potentially
misvalued, and to make appropriate adjustments to the RVUs of
such services under the Medicare physician fee schedule. To
identify potentially misvalued services, the Secretary is to
examine codes (and families of codes as appropriate) with the
fastest growth, that have experienced substantial changes in
practice expenses, for new technologies or services, that are
frequently billed in conjunction with furnishing a single
service, with low relative values, particularly those that are
often billed multiple times for a single treatment, that have
not been subject to review since the implementation of the
RBRVS (the so-called `Harvard-valued codes'), and other codes
the Secretary determines appropriate.
In its March 2013 report, MedPAC recommended that Congress
direct the Secretary to identify over-priced fee-schedule
services and that the RVU reductions should achieve a target of
1 percent of fee-schedule spending for each of five consecutive
years. MedPAC's recommendation stated that the reductions
should be budget neutral within the fee schedule.
Committee Bill
Under the Committee Bill, the Secretary could collect
information on the resources used by an eligible professional
to provide services that are paid under the Medicare physician
fee schedule. This information could be collected or obtained
from any eligible professional or any other source. The
Secretary could use this information in the determination of
relative values for physician services paid for under the
physician fee schedule.
Under the Committee Bill, the Secretary could collect or
obtain any or all of the following types of information: (1)
the time to perform each service; (2) amounts and types of
practice expense resources needed to perform each service; (3)
the prices of practice expense resources needed to perform each
service, which may include paid invoices or other documentation
or records; (4) overhead and accounting information of
physicians' practices; or (5) any other element that would
improve the valuation of physician services.
The Secretary could use any of the following mechanisms to
collect or obtain the information listed above: (1) surveys of
physicians, other suppliers, providers, manufacturers and
vendors; (2) surgical logs, billing systems, or other practice
or facility records; (3) EHRs; and (4) other mechanisms
determined appropriate by the Secretary.
The Secretary must report the source of information
collected or obtained in the determination of relative values
for physician services. The Secretary must also report how such
information was used in the determination of relative values
through notice and comment rulemaking. The Secretary may also
exclude information collected or obtained from physicians who
use a very high amount of resources to furnish services.
Information used to determine relative values for services
that are reported by the Secretary will only be made available
in aggregate form and will not disclose information that
identifies an eligible professional or a group practice or
information collected or obtained pursuant to a nondisclosure
agreement. The Federal Information Policy (Chapter 35 of Title
44 of the US Code) will not apply to information collected or
obtained.
In order to incentivize physicians to provide information,
the Secretary could provide for payments to eligible
professionals who submit information.
``Eligible professionals'' are those that meet the
definition of section 1848(k)(3)(B) of the SSA which includes:
(1) physicians, (2) physician assistants, (3) nurse
practitioners, (4) clinical nurse specialists, (5) certified
registered nurse anesthetists, (6) certified nurse midwives,
(7) clinical social workers, (8) clinical psychologists, (9)
registered dietitian or nutrition professionals, (10) physical
or occupational therapists, (11) qualified speech-language
pathologists, and (12) qualified audiologists.
In addition to funds otherwise appropriated, the Secretary
will provide for the transfer of $2 million from the SMI Trust
Fund to the CMS Program Management Account for each fiscal year
beginning with FY 2014. Amounts transferred for a fiscal year
will be available until expended.
There would be no administrative or judicial review of the
collection and use of information in the determination of
relative values.
The Secretary could use cost, charge, and other information
collected or obtained from suppliers and providers to determine
the practice expense relative values for physician services,
including the new information collected under this provision.
The Committee Bill expands the criteria the Secretary must
use for identifying potentially misvalued codes to (1) codes
that account for the majority of spending under the physician
fee schedule; (2) codes for services that have experienced a
substantial change in the hospital length of stay or procedure
time; (3) codes for which there may be a change in the typical
site of service since the code was last valued; (4) codes for
which there is a significant difference in payment for the same
service between different sites of service; (5) codes for which
there may be anomalies in relative values within a family of
codes; (6) codes for services where there may be efficiencies
when a service is furnished at the same time as other services;
(7) codes with high intra-service work per unit of time; (8)
codes with high practice expense RVUs; and (9) codes with high
cost supplies.
With respect to fee schedules established for each year of
2015 through 2018, the Secretary must determine the estimated
net reduction in expenditures under the fee schedule for a year
as a result of adjustments to the relative values for misvalued
codes. The Committee Bill sets a target of 0.5 percent of the
estimated amount of expenditures under the fee schedule for
each year of 2015 through 2018 for such reductions.
If the estimated net reduction in expenditures for the year
is equal to or greater than the 0.5 percent target for the
year, reduced expenditures attributable to such adjustments
will be redistributed in a budget neutral manner within the
physician fee schedule. Any reductions in excess of the target
will be treated as a reduction in expenditures for purposes of
meeting the target for the following year.
If the estimated net reduction in expenditures for the year
is less than the 0.5 percent target, the difference between the
target and the estimated net reduction in expenditures will not
be subject to budget neutrality and fee schedule payments will
be reduced by that difference.
Beginning in 2015, if the total reduction of the RVUs
(including work, practice expense, and malpractice) for a
service for a year is more than 20 percent of the total value
of the RVUs for the previous year, the applicable reductions in
work, practice expense, and malpractice RVUs will be phased in
over a two-year period.
The Committee Bill would give the Secretary authority to
smooth minor differences in relative values for families or
groups of procedures.
Not later than one year after enactment, the GAO will
conduct a study of the processes used by the RUC to provide
recommendations to the Secretary regarding the relative values
for specific services under the physician fee schedule.
SEC. 105. PROMOTING EVIDENCE-BASED CARE
Present Law
Medicare pays for outpatient imaging services through the
physician fee schedule. Following findings from MedPAC, GAO,
and others that the rate of growth in Medicare outpatient
imaging services was greater than for most other Medicare
covered services, Congress and CMS have initiated a number of
policies to address the issue. The Deficit Reduction Act (DRA,
P.L. 109-171) modified the payment rules for certain imaging
services by capping the technical component of the payment for
services paid under the physician fee schedule at the level
paid under the hospital outpatient prospective payment system
(OPPS) effective January 1, 2007. Services subject to the cap
are: X-rays, ultrasound (including echocardiography), nuclear
medicine (including positron emission tomography), magnetic
resonance imaging, computed tomography, and fluoroscopy.
CMS, in the November 2005 physician fee schedule
regulations, extended the multiple procedure payment reduction
policy to certain imaging services. The payment reduction was
25 percent of the technical component of certain imaging
procedures performed on contiguous body areas. Under section
1848(c)(2)(b)(vi) of the SSA the reduction is increased to 50
percent effective July 2010. CMS expanded the application of
the payment reduction to studies on noncontiguous body areas
and the professional component for the second and subsequent
services to the same patient, in the same session, on the same
day.
CMS's method for calculating the Medicare fee schedule
reimbursement rate for advanced imaging services originally
assumed that imaging machines are operated 25 hours per week,
or 50 percent of the time that practices are open for business.
Setting the equipment use factor at a lower rate has led to
higher payment for these services. Citing evidence showing that
the utilization rate is 90 percent, rather than the 50 percent
previously assumed, MedPAC urged CMS to use the higher
utilization rate in the calculation of fee schedule payments
for advanced imaging services. The ACA changed the utilization
rate assumption for calculating the payment for advanced
imaging equipment from 50 percent, as assumed in prior years,
to 75 percent for 2011 and subsequent years. The ATRA requires
the Secretary to apply a 75 percent use rate in calculating
payment rates for advanced imaging services through 2013, and a
90 percent use rate for 2014 and subsequent years.
To further address the rapid growth in advanced imaging
services, MedPAC recommended, in its June 2011 report, that
Congress direct the Secretary to establish a prior
authorization program for practitioners who order substantially
more advanced diagnostic imaging services than their peers.
Committee Bill
The Committee Bill would promote the use of evidence-based
medical care. Specifically, it would create a program to
promote utilization of appropriate use criteria by ordering
professionals for certain imaging services in designated
settings. Appropriate use criteria would be defined as criteria
used to assist ordering professionals in making the most
appropriate treatment decision for a specific clinical
condition. The Committee Bill would require professionals to
consult appropriate use criteria as a prerequisite to Medicare
payment for the applicable imaging service.
The following professionals would be subject to these
requirements: (1) medical doctors and osteopaths, (2) dentists,
(3) podiatrists, (4) optometrists, (5) chiropractors, (6)
physician assistants, (7) nurse practitioners, (8) clinical
nurse specialists, (9) certified nurse anesthetists, (10)
certified nurse-midwifes, (11) clinical social workers, (12)
clinical psychologists, and (13) registered dietitians or
nutritional professionals. Ordering professionals would be
defined as professionals who order an applicable imaging
service for an individual. Furnishing professionals would be
defined as professionals who furnish an applicable imaging
service for an individual.
Applicable imaging services would be defined as those
advanced diagnostic imaging services defined in section
1834(e)(1)(B) of the SSA for which there are one or more
appropriate use criteria specified by the Secretary through
rulemaking and at least one or more qualified clinical decision
support mechanisms that are free of charge.
These requirements would apply for diagnostic imaging
services furnished in the following settings: (1) physicians'
offices, (2) hospital outpatient departments (HOPD), (3)
ambulatory surgical centers, (4) and any other provider-led
outpatient setting determined appropriate by the Secretary. The
Secretary could only choose appropriate use criteria developed
or endorsed by national professional medical specialty
societies or other provider-led entities. Applicable payment
systems would be defined as the physician fee schedule, the
OPPS, and the ambulatory surgical center payment system.
The Secretary would required to specify appropriate use
criteria by November 15, 2015 only from among appropriate use
criteria developed or endorsed by national professional medical
specialty societies or other provider-led entities. This would
be accomplished through rulemaking and in consultation with
physicians, practitioners, and other stakeholders. In
specifying these criteria, the Secretary would consider whether
the criteria have achieved stakeholder consensus, are
scientifically valid and evidenced-based, and are based on
studies that are published and reviewable by stakeholders. The
Secretary would periodically update and revise (as appropriate)
the appropriate use criteria. In cases where more than one
appropriate use criteria applies, the Secretary would specify
one or more criteria that would be applicable.
In addition to these criteria, the Secretary would
specify--in consultation with physicians, practitioners, and
other stakeholders--one or more qualified clinical decision
support mechanisms that could be used by ordering professionals
to consult appropriate use criteria for the applicable imaging
services. These mechanisms could include certified EHR clinical
decision support modules, private sector clinical support tools
that are independent from certified EHR technology, including
clinical decision support mechanisms available from medical
specialty organizations, and other clinical decision support
mechanisms established by the Secretary.
To be qualified, the clinical decision support mechanism
would have to be able to make available to the ordering
physician the applicable appropriate use criteria and
supporting documentation, and also be able to determine the
extent to which the ordering of an applicable image complies
with the criteria. In the case where there are more than one
applicable appropriate use criteria specified for an applicable
imaging service, the mechanism must be able to indicate which
criteria it uses for the service. The mechanism would also be
able to generate and provide to the ordering physician a
certification or documentation that the criteria was consulted
by the ordering physician. It would be updated on a regular
basis to reflect revisions to the criteria, comply with all
applicable privacy and security standards, and be able to
perform other functions specified by the Secretary, which may
include a requirement to provide aggregate feedback to the
ordering physician. The Secretary would provide a list of
qualifying mechanisms by April 1, 2016 and update it
periodically.
Beginning on January 1, 2017, an ordering professional in
an applicable setting would consult appropriate use criteria
via qualified clinical decision support mechanisms for
applicable imaging services and provide the furnishing
professional with the following: (1) information about which
decision support mechanism was consulted by the ordering
professional; (2) whether the ordered imaging service adhered
to the applicable appropriate use criteria, did not adhere, or
the criteria were not applicable to the service ordered; and
(3) the NPI of the ordering professional (if different from the
furnishing professional). Payment for the imaging service would
only be made if the claim includes this information.
The appropriate use requirement would not apply to
applicable imaging services ordered: (1) for individuals with
an emergency medical condition, (2) for hospital inpatients,
(3) by professionals in an APM, as defined under section 102 of
the Committee Bill, and (4) by professionals who would face
significant hardship consulting with appropriate use criteria,
such as professionals whose practices are in a rural area
without sufficient Internet access.
Using data from January 1, 2017 onward, the Secretary would
periodically determine ordering professionals who are outliers
based on their low adherence to applicable appropriate use
criteria, which may be based on comparisons to other ordering
professionals. The Secretary's determination would also include
data for professionals who are subject to prior authorization.
In making these determinations, the Secretary would use two
years of data and consult with physicians, practitioners, and
other stakeholders in developing methods to identify outlier
professionals.
The Committee intends that the prior authorization program
would reduce inappropriate use of applicable imaging services
by professionals with a recent history of low adherence to
applicable appropriate use criteria.
In developing this program, the Secretary should include a
mechanism to support professionals who are outliers based on
their low adherence to applicable appropriate use criteria to
remove the outlier designation after demonstrating sufficient
adherence to applicable appropriate use criteria.
The Committee intends the outlier provisions to apply to a
small minority of total professionals.
Beginning on January 1, 2020, all applicable imaging
services ordered by an outlier ordering professional would be
subject to prior authorization. To fund this prior
authorization program, $5 million per year would be provided to
CMS from the SMI Trust Fund from 2019 through 2021. Amounts
transferred from the SMI Trust Fund would remain available
until expended.
The Secretary could establish an appropriate use program
for other services under Part B. Such process would replicate
the provider-developed or provider-endorsed framework for
appropriate use criteria for applicable imaging services
described above. In determining whether to establish any
additional programs, the Secretary would also take into
consideration the results of a GAO study--conducted 18 months
after enactment--on the extent to which appropriate use
criteria could be used for other services, such as radiation
therapy and clinical diagnostic laboratory services. In
addition, before issuing a proposed rule expanding appropriate
use criteria to other Part B services, the Secretary would seek
comments from stakeholders through an advance notice of
proposed rulemaking.
The Committee Bill would not authorize the Secretary to
initiate the development of clinical practice guidelines. The
intent of the Committee Bill is to empower physicians and other
professionals to lead and disseminate best practices that have
been developed and accepted by the physician and professional
stakeholder community.
SEC. 106. EMPOWERING BENEFICIARY CHOICES THROUGH ACCESS TO INFORMATION
ON PHYSICIANS' SERVICES
Present Law
Section 10331 of the ACA required the Secretary to develop,
not later than January 1, 2011, a Physician Compare website
with information about physicians enrolled in Medicare and
other eligible professionals who participate in the Physician
Quality Reporting Initiative (now the PQRS). The Secretary was
required, by January 1, 2013, to implement a plan to make
publicly available comparative information on physician
performance on quality and patient experience measures
(consistent with privacy protections codified at 5 U.S.C.
Sec. 552 and Sec. 552a).
The information on Physician Compare is required to
include, among other things, measures collected under PQRS, and
an assessment of efficiency, safety, patient health outcomes,
and patient experience. In developing and implementing this
plan, the Secretary was required to consider a number of
factors, including among others, processes to ensure
appropriate attribution and processes to ensure that data made
publicly available is statistically valid and reliable.
The Secretary is required to consider the feedback from the
multi-stakeholder groups (consistent with sections 1890(b)(7)
and 1890A of the SSA) when selecting measures for use under
this section, and must consider the plan to transition to a
value-based purchasing program for physicians (under section
131 of the MIPPA) when developing and implementing the plan
under this section. The Secretary is required to report to
Congress, not later than January 1, 2015, on the Physician
Compare website. At any time before the submission of this
report, the Secretary is authorized to expand the information
available on the Physician Compare website to other types of
Medicare providers, and is authorized to establish, at any time
not later than January 1, 2019, a demonstration program to
provide financial incentives to Medicare beneficiaries who
utilize high quality physicians (as determined by the Secretary
based on information included on the Physician Compare
website).
Committee Bill
The Committee Bill would codify section 10331 of the ACA
into the SSA by creating a new section 1848(t). It would also
direct the Secretary to post additional information on
Physician Compare on eligible professionals.
The Secretary would include the following information on
Physician Compare: (1) information on the number of services
provided by each eligible professional, which could include
information on the most frequent services furnished or
groupings of services, (2) information on submitted charges and
payments for services under Medicare Part B, and (3) a publicly
available and unique identifier, such as a national provider
identifier, for each eligible professional.
Physician Compare would be searchable by at least (1) the
specialty or type of eligible professional, (2) the
characteristics of the services furnished, such as the volume
or groupings of services, and (3) the location of the eligible
professional.
Physician Compare would also indicate, where appropriate,
that the publicized information may not be representative of
the eligible professional's entire patient population, the
variety of services provided by the eligible professional, or
the health conditions of individuals treated.
The Secretary would make this information available on
Physician Compare by July 1, 2015 for physicians and by July 1,
2016 for other eligible professionals. The Secretary would also
update Physician Compare on at least an annual basis.
SEC. 107. EXPANDING CLAIMS DATA AVAILABILITY TO IMPROVE CARE
Present Law
Section 1874(e) of the SSA requires the Secretary to make
claims data available that could be used to measure health care
provider and supplier performance. This section enables QEs to
obtain standardized extracts, as determined by the Secretary,
of Medicare Parts A, B, and D claims data for one or more
specified geographic areas and time periods. The fees for
making Medicare data available for performance measurement are
to be equal to the cost of providing the data. The Secretary
must take those actions necessary to protect the identity of
individuals entitled to or enrolled for benefits under such
parts. CMS created the QE Certification for Medicare Data
Program and published a final rule that established regulations
governing the program.
To be certified as a QE, entities must be qualified (as
determined by the Secretary) to use claims data to evaluate the
performance of providers of services and suppliers on measures
of quality, efficiency, effectiveness, and resource use. They
also must agree to requirements governing the use of the data.
QEs are only permitted to use the Medicare data for
publishing public performance reports on providers and
suppliers. When requesting the Medicare data, a QE must submit
to the Secretary a description of the methodologies that will
be used to evaluate provider performance. They must also
combine the CMS-provided data with claims data from another
source. When creating reports, they must use standard measures
if available. However, if necessary, they may use alternative
measures in consultation with appropriate stakeholders.
Additionally, the reports can only include information on a
provider of services or supplier in an aggregate form as
determined appropriate by the Secretary.
QE's public reports must include an understandable
description of the measures, which include standard quality
measures and the rationale for use of alternative measures,
risk adjustment methods, physician attribution methods, other
applicable methods, data specifications and limitations, and
the sponsors, so that consumers, providers of services and
suppliers, health plans, researchers, and other stakeholders
can assess such reports. Prior to their public release, these
reports must be made available confidentially to any provider
of services or supplier to be identified in such report, and
provide them with an opportunity to appeal and correct errors.
Prior their public release, the QEs must also make the format
of the reports available to the Secretary.
Data released to a QE is not subject to discovery or
admission as evidence in judicial or administrative proceedings
without consent of the applicable provider of services or
supplier.
Committee Bill
The Committee Bill would expand the availability of CMS
claims data to QEs and the ability of QEs to provide non-public
analyses and access to their CMS data combined with their other
data. The Committee Bill also would provide qualified clinical
data registries with access to the same CMS claims data as QEs.
Beginning July 1, 2014, to the extent consistent with
applicable information, privacy, security, and disclosure laws,
a QE would, as determined appropriate by the Secretary, be able
to use its CMS data combined with its other data to conduct
analyses for non-public uses. The QE could provide or sell
these non-public analyses to any of the following entities: (1)
a provider of services or a supplier, (2) a medical society or
hospital association, (3) a health insurance issuer providing
claims data to the QE, (4) an employer, as defined under
Section 3(5) of the Employee Retirement Insurance Security Act
of 1974 (ERISA, P.L. 93-406), but only for the purpose of
providing health insurance to its employees and retirees, or
(5) other entities approved by the Secretary. However, the
Secretary could not grant access to analyses to an employer
(under the ERISA) for purposes other than providing health
insurance to its employees and retirees or to a health
insurance insurer that does not provide claims data to the QE.
QEs would be able to perform these non-public analyses for
the following purposes: (1) helping providers develop and
participate in quality and patient care improvement activities
(including developing new models of care), (2) population
health management, (3) disease monitoring, (4) assisting
employers with providing health insurance to their employees,
and (5) other purposes approved by the Secretary.
A QE analysis for a provider could include information
individually identifying the provider's patients but only for
services performed by the provider to the identified patients.
In all other instances, QE analyses could not include any
information that individually identifies a patient. An entity
receiving an analysis from a QE could not redisclose or make
the analysis public.
If a non-public analysis were to individually identify a
provider that is not being provided or sold the analysis, the
QE would have to provide the identified provider with an
opportunity to review and submit corrections to the analysis.
A QE would also be able to provide or sell access to its
CMS data combined with its other data through a qualified data
enclave, defined as a web-based portal (or comparable
mechanism) that is capable of providing access to the combined
data maintained by the QE. The QE could provide or sell access
to the enclave to any of the following entities: (1) a provider
of services, (2) a supplier (3) a medical society or hospital
association, and (4) other entities approved by the Secretary.
However, the Secretary could not grant access to the data
through a qualified data enclave to an employer (under the
ERISA) or to a health insurance insurer.
These entities would only be permitted to use the data for
the purposes of (1) assisting providers in developing and
participating in quality and patient care improvement
activities (including developing new models of care), (2)
population health management, (3) disease monitoring, and (4)
other purposes approved by the Secretary.
A data enclave would have to block entities accessing the
data enclave from removing or extracting data from the enclave.
The enclave would also have to block access to data that
individually identifies a patient, including data on the
patient's name and date of birth as well as other data
specified by the Secretary. The data enclave could grant a
provider or supplier with access to identified patient data,
but only on services the provider or supplier performs for
their patients. QEs cannot grant access to the data enclave to
an entity (provider, medical society, etc.) unless the QE and
the entity have entered into a data use agreement.
Any QE that would provide or sell non-public analyses or
access to a qualified data enclave would have to submit to the
Secretary an annual report that includes the following
information: (1) a summary of the analyses provided or sold,
including the number of analyses, the number of purchasers, and
the total amount of fees received for the analyses; (2) a
description of the topics and purposes of the analyses; (3)
information on the entities who obtained access to the
qualified data enclave, the uses of the data, and the total
amount of fees received for providing access; and (4) other
information determined appropriate by the Secretary.
Beginning July 1, 2014, if the Secretary determines
appropriate, the Secretary could provide to QEs standardized
extracts (as the Secretary determines appropriate) of claims
data under Medicaid and the Children's Health Insurance Program
for assistance providing for one or more specified geographic
areas and time periods requested by a QE. When issuing the data
to QEs, the Secretary must take the appropriate actions needed
to protect the identity of individuals entitled to or enrolled
for these programs' benefits.
Beginning on July 1, 2014, QE fees paid to the Secretary
for providing data extracts would be deposited in the CMS
Program Management Account instead of the Federal SMI Trust
Fund.
To the extent consistent with applicable information,
privacy, security, and disclosure laws, and subject to other
requirements as the Secretary may specify, beginning July 1,
2014, qualified clinical data registries would be able to
purchase the same CMS claims data (in a form and manner
determined appropriate by the Secretary) as QEs in order to
link the data with clinical data and perform analyses and
research to support quality improvement or patient safety.
Effective July 1, 2014, if the Secretary determines
appropriate, the Secretary may make available to qualified
clinical data registries standardized extracts under Medicaid
and the Children's Health Insurance Program. Any fees the
Secretary was to collect by making such data available would be
deposited in the CMS Program Management Account.
A qualified clinical data registry could not publicly
report any research, analyses, or CMS data that individually
identifies a provider, supplier or individual unless the
registry was to obtain the consent of the provider, supplier or
individual prior to reporting.
TITLE II--EXTENSIONS AND OTHER PROVISIONS
Subtitle A--Medicare Extensions
SEC. 201. WORK GEOGRAPHIC ADJUSTMENT
Present Law
The Medicare physician fee schedule is adjusted
geographically for three factors to reflect differences in the
cost of resources needed to provide physician services:
physician work, practice expense, and medical malpractice
insurance. These geographic adjustments are an index--known as
Geographic Practice Cost Index (GPCI)--that reflect how each
area compares to the national average. A value of 1.00
represents the average across all areas. This index is used in
the calculation of the payment rate under the Medicare
physician fee schedule. A series of bills set a temporary floor
value of 1.00 on the physician work GPCI beginning January 2004
and continuing through December 31, 2013.
Committee Bill
The floor on the work geographic index would be set
permanently at 1.0.
SEC. 202. MEDICARE PAYMENT FOR THERAPY SERVICES
Present Law
The BBA established two annual per beneficiary payment caps
for all Medicare-covered outpatient therapy services furnished
by non-hospital providers, one for physical therapy services
and speech-language pathology services, the other for
occupational therapy services. Initially set at $1,500 to apply
beginning in 1999, these caps were suspended from 2000-2005.
With the application of the caps beginning in 2006, the DRA
required the Secretary to implement an exceptions process
throughout 2006 for services meeting specified criteria for
medically necessary services. Subsequent legislation has
extended the exceptions process and increased the caps each
year since then.
The Middle Class Tax Relief and Job Creation Act of 2012
(MCTRJCA, P.L. 112-96) established, in addition to the caps, an
annual threshold at $3,700 to be applied separately for the two
categories of therapy services effective October 1, 2012.
Medical review was required for services furnished above the
threshold. In addition, therapy services furnished in HOPDs
were included in the caps for the first time. The ATRA extended
the exceptions process through December 31, 2013, extended the
application of the cap and threshold to therapy services
furnished in a HOPD and requires outpatient therapy services
furnished in a Critical Access Hospital (CAH) to count towards
the cap and threshold. The ATRA also extended the medical
review requirement for therapy services furnished through
December 31, 2013.
MCTRJCA also directed the Secretary, in consultation with
relevant stakeholders, to implement a claims-based data
strategy designed to collect data on patient function during
the course of outpatient therapy services beginning January 1,
2013. The data will assist in reforming the Medicare payment
system for outpatient therapy services.
Committee Bill
The therapy cap would be repealed upon enactment. The
$3,700 threshold would be extended for one year, through the
end of 2014, after which it would be repealed. Beginning
January 1, 2015, a new medical review program for outpatient
therapy services would be established as defined below. The
Secretary would identify the services for medical review, using
appropriate factors, which could include the following:
(a) Services furnished by a therapy provider whose pattern
of billing is higher compared to peers.
(b) Services furnished by a therapy provider who, in a
prior period, has a high claims denial percentage or is least
compliant with other applicable requirements under this title.
(c) Services furnished by a therapy provider who is newly
enrolled in the Medicare program.
(d) Services furnished by a therapy provider who has
questionable billing practices, such as billing medically
unlikely units of services in a day.
(e) Services furnished to treat a type of medical
condition.
(f) Services identified by use of the standardized data
elements required to be reported.
(g) Services furnished by a single therapy provider or a
group that includes such providers.
(h) Other services as determined appropriate by the
Secretary.
The Secretary would use prior authorization medical review
for the identified outpatient therapy services furnished to a
beneficiary above certain thresholds established by the
Secretary, such as a dollar threshold or by type of outpatient
therapy service or setting.
The Secretary would end the application of prior
authorization medical review if the provider has a low denial
rate under prior authorization. The Secretary could
subsequently reapply prior authorization medical review to the
therapy provider if this were determined to be appropriate. The
Secretary would, where practicable, provide for prior
authorization medical review for multiple services at a single
time, such as services in a therapy plan of care.
The Secretary could use pre-payment review or post-payment
review for services that are not subject to prior authorization
medical review, including those services falling below the
established thresholds. So as to not interfere with an ongoing
investigation, the Secretary could determine that medical
review does not apply in the case where fraud may be involved.
The Secretary would conduct the prior authorization medical
review of outpatient therapy services using Medicare
administrative contractors (MACs) or other review contractors.
No Medicare payment would be made for outpatient therapy
services subject to this review unless a prior authorization
determination were made in advance that the services met the
Medicare reasonable and necessary requirements. A therapy
provider could submit the information necessary for medical
review by fax, by mail, or by electronic means. As soon as
practicable, but not later than 24 months after the date of
enactment, the Secretary would have to make available the
electronic means necessary to receive information.
The Secretary would make a prior authorization
determination within ten business days of receipt of the
necessary medical documentation or be deemed to have found the
services to meet the applicable requirements for Medicare
coverage. The Committee Bill would not preclude subsequent
payment denial for an outpatient therapy service that had been
affirmed by medical review but did not meet other applicable
Medicare requirements.
For outpatient therapy services furnished on or after
January 1, 2015, when payment may not be made due to medical
review, the current law limiting beneficiary liability when
Medicare claims are disallowed would apply in the same manner
as a claims denial when a service is not reasonable and
necessary.
The Secretary could implement this medical review program
by interim final rule with comment period. Requirements under
current law (44 U.S.C. Sec. Sec. 3501-3521) regarding
coordination of federal information under the Paperwork
Reduction Act would not apply to this medical review program.
For purposes of this subsection the following definitions
would apply. The term `outpatient therapy services' would mean
therapy services for which Medicare payment is made under the
physician fee schedule, under the fee schedule for outpatient
therapy services and comprehensive outpatient rehabilitation
services, and under the payment system for outpatient CAH
services. The term `therapy provider' would mean a provider of
services (as defined under current law section 1861(u) of the
SSA) or a supplier (as defined under current law section
1861(d)) who furnishes outpatient therapy services.
To implement this subsection, the Secretary would provide
for the transfer of $35,000,000 from the SMI Trust Fund to the
CMS Program Management Account for each fiscal year, beginning
with fiscal year 2014. These amounts would remain available
until expended.
Beginning with 2017 and then every two years, the Secretary
would have to determine and publicly report the improper
payment rate for outpatient therapy services for a 12-month
period. If the improper payment rate is 50 percent or less of
the Medicare FFS improper payment rate for the same period, the
Secretary would have to reduce the amount of medical review
conducted for a prospective year and return an appropriate
portion of the funding provided for that year.
The GAO would conduct a study on the effectiveness of
medical review of outpatient therapy. The study would include
an analysis of aggregate data on the number of individuals,
therapy providers, and claims subject to review; the number of
reviews conducted; and the outcomes of such reviews. Not later
than three years after the date of enactment, the GAO would
submit a report to Congress including recommendations for
legislation and administrative action.
The Committee Bill would establish the collection of
standardized data elements for outpatient therapy services. Not
later than six months after enactment, the Secretary would post
a draft list of standardized data elements on the CMS website.
The standardized data elements would include information with
respect to the following domains, as determined appropriate by
the Secretary: (1) demographic information, (2) diagnosis, (3)
severity, (4) affected body structures and functions, (5)
limitations with activities of daily living and participation,
(6) functional status, and (7) other domains determined
appropriate by the Secretary.
The Secretary would accept comments from stakeholders for
60 days after the posting date of the draft standardized data
elements. In seeking such comments, the Secretary would use one
or more mechanisms to solicit input from stakeholders that
could include use of open door forums, town hall meetings,
requests for information, or other mechanisms as determined
appropriate by the Secretary.
No later than 120 days after the end of the comment period,
the Secretary would post an operational list of standardized
data elements on the CMS website, taking into account such
comments. Subsequent revisions to the operational list of
standardized data elements would be made through rulemaking and
could be based on experience and input from stakeholders. No
later than 18 months after posting the operational list of
standardized data elements, the Secretary would develop and
implement a system, which may be a web portal, for therapy
providers to report the standardized data elements for
individuals receiving outpatient therapy services. The
Secretary would seek comments from stakeholders regarding the
best way to report the standardized data elements.
The Secretary would specify the frequency of reporting
standardized data elements and seek comments from stakeholders
regarding the frequency of the reporting. Beginning on the
operational date of the reporting system, no Medicare payment
would be made for outpatient therapy services furnished to a
beneficiary unless a therapy provider were to report the
standardized data elements for the beneficiary.
No later than 18 months after the date the data reporting
system is operational, the Secretary would submit a report to
Congress on the design of a new payment system for outpatient
therapy services. The report would include an analysis of the
standardized data elements collected and other appropriate data
and information. It would consider (1) appropriate adjustments
to payment (such as case mix and outliers), (2) payments on an
episode of care basis, and (3) reduced payment for multiple
episodes. The Secretary would consult with stakeholders
regarding design of such a new payment system.
To implement the data collection effort and develop the
report on a new outpatient therapy payment system, the
Secretary would provide for the transfer of $7,000,000 from the
SMI Trust Fund to the CMS Program Management Account for each
fiscal year from 2014 through 2018. The amounts transferred
would remain available until expended.
Requirements under current law (44 U.S.C. Sec. Sec. 3501-
3521) regarding coordination of federal information, including
the Paperwork Reduction Act, would not apply to the
specification of the standardized data elements and
implementation of the reporting system. There would be no
administrative or judicial review of the specification of
standardized data elements required under this subsection or
the reporting system. For purposes of the specification of
standardized data elements and the implementation of the
reporting system, the terms `outpatient therapy services' and
`therapy provider' have the meaning given those terms for the
new medical review program.
The current claims-based data collection strategy designed
to assist in reforming the Medicare payment system for
outpatient therapy services, which was mandated by the MCTRJCA,
would sunset effective the date of implementation of the data
collection effort established above.
The Committee Bill would require that each request for
payment, or bill submitted on or after January 1, 2015, by a
therapy provider for an outpatient therapy service furnished by
a therapy assistant include an indication that the service was
furnished by a therapy assistant (in a form and manner
specified by the Secretary).
SEC. 203. MEDICARE AMBULANCE SERVICES
Present Law
The Medicare Prescription Drug, Improvement and
Modernization Act (MMA, P.L. 108-173) established temporary
bonus payments for ground ambulance services that originate in
a qualified rural area furnished on or after July 1, 2004 and
before January 1, 2010. Qualified rural (also referred to as
``super rural'') areas are those where the ambulance transport
originates in a rural area determined by the Secretary to be in
the lowest 25th percentile in terms of population density of
all rural county populations. The bonus payment is a 22.6
percent increase. Subsequent legislation has extended the bonus
payments for super rural ambulance services until December 31,
2013.
The MMA also provided temporary increases to ground
ambulance services that originate in rural and urban areas. The
MIPPA extended the ground ambulance add-on policy in July 2008
after a short lapse. The MIPPA also increased the level of the
add-on payment from one percent to two percent for urban
ambulance services and from two percent to three percent for
rural ambulance services. Subsequent legislation has extended
the temporary add-on payments until December 31, 2013.
Committee Bill
The Committee Bill would extend all of the current
temporary ambulance payments an additional five years for
services furnished before January 1, 2019.
Additionally, the Committee Bill would require the
Secretary to develop a data collection system for ambulance
providers and suppliers in consultation with stakeholders. The
data collection system for ambulance services would include
cost, revenue, utilization, and other information to evaluate
appropriate payment rates, the utilization of capital equipment
and ambulance capacity, and the different types of ambulance
services furnished in different geographic regions. No later
than January 1, 2015, the Secretary would be required to
specify the data collection methodology and to identify a
sample of providers and suppliers required to submit such data.
Beginning July 1, 2015, identified providers and suppliers who
fail to submit such data would receive a five percent reduction
in Medicare ambulance payments for a one-year period.
Under the Committee Bill, the Secretary would be permitted
to revise the data collection system as appropriate, after
consultation with providers and suppliers of ambulance
services. Such consultation would include the use of requests
for information and other appropriate mechanisms. In order to
continue to evaluate the appropriateness of payment rates,
ambulance providers and suppliers would be required to submit
such information no less than once every three years.
Requirements under current law (44 U.S.C. Sec. Sec. 3501-3521)
regarding coordination of federal information, including the
Paperwork Reduction Act, would not apply to the collection of
this information. There would be no administrative or judicial
review of the data collection system or those identified as
required to submit such information.
For purposes of developing this data collection system, the
Secretary would provide for the transfer of $1 million from the
SMI Trust Fund to the CMS Program Management Account for fiscal
year 2014.
SEC. 204. MEDICARE DEPENDENT HOSPITALS
Present Law
The Omnibus Budget Reconciliation Act of 1989 (OBRA89, P.L.
101-239) created a new Medicare Dependent Hospitals (MDHs)
program that made small, rural hospitals eligible for
additional payments. The MDH program lapsed in 1994 but was
reinstated by the BBA. The program has been extended
periodically and changed by subsequent legislation. The MDH
special payment status expired on September 30, 2013.
MDHs are small rural hospitals with a high proportion of
patients who are Medicare beneficiaries. MDHs have no more than
100 beds and at least 60 percent of acute inpatient days or
discharges attributable to Medicare in FY1987 or in two of the
three most recently audited cost reporting periods.
Specifically, an MDH hospital will be paid the inpatient
prospective payment system (IPPS) rate plus a percentage
difference between that amount and a hospital-specific cost per
discharge amount from a given year. Before October 1, 2006 an
MDH received 50% of the difference between the base rate and
its adjusted hospital-specific costs. Since October 1, 2006, a
MDH has received 75% of the difference between the base rate
and its adjusted hospital-specific costs.
Committee Bill
The Committee Bill would make the MDH program permanent.
SEC. 205. LOW VOLUME HOSPITALS
Present Law
Under the Medicare IPPS, certain low-volume hospitals
receive a higher payment amount to account for their higher
costs per discharge in 2012 and 2013. The adjustment operates
on a sliding scale with hospitals having fewer than 200
Medicare discharges receiving a 25% payment increase,
decreasing on a sliding scale to 0% for hospitals with more
than 1,600 Medicare discharges. These hospitals must be located
15 miles or more from another comparable hospital. This
adjustment expired on September 30, 2013.
The low-volume adjustment is based on the concept that
large hospitals benefit from certain economies of scale that
are not available to small hospitals with limited discharges.
MedPAC has reported that this adjustment is not well targeted
because hospitals may have a small number of Medicare patients
while also treating a large number of non-Medicare patients. In
MedPAC's view, Congress may wish to consider changing the low
volume formula to reflect total discharges rather than Medicare
discharges.
Committee Bill
The Committee Bill would make the low-volume hospital
policy permanent.
SEC. 206. MEDICARE SPECIAL NEEDS PLANS
Present Law
Section 231 of the MMA established a new type of MA
coordinated care plan to focus on individuals with special
needs. SNPs are allowed to target enrollment to one or more
types of special needs individuals including (1)
institutionalized (I-SNPs), (2) dually eligible (D-SNPs), and/
or (3) individuals with severe or disabling chronic conditions
(C-SNPs). Fully Integrated Dual Eligible SNPs (FIDE-SNPs) are a
subset of D-SNPs that must fully integrate Medicare and
Medicaid benefits, including long-term care services and
supports, and have a contract with the state Medicaid program
among other requirements.
In general, SNPs are required to meet all applicable
statutory and regulatory requirements that apply to MA plans,
including: state licensure as a risk-bearing entity; MA
reporting requirements that are applicable depending on plan
size; and Part D prescription drug benefit requirements. SNP
payment procedures mirror CMS's procedures for MA plans. SNPs
prepare and submit a bid like other MA plans, and are paid in
the same manner as other MA plans based on the plan's
enrollment and risk adjustment payment methodology.
Among other changes, the MIPPA required that all SNPs have
evidenced-based models of care (MOC). An MA organization must
design separate MOCs to meet the special needs of the target
population for each SNP it offers. MOCs must have goals and
objectives for the targeted population, a specialized provider
network, use nationally-recognized clinical practice
guidelines, conduct health risk assessments to identify the
special needs of beneficiaries, and add services for the most
vulnerable beneficiaries including, but not limited to those
beneficiaries who are frail, disabled, or near the end-of-life.
The ACA extended SNP authority through December 31, 2013
and temporarily extended authority through the end of 2012 for
SNPs that do not have contracts with state Medicaid programs to
continue to operate, but not to expand their service areas.
Other ACA changes applicable to SNPs included the following:
(1) required all SNPs to comply with an approval process that
will be based on CMS standards and executed by the National
Committee for Quality Assurance (NCQA) beginning January 1,
2012. NCQA rating is based on scores for each of eleven
clinical and non-clinical elements in each SNPs MOC; (2)
authorized CMS to pay a frailty adjustment payment to FIDE-
SNPs; (3) established new cost-sharing requirements for SNPs;
and (4) required CMS to implement new quality-based payment
procedures for all MA plans by 2012.
In addition, the ACA required the Secretary to establish
the Federal Office of Coordinated Health Care (MMCO) within CMS
to facilitate Medicare and Medicaid coordination for dually
eligible beneficiaries.
The ATRA extended SNP authority through December 31, 2014,
and also temporarily extended authority for SNPs that do not
have contracts with state Medicaid programs to continue to
operate, but not to expand their service areas. Beginning
January 1, 2015, SNP enrollment will not be restricted only to
special needs individuals.
Committee Bill
The Committee Bill would permanently authorize I-SNPs, re-
authorize D-SNPs through December 31, 2020, and re-authorize C-
SNPs through December 31, 2017.
The Committee Bill would require the Secretary to establish
by, April 1, 2015, procedures that would unify the Medicare and
Medicaid appeals procedures applicable to D-SNPs. In
establishing unified Medicare-Medicaid appeals procedures, the
Secretary would be required to solicit comments from states,
plans, beneficiary representatives, and other relevant
stakeholders. To the extent compatible with the process for
unifying Medicare and Medicaid appeals procedures, the
Secretary would ensure that the following requirements were
included: (1) adoption of the most protective provisions for D-
SNP enrollees under current law, including continuation of
benefits under Medicaid pending timely filed appeals; (2)
differences in Medicaid state plans are taken into account; and
(3) be easily navigable by D-SNP enrollees.
The unified procedures must also include: (1) a single
notification of all applicable Medicare and Medicaid appeal
rights; (2) appeals notices written in plain language and
available in a language and format that is accessible to
enrollees; (3) unified Medicare and Medicaid timeframes for
internal (plan) and external (Medicare and Medicaid) appeals,
such as the enrollee's filing of appeals, plan acknowledgement,
and appeal resolution and notification of appeal decisions; and
(4) mechanisms to allow D-SNP plans to track and resolve
grievances. The Committee Bill would require that, beginning
January 1, 2016, D-SNP plan contracts use the unified Medicare-
Medicaid appeals procedures.
The Committee Bill would require that, beginning January 1,
2018, most D-SNPs would be required to integrate all Medicare
and Medicaid benefits and meet the requirements for a FIDE-SNP,
including, to the extent current state law under the state's
Medicaid plan permitted capitated payments for long-term care
services or behavioral health services. However, for purposes
of the integration requirements beginning in 2018, the
definition of a FIDE-SNP does not include the requirement that
the D-SNP's enrollment have similar average levels of frailty
as the Programs of All-Inclusive Care for the Elderly (PACE)
program. If the Secretary determines that D-SNPs failed to meet
contract requirements for full integration of all Medicare and
Medicaid benefits for 2018 or 2019, the Secretary is authorized
to impose one of the following sanctions: (1) reduce MA
payments; (2) close enrollment to new plan enrollees; (3) apply
MA sanctions, including civil money penalties and suspension;
and (4) other reasonable actions as determined by the Secretary
(except deeming that the plan no longer meets the definition of
a D-SNP). Finally, the Committee Bill requires that in order to
meet the definition of a D-SNP for 2020 and subsequent years,
D-SNPs must fully integrate Medicare and Medicaid benefits and
meet the current law definition of a FIDE-SNP.
D-SNPs that only enroll Medicare beneficiaries for whom the
only Medicaid benefit to which the individuals are entitled is
Medicare cost-sharing assistance would not be required to fully
integrate Medicare and Medicaid benefits in their contracts
effective January 1, 2018.
The Committee Bill would designate the MMCO as the
dedicated CMS contact to assist states in addressing D-SNP
Medicare-Medicaid misalignments. In this role, MMCO would be
required to establish a uniform process for disseminating
Medicare contract information to state Medicaid agencies as
well as to D-SNPs. MMCO would also be required to establish
basic resources for states that are interested in exploring D-
SNPs as a platform for integrating Medicare-Medicaid services
for dual eligible beneficiaries.
The Committee Bill would add the following requirements for
C-SNP care management plans beginning with contracts effective
January 1, 2016: (1) the interdisciplinary provider team that
C-SNPs are required to have would include providers with
training in an applicable specialty and demonstrated expertise
in treating individuals with the chronic conditions the C-SNP
would target; (2) requirements developed by the Secretary to
provide face-to-face encounters with the C-SNP's enrollees; (3)
a requirement that MOC include the results of the initial
assessment and each annual reassessment are addressed in the
enrollee's required individualized care plan; (4) the Secretary
would be required to ensure that as part of the annual MOC
evaluation that whether or not the plan fulfilled the goals
identified would be taken into account; and (5) the Secretary
would be required to establish a minimum benchmark for each MOC
element and to only approve a C-SNPs MOC if each element met
those minimum benchmarks.
The Committee Bill would make changes to the SNP quality
ratings and measurement and publication. Beginning with
contracts effective January 1, 2016, the Secretary would be
required to increase emphasis on SNPs' performance improvement
or decline when determining a plan's annual star ratings.
Specifically, the Secretary would be required to ensure that at
least 25 percent but not more than 33 percent of the annual
star rating is based on the SNP's performance improvement or
decline. The Secretary would be required to measure the SNP
performance improvement or decline based on the net change in
the SNP plan's individual star rating measures. In order to
ensure that plans are not punished in cases where it is
impossible to improve, the Secretary would be authorized to
appropriately adjust SNP plan improvement ratings when plans
have achieved a 5-Star rating or the highest overall rating
possible for individual measures. This increased emphasis on
improvement would not apply to SNPs with an overall star rating
of not more than 2.5 stars.
The Committee Bill would allow the Secretary to report and
apply quality ratings of SNPs at the plan level instead of the
contract level, as it is under current law. In requiring
reporting and applying quality ratings at the plan level, the
Secretary would be required to take into consideration the
minimum enrollment that would be necessary to enable valid
quality measurement at the plan level. In the instance the
Secretary reports quality measures at the plan level, the
quality measurement must include the Medicare Health Outcomes
Survey, Healthcare Effectiveness Data Information Set, and
Consumer Assessment of Healthcare Providers and Systems
measures. Also, if the Secretary uses the option to require
quality reporting and the application of ratings at the plan
level, then payment and other administrative actions linked to
qualify measurement would be applied at the plan level.
The Committee Bill would require that GAO conduct a study
to determine how the Secretary could change the MA SNP quality
measurement system to allow an accurate comparison of the care
quality provided by SNPs for individual plans as well as for
SNPs overall, to the care quality delivered under Medicare FFS
and other MA plans for similar populations. GAO would be
required to submit the report on SNP quality compared to other
Medicare delivery sources by July 1, 2016. GAO's report would
be required to contain recommendations for legislative and
administrative action as determined appropriate by GAO.
SEC. 207. MEDICARE COST CONTRACTS
Present Law
Medicare cost contracts are contracts with private health
plans where plan payment is based on the reasonable costs
actually incurred to provide Medicare covered benefits to
enrollees. Cost contracts were first authorized by the Social
Security Amendments of 1972 (P.L. 92-603), as were contracts
that paid private health plans a modified per capita (risk-
based) monthly payment. The BBA prohibited the Secretary from
extending or renewing cost contracts beyond December 31, 2002,
while also transitioning the risk-based contracts to the new
Medicare+Choice program, later to become the MA program. Seven
subsequent pieces of legislation extended the Secretary's
authority to enter into cost contracts, as follows:
(1) The Balanced Budget Refinement Act of 1999 (BBRA, P.L.
106-113) extended the authority through 2004.
(2) The Medicare, Medicaid, and SCHIP Benefits Improvement
and Protection Act of 2000 (BIPA, P.L. 106-554) allowed cost
contracts to expand their service areas if the request was
submitted to the Secretary before September 1, 2003.
(3) The MMA allowed cost contracts to be extended or
renewed indefinitely. However, beginning in 2008, these
contracts could not be extended or renewed for a service area
that during the previous year had two or more MA regional plans
or two or more MA local (formerly Medicare+Choice) plans.
(4) The Medicare, Medicaid, and SCHIP Extensions Act of
2007 (MMSEA, P.L. 110-173) extended by one year--from January
1, 2008, to January 1, 2009--the length of time a cost plan
could continue to operate in an area previously served by two
or more local MA plans or two or more regional MA plans.
(5) The MIPPA extended by one year--from January 1, 2009,
to January 1, 2010--the length of time a cost plan could
continue to operate in an area previously served by two or more
local or two or more regional plans. To prohibit a cost plan
from participating after January 1, 2010, the two or more plans
in the service area were required to be offered by different
organizations, and meet minimum enrollment requirements.
(6) The ACA extended by three years--from January 1, 2010
to January 1, 2013--the length of time a cost plan could
continue to operate in an area previously served by two or more
local or two or more regional plans that met minimum enrollment
requirements.
(7) The ATRA extended by one year--from January 1, 2013 to
January 1, 2014--the length of time a cost plan can continue to
operate in an area previously served by two or more local or
two or more regional plans that meet minimum enrollment
requirements.
Under current law, Medicare cost contracts can be extended
or renewed indefinitely, except that, under current authority,
beginning on or after January 1, 2014, these contracts may not
be extended or renewed in areas that during the entire previous
year (2013) had two or more MA regional plans or two or more MA
local plans offered by different organizations, with a minimum
enrollment. These cost contracts will not be renewed at the end
of 2014, based on minimum enrollment data for the 2013 contract
year, and will cease to operate after 2014.
Committee Bill
Effective for plan year 2015, the Committee Bill would
allow the Secretary to extend or renew cost contracts that had
served an area where two or more local or regional MA plans
with minimum enrollment had served in 2013, but would prohibit
new enrollment into those cost contract plans for 2015.
Cost contract plans with restricted enrollment in 2015
would be able to apply to convert to a new (MA) plan under Part
C in 2016 (if they were to notify the Secretary of their intent
to do so by a date specified by the Secretary), or have their
contract terminated effective 2016.
The Secretary would be required to establish a process
whereby the enrollees of the cost contract plans that were to
convert to MA plans for 2016 would be automatically enrolled
into a new MA plan. The automatic enrollment into the newly
converted MA plans would also apply to the cost plan's
enrollees with End Stage Renal Disease. Cost plans that
included a drug benefit would be required to retain drug
coverage as part of their new MA plan. Similarly, cost plans
that did not include a drug benefit would not be allowed to add
one when applying to convert to MA plans. The MA monthly
beneficiary premium for a converted plan would not be allowed
to exceed the monthly premium under the previous cost contract
by more than ten percent. The converted plan would be required
to provide benefits, premiums, and access to providers
comparable to what was available under the cost plan the
previous year. To ensure continuity of care, the converted MA
plan would be required to maintain current providers and
courses of treatment for enrollees at the time of enrollment
for at least 90 days after enrollment. During this 90-day
period, the converted plan would be required to pay non-
contracted providers for items and services furnished to
enrollees at amounts not less than amounts paid under original
FFS Medicare.
The Secretary would be required to identify the affected
enrollees of plan conversions by no later than 30 days prior to
the start of the annual coordinated election period (which
begins on October 15th). Enrollees subject to the automatic
enrollment would be able to change their enrollment during the
annual, coordinated election period to a different MA plan or
to Medicare fee-for-service and could also change their
enrollment one additional time during a period starting after
the last day of the annual, coordinated election period
(December 7th) and ending on the last day of February of the
following year.
Prior to the start of the annual coordinated election
period, the Secretary would be required to send affected
enrollees a notification of their automatic enrollment into the
new MA plan and information about their options to make a
different election during the annual coordinated election
period and/or their additional special election period. The
Secretary would also be required to provide affected enrollees
with a description of the differences in benefits, cost-
sharing, premiums, drug coverage, and provider networks between
their former cost plan and the new MA plan.
The Secretary would be required to adjust the star quality
rating used to set the maximum payment rate for MA plans so
that the star rating for the newly converted MA plan for its
first two plan years would be equal to the star rating assigned
to the cost plan in the last year before it was converted to a
new MA plan.
SEC. 208. QUALITY MEASURE ENDORSEMENT AND SELECTION
Present Law
As required by section 1890 of the SSA, the Secretary
identifies and contracts with a consensus-based entity, such as
the National Quality Forum, that makes recommendations on an
integrated national strategy and priorities for health care
performance measurement. The entity is required to carry out
specified duties related to performance improvement and
measurement. These duties include, among others, priority
setting; measure endorsement; measure maintenance; convening
multi-stakeholder groups to provide input on the selection of
quality measures and national priorities; and annual reporting
to Congress. The MIPPA (which added section 1890 of the SSA)
appropriated $10 million for each of the FY2009 through FY2012;
subsequent legislation extended this funding through FY2013.
Under current law, the Secretary is required to establish a
pre-rulemaking process to select quality measures for use by
Medicare. This process includes gathering multi-stakeholder
input; making measures under consideration available to the
public; transmission to, and consideration by, the Secretary of
the input of multi-stakeholder groups; and the publication of
the rationale for the use of any quality measure in the Federal
Register; among others. The Secretary is also required to
establish a process for disseminating quality measures used and
to periodically review quality measures and determine whether
to maintain the use of a measure or to phase it out.
Committee Bill
Generally, the Committee Bill would modify the duties for
the consensus-based entity, create a new entity to carry out
duties related to the selection of quality measures, and modify
the duties for the Secretary in a new section of the SSA. The
changes under this section would be effective as of October 1,
2014, and would apply to contract periods that begin on or
after October 1, 2014. Specifically, the Committee Bill would
re-designate existing SSA section 1890A as section 1890B, and
would add a new section1890A titled ``Contract with an Entity
Regarding Input on the Selection of Measures.''
The Committee Bill creates a new entity to carry out duties
related to the selection of quality measures in order to allow
more entities to bid for the contract and enhance the
competitiveness of the process. The new entity must meet a
number of requirements to qualify for becoming the measure
selection entity. Specifically, an entity must meet the
following requirements to qualify for becoming the new entity
under section 1890A: (1) be a private nonprofit entity; (2) be
governed by a board including representatives of health plans,
health care providers and practitioners, health care consumers,
purchasers, and employers; (3) have at least four years of
experience working with measures; (4) have no membership fees
or fees that are reasonable and adjusted based on the capacity
of a potential member to pay. Membership fees would not be
allowed to pose a barrier to the participation of individuals
or groups with low or nominal resources in the entity's
functions; and (5) not be a measure developer.
The Committee Bill would transfer to the measure selection
entity the following duties currently under the consensus-based
entity: (1) priority setting, (2) the convening of multi-
stakeholder groups, and (3) the transmission of multi-
stakeholder input. The Committee Bill would also create
additional duties for the new measure selection entity. The
entity would facilitate increased coordination and alignment
between the public and private sectors with respect to quality
and efficiency measures. The entity would have to conduct an
ongoing analysis of gaps in endorsed quality and efficiency
measures. By March 1st of each year, the new entity would have
to issue a report on (1) the performance of its duties, (2) the
recommendations of the entity's priority setting process, (3)
the multi-stakeholder groups' input on the selection of quality
and efficiency measures, (4) the findings of its gap analysis,
and (5) any other items determined appropriate by the
Secretary. The contract must be awarded beginning in FY2015;
continue for a period of three years; and adhere to competitive
bidding procedures.
The Committee Bill would require the Secretary to provide
for the transfer of $7 million for FY2014, from the Hospital
Insurance (HI) and SMI Trust Funds to the CMS Program
Management Account, to carry out the activities in existing
section 1890 and section 1890A(a)-(d). These amounts would
remain available until expended. The Committee Bill would also
require the Secretary to provide for the transfer of $25
million for each of fiscal years 2015 through 2017, from the HI
and SMI Trust Funds to the CMS Program Management Account, to
carry out section 1890; section 1890A; and section 1890B
(excluding sections 1890B(e) and (f)).
While acknowledging that it can be difficult to recruit all
appropriate stakeholders, the measure selection entity, to the
extent feasible, would make every effort to ensure its multi-
stakeholders groups are balanced across stakeholders. The
Committee Bill would also require the multi-stakeholder groups'
input to include a detailed description of the rationale for
each recommendation made. Such rationales could include (1) the
expected impact of the measure on individuals, (2) the burden
on providers and suppliers, (3) the expected influence over the
behavior of providers and suppliers, (4) applicability of a
measure for more than one setting or program, and (5) other
areas determined in consultation with the Secretary. In
providing the input, the entity could consider whether it is
appropriate to provide separate recommendations with respect to
measures for the internal use of a provider or supplier,
quality reporting, public reporting, and payment provisions.
The Committee Bill would also direct the multi-stakeholder
group to provide input on the selection of quality and
efficiency measures for use in other SSA health care programs
other than Medicare.
In order to make the contracting process more competitive,
the Committee Bill would modify the process for the consensus-
based entity, requiring the Secretary to rebid the contract for
the entity at least every three years, instead of every four
years. It would strike the statutory reference to the National
Quality Forum as an example of a possible consensus-based
entity. In order to avoid potential conflicts of interest, it
would also require that the entity not be a measure developer.
The Committee Bill would strike the existing requirement
that the consensus based entity review and endorse episode
groupers. The consensus based entity would also facilitate
increased coordination and alignment between the public and
private sector with respect to quality and efficiency measures.
In order to provide flexibility and facilitate management
of the measures workload, the Committee Bill would require the
Secretary to make its list of measures available to the public
and the measure selection entity for pre-rulemaking input by no
later than October 1st or December 31st of each year. The
Committee Bill directs the Secretary to provide for an
appropriate balance of the number of measures to be made
available by each of the two dates in a year. This change would
space out the measure selection entity's receipt of measures
and ensure that the entity has enough time to review the
measures. For measures received on October 1st, the entity
would have to transmit the input by February 1st. For measures
received on December 31st, the entity would have to transmit
the input by April 1st. However, the Secretary could make
available to the public a limited number of measures apart from
the dates above. In turn, the entity with a contract under
section 1890A would transmit to the Secretary the multi-
stakeholder group's input on a timely basis.
The Committee Bill would also require the Secretary to
consider the benefits of the alignment of measures between the
public and private sector when periodically reviewing quality
and efficiency measures.
The Secretary would also be required to publish a list of
concordance rates for each type of provider or supplier. Each
annual final rule would contain the concordance rate for the
applicable type or types of providers and suppliers. The
Secretary would also have to publish in the Federal Register
the rationale for the use of any quality and efficiency measure
that has not been recommended by the multi-stakeholder group.
SEC. 209. OUTREACH AND ASSISTANCE FOR LOW-INCOME PROGRAMS
Present Law
Section 119 of the MIPPA appropriated $25 million for
FY2008 and FY2009 for low-income Medicare beneficiary outreach
and education activities through the following programs: State
Health Insurance Counseling and Assistance Programs (SHIPs),
Area Agencies on Aging (AAAs), Aging and Disability Resource
Centers (ADRCs), and the Administration on Aging (AoA). Section
3306 of the ACA extended authority for the low-income outreach
activities and appropriated $45 million for these programs. The
appropriations authorized by the ACA were available for
obligation through FY2012. Section 610 of the ATRA extended
these appropriations through FY2013 and appropriated the
following amounts for low-income Medicare beneficiary outreach
and assistance activities: SHIPs, $7.5 million; AAAs, $7.5
million; ADRCs, $5 million; and the Contract with the National
Center for Benefits and Outreach Enrollment, $5 million.
Outreach activities include counseling, education,
enrollment assistance, health promotion, and other activities
to help low-income Medicare beneficiaries understand their
health insurance choices so they can make informed decisions.
In addition to providing Medicare beneficiaries with counseling
and education about their health insurance choices, outreach
activities are intended to help low-income Medicare
beneficiaries enroll in the Medicare Savings Program (MSP). MSP
helps pay Medicare premiums and cost-sharing for beneficiaries
who, due to their low income and assets, are eligible for both
Medicare and Medicaid. MSP enrollment historically has been
low, so outreach activities have been used to identify
individuals who qualify for assistance.
Committee Bill
The Committee Bill would permanently appropriate current
level funding ($25 million each fiscal year) for low-income
outreach and assistance activities. These funds would be
allocated to the following programs in the same amounts as they
are under current law: SHIPs, $7.5 million; AAAs, $7.5 million;
ADRCs, $5 million; and the Contract with the National Center
for Benefits and Outreach Enrollment, $5 million.
Subtitle B--Medicaid and Other Extensions
SEC. 211. QUALIFYING INDIVIDUAL PROGRAM
Present Law
The Qualifying Individual (QI) program requires states,
through their Medicaid programs, to pay Medicare Part B
premiums for Medicare beneficiaries with incomes between 120
and 135 percent of the Federal Poverty Limit (FPL). Medicaid
payment for the QI program is transferred annually from the SMI
Trust Fund to the Treasury account that funds medical
assistance payments to states and the District of Columbia.
Congress appropriates annual funding amounts for all states and
CMS allocates the funding to state Medicaid programs. States
receive 100 percent federal funding to pay program
participant's Medicare Part B premiums up to the maximum number
of beneficiaries whose Part B premiums can be paid from their
federal allocation, but no additional matching beyond this
annual allocation is available. The QI program has been
reauthorized and funded a number of times since it was
originally authorized. In December 2012, there were
approximately 480,300 low-income Medicare beneficiaries who
received financial assistance from state Medicaid programs to
pay their Part B premiums.
Committee Bill
The Committee Bill would amend the SSA to authorize and
fund the QI program by annually transferring funds from the SMI
Trust Fund to the Treasury account that funds medical
assistance payments to states and the District of Columbia for
calendar years 2014 through 2018. The Committee Bill also would
remove restrictions on the number of beneficiaries who may
receive QI assistance due to the capped allocation that states
were required to use in determining which eligible
beneficiaries would receive assistance.
SEC. 212. TRANSITIONAL MEDICAL ASSISTANCE
Present Law
Federal law requires states to continue Medicaid benefits
for certain low-income families who would otherwise lose
coverage because of changes in their income under section
1902(e), of the SSA. This continuation of benefits is known as
transitional medical assistance (TMA). Federal law permanently
requires states to provide four months of TMA for families who
lose Medicaid eligibility due to increased child or spousal
support collections. Federal law also permanently requires four
months of TMA for families who lose Medicaid eligibility due to
an increase in earned income or hours of employment. Congress
expanded work-related TMA benefits under section 1925 of the
SSA as part of the Family Support Act of 1988 (FSA, P.L. 100-
485), requiring states to provide at least six, and up to 12,
months of TMA coverage to families losing Medicaid eligibility
due to increased hours of work or income from employment, as
well as to families who lose eligibility due to the loss of a
time-limited earned income disregard. FSA originally authorized
section 1925 of the SSA to replace the four-month requirement
in section 1902(e)(1) of the SSA through FY1998. However, the
provision has continued to exist under a series of extensions
since its inception.
Committee Bill
The Committee Bill would extend section 1925 TMA through
December 31, 2018. The Committee Bill would also permit states
and the District of Columbia that: (1) take up the ACA Medicaid
expansion and (2) take up a new continuous eligibility option
to seek CMS approval to opt out of sections 1902(e) and 1925
TMA-related requirements. Such an opt out would not violate the
ACA child maintenance of effort provision which requires states
to maintain their Medicaid programs with the same eligibility
standards, methodologies and procedures for children up to age
19 until September 30, 2019.
The Committee Bill also modifies the TMA-related
requirements under Medicaid and Temporary Assistance for Needy
Families (TANF) to consider only increases in income due to
spousal support collections as a trigger for TMA eligibility.
This change would conform the income counting rules for TMA to
the new Modified Adjusted Gross Income counting rules that will
be used to determine Medicaid income eligibility for most
Medicaid-eligible populations beginning January 1, 2014.
SEC. 213. EXPRESS LANE ELIGIBILITY
Present Law
The Children's Health Insurance Program Reauthorization Act
of 2009 (CHIPRA, P.L. 111-3) created a state plan option for
``Express Lane'' eligibility whereby states are permitted to
rely on a finding from specified ``Express Lane'' agencies
(e.g., those that administer programs such as TANF, Medicaid,
CHIP, and Supplemental Nutrition Assistance Program) for: (1)
determinations of whether a child has met one or more of the
eligibility requirements necessary to determine his or her
initial eligibility or (2) eligibility redeterminations.
Authority for ``Express Lane'' eligibility determinations will
sunset on September 30, 2014.
Committee Bill
The Committee Bill would extend the authority for ``Express
Lane'' eligibility determinations until September 30, 2015.
SEC. 214. PEDIATRIC QUALITY MEASURES
Present Law
Section 401 of CHIPRA required the Secretary to: identify
and publish an initial core set of pediatric quality measures;
submit a report to Congress on the quality of children's health
care under Medicaid and CHIP; and to establish a Pediatric
Quality Measures Program to identify pediatric measure gaps and
development priorities, award grants and contracts to develop
measures, and revise and strengthen the core measure set.
States are required to submit reports to the Secretary annually
to include information about state-specific child health
quality measures applied by the state. The Secretary is
required to collect, analyze, and make publicly available the
information reported by states annually. Section 401 also
included funding for ten grants to states for demonstration
projects to evaluate ideas to improve the quality of children's
health care. Funding for these activities was appropriated in
the amount of $45 million for each of FY2009 through FY2013.
Committee Bill
The Committee Bill would modify the funding for adult
quality measure development in SSA section 1139B to require the
Secretary to spend at least $15 million of the $60 million
appropriated on pediatric quality measure development under SSA
section 1139A instead. This would provide the Secretary with
the funding needed to continue the development of pediatric
quality measures established under CHIPRA section 401(b)
through September 30, 2015.
The Committee Bill would also eliminate a requirement that
limits the aggregate amount the Secretary could award for
grants and contracts for the development, testing, and
validation of emerging and innovative evidence-based adult
quality measures.
SEC. 215. SPECIAL DIABETES PROGRAM
Present Law
The BBA authorized two diabetes-related programs within the
Public Health Service Act. The first, authorized in section
330B, provides funding for the National Institutes of Health to
award grants for research into the prevention and cure of Type
I diabetes. The second, authorized in Section 330C, provides
funding for the Indian Health Service (IHS) to award grants for
services related to the prevention and treatment of diabetes
for American Indians and Alaska Natives who receive services at
IHS-funded facilities. Since the BBA, additional funding for
this program has been appropriated in a series of laws, most
recently in section 625 of the ATRA which extended funding for
these programs through FY2014.
Committee Bill
The Committee Bill would extend funding for both programs
through FY2019. Specifically, it would appropriate $150 million
for each program annually.
Subtitle C--Human Services Extensions
SEC. 221. ABSTINENCE EDUCATION GRANTS
Present Law
Section 912 of The Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (PRWORA, P.L. 104-193)
authorized abstinence education formula grants in SSA section
510. To receive these formula grants, states must request
funding when applying for Maternal and Child Health Block Grant
funds authorized in SSA section 501. Funds provided under SSA
section 510 must be used exclusively for teaching abstinence
from sexual activity outside of marriage. PRWORA authorized and
appropriated $50 million for each of FY1998 through FY2002 for
abstinence education. Subsequently, funding for this program
was extended through June 30, 2009, by a series of legislation.
Most recently, section 2954 of the ACA appropriated $50 million
for each of FY2010 through FY2014 for this program. In
addition, $5 million was added to be used to award competitive
grants for FY2012 by the Consolidated Appropriations Act of
2012 (P.L. 112-74) and the Consolidated and Further Continuing
Appropriations Act of 2013 (P.L. 113-6). FY2014 is the final
year of funding for this program.
Committee Bill
The Committee Bill would extend authorization and funding
for the SSA section 510 Abstinence Education program for five
years, from FY2015 through FY2019, at $50 million for each
year.
SEC. 222. PERSONAL RESPONSIBILITY EDUCATION PROGRAM
Present Law
Section 2953 of the ACA established the Personal
Responsibility Education Program (PREP) in section 513 of the
SSA. PREP is a state formula grant program to support evidence-
based programs designed to educate adolescents about
abstinence, contraception, and adulthood. The ACA also required
the Secretary to award grants to implement innovative youth
pregnancy prevention strategies and to target services to high-
risk populations. The ACA appropriated $75 million for each of
FY2010 through FY2014. The ACA required that $10 million each
year be reserved for the youth pregnancy prevention grants. The
funds are available until expended. FY2014 is the final year of
funding for this program.
Committee Bill
The Committee Bill would extend authorization and funding
for PREP for five years, from FY2015 through FY2019, at $75
million for each year. The target population of the formula
grant portion of the program would be expanded to include youth
at risk for being a victim of sex trafficking or a victim of a
severe form of trafficking in persons. The target population of
the innovative strategies portion of the program would be
expanded to include youth at risk for being a victim of sex
trafficking or a victim of a severe form of trafficking in
persons. The dates in the provision related to the mandatory
use of unexpended allotments would be modified to conform to
the five year extension of PREP. The base year for the
maintenance-of-effort for non-federal funding would be changed
from FY2009 to FY2014.
SEC. 223. FAMILY-TO-FAMILY HEALTH INFORMATION CENTERS
Present Law
Section 6064 of the DRA established the Family-to-Family
Health Information Centers program in SSA section 501(c). The
program provides grants to family-staffed organizations that
provide health care information and resources to families of
children with special health care needs. The DRA appropriated
$12 million for FY2007 through FY2009 for Family-to-Family
Health Information Centers; section 5507(b) of the ACA
appropriated $5 million for each of FY2009 through FY2012, with
funding to remain available until expended. An additional $5
million for FY2013 was included in section 624 of the ATRA.
FY2013 was the final year of funding for this program.
Committee Bill
The Committee Bill would amend SSA section 501(c) to
appropriate $6 million for each of FY2014 through FY2018. The
Bill would also add territories as eligible for the program by
eliminating language in the subsection which defines ``states''
as the 50 states and the District of Columbia. This provision
would be effective as if enacted on October 1, 2013.
SEC. 224. HEALTH WORKFORCE DEMONSTRATION PROJECT FOR LOW-INCOME
INDIVIDUALS
Present Law
Section 5507(a) of the ACA requires the Secretary to
establish a demonstration project under SSA section 2008(a)
that award funds to states, Indian tribes, institutions of
higher education, and local workforce investment boards for
health profession opportunity grants (HPOG). These grants are
designed to help provide low-income individuals--including
individuals receiving assistance from the TANF program--to
obtain education and training in health care jobs that pay well
and are in high demand. Funds are also used to provide
financial aid and other supportive services. The ACA
appropriated $85 million for each of FY2010 through FY2014 to
carry out this demonstration project and another demonstration
project established by the ACA, under SSA section 2008(b), to
develop training and certification programs for long-term care
workers. FY2014 is the final year of funding for this program.
Committee Bill
The Committee Bill would amend section 2008(c) of the SSA
to extend funding of $85 million for the HPOG demonstration
under section 2008(a) of the SSA, for each of FY2015 and
FY2016. In addition, the funding would continue to be
streamlined and does not apply to the certification of home
health aides for FY2013 through FY2016.
Subtitle D--Program Integrity
SEC. 231. REDUCING IMPROPER MEDICARE PAYMENTS
Present Law
CMS relies on a variety of contractors to help administer
the Medicare program, including MACs for FFS Medicare. Section
911 of the MMA required the Secretary to implement Medicare
contracting reform, which was intended to improve Medicare's
administrative services through the use of competition and
performance incentives. MACs process Medicare claims, and serve
as the primary operational contact between the FFS program, and
Medicare's approximate 1.5 million health care providers and
suppliers. MACs enroll providers and suppliers in Medicare and
educate providers on Medicare billing requirements, as well as
answering provider and beneficiary inquiries.
MACs are required to educate providers about the
fundamentals of the program, policies and procedures, new
initiatives, and other significant changes. MACs also identify
potential improper payment issues through analyses of provider
inquiries, claim submission errors, medical review data,
Comprehensive Error Rate Testing data, and the Recovery Audit
Program data.
In addition to MACs, CMS also relies on other contractors
that support program integrity activities such as Recovery
Audit Contractors (RACs). Unlike other Medicare contractors,
RACs are compensated on a contingency fee basis--their only
payment is a percentage of the amount of each improper payment
they identify, regardless of whether the claim was an
overpayment or underpayment. RAC contingency fees vary
depending on the contractor, the type of claim, and the part of
Medicare. RACs must return contingency fees when overpayments
are overturned on appeals filed by the Medicare providers and
suppliers. Overpayments identified by RACs are recouped by MACs
and the amount of recouped funds less contingency fees paid to
RACs and expenses for administering the RAC program are
returned to the Medicare Trust Funds. RAC overpayment decisions
that are appealed by providers affect the overpayment amount
identified by RACs and the amount returned to the Medicare
Trust Funds. The Medicare FFS appeals process has five levels:
(1) the MACs, (2) Qualified Independent Contractors, (3) an
Administrative Law Judge, (4) the Medicare Appeals Council, and
(5) a federal court.
Committee Bill
The Committee Bill would require the Secretary to implement
the following three initiatives: an improper payment outreach
and education program; enhanced RAC transparency, and a RAC
demonstration project.
The Committee Bill would require MACs to implement an
improper payment outreach and education (OE) program. Each MAC
would be required to have an improper payment OE program to
provide outreach, education, training, and technical assistance
activities to providers and suppliers in their geographic
service areas. The improper payment OE would be conducted
through the following: emails and other electronic
communications, webinars, telephone calls, in-person training,
and other forms of communications the Secretary deems
appropriate. The information that would be conveyed through the
improper payment OE program would include all of the following:
(1) a list of each provider's and supplier's most frequent and
expensive payment errors over the last quarter; (2) specific
instructions on how to correct or avoid these errors in the
future; (3) notice of all new procedures that the Secretary has
approved for RACs; (4) specific instructions to prevent future
issues related to new RAC procedures approved by the Secretary;
and (5) other information the Secretary determines appropriate.
MACs would be required to ensure that all providers and
suppliers in their geographic area are invited to participate
(either in person or online) in an annual improper payment
error rate reduction training.
The MAC OE program also would be required to include annual
error rate reduction training. This training would give
priority to reduce Medicare improper payments that: have the
highest rate of improper payment; have the greatest total
dollar amount of improper payments; are due to clear
misapplication or misinterpretation of Medicare policies; are
clearly due to common and inadvertent clerical or
administrative errors; or are due to other error types the
Secretary determined could be prevented by the error training
rate reduction program.
To assist MACs in conducting the improper payment error
reduction training program, the Secretary would be required to
supply MACs on a quarterly basis with a complete list of
improper payments identified by RACs for the providers and
suppliers in the MACs region. The quarterly list of improper
payments identified by RACs that the Secretary would be
required to supply would include the following information: (1)
the providers and suppliers that have the highest improper
payment rates; (2) the providers and suppliers that have the
greatest improper payment amounts; (3) the items and services
furnished in each MAC's geographic region that have the highest
improper payment error rates; (4) the items and services in
each MAC's geographic region that are responsible for the
greatest improper payment amounts; and (5) other information
the Secretary determines would be helpful to MACs in conducting
the improper payment error reduction training program.
In providing information to assist MACs in conducting the
improper payment error reduction training, the Secretary would
be required to transmit that information so that it would be
easy for MACs to identify the improper payment issues where
outreach, education, training, and technical assistance would
be most effective. The Secretary would ensure that information
supplied to MACs was in an electronic and easily searchable
format as well as that it clearly displayed the name and
address of the provider or supplier, the amount of improper
payment, and any other information the Secretary determines
appropriate.
The Secretary would be authorized to retain up to 25
percent of the amounts recovered by the RAC program to
implement the MAC OE program and to implement corrective
actions to help reduce Medicare's error rate. The OE program
requirements would be effective beginning on January 1, 2015.
The Committee Bill would add to the reporting requirements
of the annual RAC report to Congress that is required under
current law. Specifically, the Committee Bill would require
information on the results of appeals at each appeal level for
the following RAC review types: (1) automated, (2) complex, (3)
medical necessity, (4) Part A, (5) Part B, and (6) durable
medical equipment.
The Committee Bill would require the Secretary to conduct a
three-year Medicare demonstration project to better target RAC
audits. The demonstration would begin January 1, 2015. The
Secretary would be required to consider the following in
determining the demonstration's geographic area: a region's
total number of providers and suppliers, the diversity of the
region's providers and supplier types, the region's improper
payment rate variation among individual providers and
suppliers, and a mix of urban and rural providers and
suppliers.
In conducting the demonstration, the Secretary would be
required to identify the following two groups of providers and
suppliers: (1) providers with low improper payment error rates,
and (2) providers with high improper payment error rates. To
assign a select group of providers and suppliers in the
geographic region to one of these groups, the Secretary would
be required to analyze the following as they relate to the
total number and dollar amount of claims submitted: (1) the
improper payment rates of individual providers of services and
suppliers; (2) the amount of improper payments made to
individual providers of services and suppliers; (3) the
frequency of errors made by the provider of services or
supplier over time; and (4) other information determined
appropriate by the Secretary.
Only a small proportion of the total number of providers
and suppliers in the demonstration's geographic area would be
assigned to either the low error rate or the high error rate
group. Providers and suppliers with high, expensive, and
frequent improper payment errors would be identified as high-
error providers and suppliers. Providers and suppliers with
few, inexpensive, and infrequent errors would be identified as
low error rate providers and suppliers.
Under the demonstration, the Secretary would be required to
adjust the number of records that could be requested from
providers and suppliers by RACs. The Secretary would be
required to increase the maximum number of records that could
be requested by RACs from providers and suppliers identified as
having high error rates and decrease the maximum number of
records that could be requested by RACs from providers and
suppliers identified by composite scores as having low error
rates.
The Secretary would have further authority under the
demonstration to make additional adjustments to RAC
requirements to offer incentives to reduce improper payment
error rates for providers and suppliers assigned to either the
low error rate group or the high error rate group. However, the
Secretary would be prohibited from exempting any provider from
being subject to RAC audits under the demonstration project.
The HHS Office of Inspector General (OIG) would be required
to evaluate the RAC demonstration and submit a report to
Congress within 12 months of completion of the RAC
demonstration.
To implement the RAC incentive demonstration project, the
Secretary would provide for the transfer of $10 million to
CMS's Program Management Account from the HI and the SMI Trust
Funds in a proportion to be determined by the Secretary. These
funds would be available until expended. In addition, the
Secretary would be authorized to transfer to the OIG $245,000
from the HI and SMI Trust Funds in a proportion to be
determined by the Secretary.
SEC. 232. AUTHORITY FOR MEDICAID FRAUD CONTROL UNITS TO INVESTIGATE AND
PROSECUTE COMPLAINTS OF ABUSE AND NEGLECT OF MEDICAID PATIENTS IN HOME
AND COMMUNITY-BASED SETTINGS
Present Law
Medicaid Fraud Control Units (MFCUs) act upon complaints of
abuse or neglect occurring in one of two settings: (1)
Medicaid-funded ``health care facilities'' or (2) ``board and
care'' facilities that receive payment from the Medicaid
program.
Medicaid regulations (42 C.F.R. Sec. 447.10(b)) define a
``facility'' as ``an institution that furnishes health care
services to inpatients'' and separate regulations (42 CFR
Sec. 435.1010) define an ``institution'' as, ``an establishment
that furnishes (in single or multiple facilities) food,
shelter, and some treatment or services to four or more persons
unrelated to the proprietor.''
Section 1903(q)(4)(B) of the SSA defines ``board and care
facility'' to mean ``a residential setting which receives
payment (regardless of whether such payment is made under the
State plan under [Medicaid]) from or on behalf of two or more
unrelated adults who reside in such facility, and for whom one
or both of the following is provided: (i) Nursing care services
. . . [and] (ii) A substantial amount of personal care
services. . . .'' Such facilities are typically identified as
``assisted living facilities.''
Section 1903(q) of the SSA does not permit payment for a
MFCU's investigation or prosecution of abuse and neglect in a
variety of settings outside of an institution or facility. The
statute's limitation was logical when the MFCU program was
established in 1978, at a time when Medicaid services were
typically provided in an institutional setting, but has become
outdated as the delivery and payment for health services has
shifted to in-home and community-based settings.
Committee Bill
The Committee Bill allows payment to a MFCU that chooses to
investigate and prosecute (or refer for prosecution) complaints
of abuse or neglect of individuals in connection with any
aspect of benefits or services provided by the state Medicaid
program and for activities of providers of such benefits or
services in a home or community based setting that is paid for
under the state Medicaid program. The Committee Bill also
allows payment to a MFCU that chooses to investigate and
prosecute (or refer for prosecution) of complaints of abuse or
neglect of patients residing in board and care facilities.
SEC. 233. IMPROVED USE OF FUNDS RECEIVED BY THE HHS INSPECTOR GENERAL
FROM OVERSIGHT AND INVESTIGATIVE ACTIVITIES
Present Law
The Health Insurance Portability and Accountability Act of
1996 (HIPAA, P.L. 104-191) established the Health Care Fraud
and Abuse Control Program (HCFAC). Funds from the HI Trust Fund
are used to finance anti-fraud activities. These funds are
shared by the Secretary, acting through the HHS OIG, and the
Attorney General.
The TRHCA amended HIPAA so that the HCFAC funds may be
available until expended and allowed for increases in the
amount of funding for HCFAC annually, based on the change in
the consumer price index. The ACA extended these increases
permanently. The HCFAC funds typically constitute approximately
three-fourths of the budget of the HHS OIG.
The HHS OIG conducts investigations, inquiries and utilizes
other tools in order to combat fraud in health care. In
furtherance of this goal, the HHS OIG staff and support the
Medicare Strike Force, in conjunction with the Department of
Justice, the FBI, and state and local enforcement agencies. The
Strike Force focuses its efforts on investigating and
prosecuting entities that defraud Medicare and other government
health care programs. Other tools utilized by the HHS OIG
include excluding providers and suppliers who have engaged in
fraud from Medicare and Medicaid. HHS OIG also may impose civil
monetary penalties for false claims against the government,
audit and evaluate questionable conduct by providers, oversee
the activities of all Medicaid Fraud Control Units, operate the
HEAT Provider Compliance Training Initiative (which provides
compliance training for providers), and offer advisory
opinions.
Committee Bill
The Committee Bill allows the HHS OIG to receive and retain
three percent of funds collected as a result of civil debt
collect actions related to false claims or fraud under Medicare
and Medicaid. The Committee Bill would require this funding to
be designated for oversight and enforcement activities
conducted by the HHS OIG.
SEC. 234. PREVENTING AND REDUCING IMPROPER MEDICARE AND MEDICAID
EXPENDITURES
Present Law
Program integrity (PI) initiatives are designed to combat
fraud, waste, and abuse. This includes processes directed at
reducing improper payments, as well as activities to prevent,
detect, investigate, and ultimately prosecute health care fraud
and abuse. PI encompasses a broad range of activities intended
to ensure proper payments are made. These activities can
include post-payment claim reviews as well as pre-payment
claims monitoring. PI emphasis has shifted from post-payment to
pre-payment review to replace costly and time-consuming pay-
and-chase methods with processes to prevent improper payments
from being made. One of the most important prevention
activities is to carefully scrutinize and block or otherwise
restrict participation by providers that are at higher risk of
committing fraud.
CMS shares responsibility for combating health care fraud
with the HHS OIG, the Department of Justice, and the Federal
Bureau of Investigation. Initially, Medicare contractors,
called fiscal intermediaries (Part A) and carriers (Part B)
were responsible for all PI activities. As the Secretary and
government oversight entities recognized risks to the program,
CMS tightened PI requirements on fiscal intermediaries and
carriers.
CMS relies on a variety of contractors to help administer
the Medicare program, including MACs for FFS Medicare. Section
911 of the MMA required the Secretary to implement Medicare
contracting reform which was intended to improve Medicare's
administrative services through the use of competition and
performance incentives. MACs process Medicare claims, and serve
as the primary operational contact between the FFS program, and
Medicare's approximately 1.5 million health care providers and
suppliers. MACs enroll providers and suppliers in Medicare and
educate providers on Medicare billing requirements, in addition
to answering provider and beneficiary inquiries.
MACs are required to educate providers and their staffs
about the fundamentals of the program, policies and procedures,
new initiatives, and other significant changes. MACs also
identify potential improper payment issues through analyses of
provider inquiries, claim submission errors, medical review
data, Comprehensive Error Rate Testing data, and the Recovery
Audit Program data.
In addition to MACs, CMS also relies on other contractors
that support program integrity activities such as RACs. In FFS
Medicare, RACs focus primarily on post-payment claim review and
identification of overpayments to be recouped by MACs, although
they also indirectly provide insight to CMS and other Medicare
contractors on topics for provider education and outreach and
identification of fraud and abuse vulnerabilities. In a March
2010 report, GAO indicated that CMS had not established
processes to ensure that vulnerabilities identified by RACs
were effectively communicated to other Medicare entities and
that there was limited follow-up to ensure that these
contractors implemented measures to reduce these
vulnerabilities.
In general, under MMA, Part D prescription drug plan
sponsors must comply with certain requirements to assist CMS in
administering and monitoring the program, including effective
program integrity safeguards. Part D plans must submit to CMS
an electronic prescription drug event (PDE) record for each
covered prescription the plan fills for their enrollees. PDEs
are similar to other health claim forms and contain a number of
fields that enable CMS to determine plan payments and oversee
the benefit. CMS requires that most PDEs contain a drug
prescriber's identifier. Acceptable identifiers include the
NPI, Drug Enforcement Administration registration numbers,
Unique Physician Identification Numbers, and state license
numbers. However, some drug prescribers are not considered
covered entities under HIPAA and therefore may not be required
to obtain an NPI (covered entities include health plans, health
care clearinghouses, and health care providers that submit
claims electronically). CMS instructed plans that non-NPI
prescriber identifiers may be used on PDEs when the prescriber
does not have an NPI, but that plans and pharmacies should make
reasonable efforts to submit NPIs in the PDE prescriber field.
Prescriber identifiers are valuable program integrity
safeguards, in that they can indicate if legitimate
practitioners prescribed an enrollee's drugs. Valid identifiers
make it possible for plans and CMS to review claims and to
investigate who prescribed covered drugs. In a June 2010
report, the HHS OIG found that there were a number of Part D
claims with invalid prescriber identifiers and these claims
accounted for $1.2 billion in Medicare Part D expenditures.
The Secretary is required to submit an annual report to
Congress on the use of RACs. These reports include information
on the performance of RACs in identifying under- and over
payments and in recouping overpayments.
The Federal Office of Child Support Enforcement (OCSE)
operates the National Directory of New Hires (NDNH), a database
established by the PRWORA. The primary purpose of the NDNH is
to assist state child support agencies in locating parents and
enforcing child support orders; however, Congress has only
authorized specific state and federal agencies to receive
information from the NDNH for a limited set of authorized
purposes.
The NDNH is a national database of wage and employment
information. Its primary purpose is to assist state child
support agencies in locating noncustodial parents, putative
fathers and custodial parties in order to establish paternity
and child support obligations, as well as to enforce and modify
orders for child support, custody and visitation. The NDNH is
located at the Social Security Administration's National
Computing Center. NDNH data are only available to specific
entities for authorized purposes, which include the Secretary
of the Treasury, state foster care and adoption assistance
agencies, state welfare agencies, state child and family
services agencies, the Social Security Commissioner, the
Secretary of Education, and some de-identified uses by
researchers. Statutory authority is required to receive NDNH
information or to request an information comparison. OCSE may
not disclose NDNH information without appropriate statutory
authority.
The federal government and states contribute equally to
fund most Medicaid and CHIP PI activities, although for some
activities, the federal government provides additional funds
through enhanced Federal Medical Assistance Percentage (FMAP)
matching rates. All states receive the same FMAP rate for
administrative expenditures, including most PI activities,
which is generally 50%.
Under section 4735 of the BBA, states were required to
submit Medicaid data to CMS using the Medicaid Statistical
Information System (MSIS). In addition, each state is required
to have its own Medicaid Management Information System (MMIS),
and integrated group of procedures and computer processing
operations that functions as a claims processing and
information retrieval system. The Secretary must approve
states' MMISs and have found them to meet a number of
requirements including compatibility with Medicare claims
processing and information systems, and consistency with
uniform coding systems for claims processing and data
interchange. Among other requirements, MMISs also must be
capable of providing timely and accurate data, meet other
specifications as required by the Secretary, and provide for
electronic transmission of claims data as well as be consistent
with MSIS data formats. A 90 percent federal match is available
for MMIS design, development, or installation and a 75 percent
federal match is available for the operation of an approved
MMIS.
Each state has its own MMIS which it uses to process claims
and monitor service use, but CMS maintains MSIS data for all
states. CMS's MSIS data is an extract of states' MMISs and
contains enrollee and claims information from all 50 states and
the District of Columbia. MSIS is used for analytical research,
program integrity, planning, budgeting, and Medicaid policy
analyses. MSIS is the only nationwide Medicaid eligibility and
claims database, although CMS is developing other data systems
to help monitor and assist states in administering the Medicaid
program.
More recently, section 6402 and 6504 of the ACA
strengthened this provision by requiring states to include data
elements the Secretary determines necessary for program
integrity, program oversight, and administration, including
managed care encounter data.
In 2005, the DRA amended the SSA to add section 1936
established the Medicaid Integrity Program (MIP). Section 1936
appropriated as much as $75 million annually in MIP funding to
support and enhance state PI efforts by expanding and
sustaining national activities such as provider audits,
overpayment identification, and payment integrity and quality
of care education. Section 1936, as originally enacted,
restricted how MIP funding could be used and required that the
Secretary employ a specified number of full-time equivalent
staff. Section 1936 also restricted MIP funding to contractor
payments and limited the Secretary's ability to use MIP funds
for equipment, travel, benefits, training, and salaries.
In addition to establishing the MIP, section 6034 of the
DRA established the Medicare-Medicaid Data Match (Medi-Medi)
Program. The Medi-Medi program was created to help identify
Medicare and Medicaid program integrity vulnerabilities using
computer algorithms (billing or billing patterns related to
service, time, or patients that appear suspect or otherwise
implausible).
Under the Medi-Medi program, state participation is
voluntary. States receive no direct support other than their
FMAP administrative match of 50%. Medicare Program Safeguard
Contractors (PSCs) conducted most of the analysis. Ten states
volunteered to participate in the Medi-Medi program. In an
April 2012 report, the HHS OIG found that the Medi-Medi program
produced limited results and benefitted Medicare more than
Medicaid. HHS OIG recommended that the Secretary make changes
to the Medi-Medi program.
Another program integrity area where Medicare and Medicaid
coordination could be important is reviewing and monitoring
expenditures for individuals dually eligible for both programs.
Although dual eligible beneficiaries are only approximately 25%
of both programs' enrollment, they account for approximately
75% of the programs' expenditures, so monitoring their service
use is important. However, because there are shared
responsibility for the cost of dual eligibles' care, oversight
of these expenditures, including program integrity, can be
fragmented and lack direct timely, accurate data on
utilization.
Committee Bill
The Committee Bill prohibits, for 2015 and for each
subsequent year, Prescription Drug Plans from paying claims for
prescription drugs under Part D that do not include a valid
prescriber NPI.
The Committee Bill requires that the annual report to
Congress on RACs for 2015 and each subsequent year include a
description of (1) the types and financial cost to Medicare of
improper payment vulnerabilities identified by RACs and (2) how
the Secretary is addressing such improper payment
vulnerabilities. The Committee Bill also requires the annual
report to Congress include an assessment of the effectiveness
of changes made to payment policies and procedures in Medicare
in order to address the vulnerabilities so identified.
The Committee Bill allows the Secretary to use MIP funding
for equipment, travel, benefits, training and salaries. The
Committee Bill also allows MIP funding to be used to employ a
number of staff as the Secretary determines necessary to carry
out PI.
The Committee Bill requires the Administrator of CMS have
access to the information in the NDNH for purposes of
determining the eligibility of an applicant for, or enrollee
in, Medicare or a state health subsidy program.
The Committee Bill requires that if the HHS OIG transmits
to the Secretary the names and Social Security Numbers of
individuals, the Secretary must disclose to the HHS OIG
information on such individuals and their employers maintained
in the NDNH. The HHS OIG may use this information only for the
purposes of determining eligibility of an applicant for, or
enrollee in, Medicare or a state health subsidy program or
evaluating the integrity of the Medicare program or a state
health subsidy program.
If, for the purposes of determining eligibility, a state
health subsidy program transmits to the Secretary the names,
dates of birth and Social Security Numbers of individuals, the
Secretary must disclose to the state agency information on such
individuals and their employers maintained in the NDNH.
The Committee Bill requires the Secretary to establish a
plan to encourage and facilitate the participation of states in
the Medicare-Medicaid Data Match Program, or Medi-Medi Program.
The Committee Bill requires the Secretary to develop and
implement a plan that allows state Medicaid programs access to
relevant data on improper or fraudulent payments made under
Medicare. The Committee Bill makes technical changes to the
Medi-Medi program to improve the participation of states.
Subtitle E--Other Provisions
SEC. 241. COMMISSION ON IMPROVING PATIENT DIRECTED
HEALTH CARE
Present Law
No provision.
Committee Bill
The purpose of section 241 of the Committee Bill would be
to create a Commission on Improving Patient Directed Health
Care, which is a 15-member group charged with providing a forum
for nationwide public debate in improving patient self-
determination in health care decision-making; identifying
strategies to ensure every American receives the health care
they want; and providing recommendations to Congress. The
Commission, which includes the Secretary and 14 GAO-appointed
members selected to represent a diverse range of perspectives
and experience, will conduct hearings across the country to
allow Americans to provide input. The Commission will issue a
Report to the American People on Patient Directed Health Care
that, among other things, summarizes what the Commission
learned at its hearings and solicits comment from the public.
Following close of the public comment period, the Commission
will submit recommendations to the President and Congress. The
Bill makes $3,000,000 available in each of fiscal years 2014
and 2015 for the Commission to conduct its work.
SEC. 242. EXPANSION OF THE DEFINITION OF INPATIENT HOSPITAL SERVICES
FOR CERTAIN CANCER HOSPITALS
Present Law
From the outset of the Medicare program, the statute and
regulations have expressly authorized payment for services
furnished ``under arrangement'' between a provider and an
outside vendor. Medicare will pay for diagnostic and other
therapeutic services if furnished by others under arrangement
with the hospital as along as the hospital exercises some
oversight over the vendor. Medicare statute specifies that
routine services, including bed, board and nursing, are to be
provided by the hospital. In FY2012, CMS implemented a
regulation that would require hospitals to provide routine
services directly and not under arrangement with other
providers. Enforcement of this regulation has been delayed
until January 1, 2015.
There are 11 cancer hospitals that are exempt from
Medicare's IPPS used to pay acute care hospitals. Some of these
cancer hospitals are located in the same building or on the
same campus as another hospital and obtain routine services
under arrangement with other providers.
Committee Bill
The Committee Bill would permit cancer hospitals that are
located in the same building or on the same campus as another
hospital as of the date of enactment to obtain routine services
furnished after enactment under arrangement.
SEC. 243. QUALITY MEASURES FOR CERTAIN POST-ACUTE CARE PROVIDERS
RELATING TO NOTICE AND TRANSFER OF PATIENT HEALTH INFORMATION AND
PATIENT CARE PREFERENCES
Present Law
To differing degrees, acute care hospitals and other Part A
providers are subject to pay-for-reporting and pay-for-
performance requirements under the Medicare program that can
use endorsed measures from a consensus-based entity such as the
National Quality Forum.
Committee Bill
The Committee Bill would require the Secretary to provide
for the development of one or more Medicare quality measures to
accurately communicate the existence and provide for the
transfer of patient health information and patient care
preferences when an individual is discharged from a hospital to
return home or to other post-acute care settings. The Secretary
would arrange for the development of these measures by
appropriate measure developers that would submit the measures
for endorsement buy a consensus-based entity. These measures
would be included through notice and comment rulemaking in
different quality reporting programs for acute care hospitals,
skilled nursing facilities, home health agencies and, as
determined by the Secretary, other appropriate providers and
suppliers.
SEC. 244. CRITERIA FOR MEDICALLY NECESSARY, SHORT INPATIENT HOSPITAL
STAYS
Present Law
CMS established regulations to provide guidance on the
appropriateness of a Medicare inpatient admission as part as
its FY2014 IPPS rulemaking. Inpatient hospital stays that are
ordered by physicians with appropriate documentation in the
patient's medical record that span (or are expected to span)
two midnights at the hospital will generally be presumed to be
medically appropriate admissions. CMS has delayed
implementation of this requirement for six months until March
31, 2014.
Committee Bill
The Committee Bill would require the Secretary to consult
with and seek input from interested stakeholders to determine
appropriate criteria to determine medically necessary care that
is an inpatient hospital stay that is less than two midnights
(as established by 42 CFR 412.3 finalized in the FY2014 IPPS
rule). Stakeholders would be hospitals, physicians, MACs, RACs,
and other appropriate parties as determined by the Secretary.
SEC. 245. TRANSPARENCY OF REASONS FOR EXCLUDING ADDITIONAL PROCEDURES
FROM THE MEDICARE AMBULATORY SURGICAL CENTER (ASC) APPROVED LIST
Present Law
Covered surgical procedures in an ambulatory surgical
center (ASC) are surgical procedures that are separately paid
under the OPPS, that would not be expected to pose a
significant risk to beneficiary safety when furnished in an
ASC, and that would not be expected to require active medial
monitoring and care at midnight following the procedure.
The criteria used to identify a significant safety risk
when furnished in an ASC include, but are not limited, to those
procedures that: generally result in extensive blood loss;
require major or prolonged invasion of body cavities; directly
involve major blood vessels; are generally emergent or life
threatening in nature; or commonly require systemic
thrombolytic therapy. Medicare will not cover unlisted
procedures associated with a specific anatomic location (for
example, unlisted codes associated with eye procedures) in an
ASC. Also, certain procedures have been designated as covered
only when provided in an inpatient setting.
CMS updates the lists of covered surgical procedures and
ancillary services in ASCs as part of the ASC annual rulemaking
process. For CY2014, commenters requested that CMS add 54
additional surgical procedures to the list of ASC covered
surgical procedures. Of these codes, CMS did not review 15
procedures that were either unlisted codes (2), only covered on
an inpatient basis (6), or already covered in an ASC (7). Of
the 39 remaining codes, four were included on the ASC covered
surgical procedure list starting with CY2014. CMS determined
that the remaining 35 codes were not appropriate to perform in
an ASC, but did not provide a reason to justify its decision
for each code.
Committee Bill
The Committee Bill would require that the Secretary
describe the specific safety criteria for not including the
requested procedure on the list of ASC covered procedures.
SEC. 246. SUPERVISION IN CRITICAL ACCESS HOSPITALS
Present Law
Medicare provides coverage for a wide range of diagnostic
and therapeutic services in HOPDs. In the CY2009 hospital OPPS
final rule published on November 18, 2008, CMS codified a
longstanding expectation that hospital outpatient therapeutic
services provided `incident to' a physician must be under the
direct supervision of a physician. The term ``physician''
refers to (1) a doctor of medicine or osteopathy legally
authorized to practice in their state; (2) a doctor of dental
surgery or dental medicine; (3) a doctor of podiatric medicine;
(4) a doctor of optometry; (5) a chiropractor, or (6) a
clinical psychologist. Additionally, the term ``direct
supervision'' requires that such physician be on the hospital
premises (or department premises for off-campus hospital
departments) and immediately available to furnish assistance
and direction throughout the performance of the service or
procedure if the need arises, but not necessarily in the room
of service.
In the CY2010 final rule, after receiving comments from
stakeholders, CMS modified the direct supervision requirement
for hospital outpatient therapeutic services. Effective January
1, 2010, nurse practitioners, physician assistants, clinical
nurse specialists, or certified nurse-midwives authorized under
state law could also provide and meet the direct supervision
requirement. Additionally, CMS implemented a technical
correction which clarified that the direct supervision
requirement applied to both hospitals and CAHs--a specific type
of small rural hospitals.
On March 15, 2010, in consideration of stakeholder
comments, CMS issued a notice of non-enforcement of the direct
supervision of outpatient therapeutic services in CAHs for
CY2010. While CAHs remained subject to the direct supervision
standard, contractors were instructed not to evaluate or
enforce the direct supervision standard against such hospitals.
In the CY2011 final rule, the notice of non-enforcement was
extended through CY2011 and applied to small rural hospitals
with 100 beds or fewer that did not otherwise meet the
definition of a CAH. In the CY2012 final rule, the notice of
non-enforcement was extended for CYs 2012 and 2013.
Additionally, CMS established a Hospital Outpatient Payment
Panel to advise CMS on appropriate supervision levels other
than direct supervision for specific outpatient hospital
therapeutic services. Beginning January 1, 2014, the direct
supervision requirement will be enforced for certain hospital
outpatient therapeutic services provided in CAHs and small
rural hospitals.
Committee Bill
Section 246 of the Committee Bill would allow general
supervision by a physician at CAHs for payment of therapeutic
hospital outpatient services.
Additionally, professionals including: (1) a doctor of
medicine or osteopathy legally authorized to practice in their
State; (2) a doctor of dental surgery or dental medicine; (3) a
doctor of podiatric medicine; (4) a doctor of optometry; (5) a
chiropractor, or (6) a clinical psychologist, at CAHs may
directly supervise cardiac and pulmonary rehabilitation. This
fixed a technical problem that prohibits non-physician
practitioners from directly supervising cardiac and pulmonary
rehabilitation services.
SEC. 247. REQUIRING STATE LICENSURE OF BIDDING ENTITIES UNDER THE
COMPETITIVE ACQUISITION PROGRAM FOR CERTAIN DURABLE MEDICAL EQUIPMENT,
PROSTHETICS, ORTHOTICS, AND SUPPLIES (DMEPOS)
Present Law
Under Medicare's competitive bidding program, CMS may only
award contracts to suppliers if the following requirements are
met: (1) the supplier is accredited by a CMS-approved national
accrediting organization, (2) the supplier meets applicable
financial standards specified by the Secretary, (3) the total
amount to be paid under contracts in competitive bidding areas
is expected to be less than amounts that would be paid under
the fee schedule methodology, and (4) beneficiaries have a
choice of multiple suppliers in each area.
Suppliers must also be in good standing with an active
Medicare provider number, meet all applicable state and federal
regulatory and licensure requirements, and be ready to provide
services on the first day of the contract period.
Committee Bill
For rounds of competitive bidding beginning on or after the
enactment of the Committee Bill, the Secretary may only accept
a bid from an entity for an area if the entity already meets
applicable state licensure requirements for such area for all
items in such bid.
SEC. 248. RECOGNITION OF ATTENDING PHYSICIAN ASSISTANTS AS ATTENDING
PHYSICIANS TO SERVE HOSPICE PATIENTS
Present Law
Currently, under Medicare, physicians and nurse
practitioners can serve as attending physicians for
beneficiaries during hospice care. Physician assistants are not
permitted to serve as a beneficiary's attending physician under
the hospice benefit services.
Committee Bill
The Committee Bill would amend section 1861(dd)(3)(B) and
section 1814(a)(7)(A)(i)(I) of the SSA to allow physician
assistants, in addition to physicians and nurse practitioners,
to be attending physicians reimbursed for the services
furnished they provide during hospice care. The amendments do
not grant physician assistants the authority to order hospice
care for beneficiaries.
SEC. 249. REMOTE PATIENT MONITORING PROJECT
Present Law
Under certain circumstances, the Medicare program provides
reimbursement for remote monitoring under the physician fee
schedule
Committee Bill
The Committee Bill would require the Secretary of Health
and Human Services to create pilot projects that incentivize
home health agencies and other entities to purchase and utilize
remote patient monitoring and communications technologies. Home
health agencies participating in the pilot would receive an
incentive payment based on a percentage of the Medicare savings
realized as a result of the pilot projects.
The incentive payments would not exceed the amount that the
Secretary estimates would be expended to home health agencies
if the pilot projects had not been implemented. These
technologies must both enhance health outcomes for Medicare
beneficiaries and reduce total spending under the Medicare
program.
Incentive payments would not reduce the payments that home
health agencies would otherwise receive for providing home
health benefits to Medicare beneficiaries, and performance
targets would be established based on historic spending in
Medicare.
The pilot projects would be conducted in both urban and
rural areas and at least one project would be conducted in a
state with a population of less than one million.
The Secretary would conduct a study on the appropriate
valuation of remote patient monitoring services under the
Medicare physician fee schedule in order to accurately reflect
the resources used in furnishing such services. Not later than
six months after the date of enactment of the Committee Bill,
the Secretary would submit to Congress a report on the study
referenced above.
SEC. 250. COMMUNITY-BASED INSTITUTIONAL SPECIAL NEEDS PLAN
DEMONSTRATION PROGRAM
Present Law
Section 231 of the MMA established a new type of MA
coordinated care plan to focus on individuals with special
needs. SNPs are allowed to target enrollment to one or more
types of special needs individuals including individuals who
are institutionalized or who require nursing home level of
care. These types of SNPs are referred to as Institutionalized
SNPs (I-SNPs).
The Committee Bill
The Committee Bill requires the Secretary to conduct a
Community-Based Institutional Special Needs Plan demonstration
program aimed at preventing and delaying institutionalization
of Medicaid beneficiaries enrolled in plans participating in
the demonstration. The demonstration would include up to five
I-SNPs that have experience offering services to enrollees who
live in the community and are located in a state that has
agreed to participate in the demonstration. These participating
plans would be required to provide certain long term care
services and supports as a supplemental benefit to their
enrollees. The plans participating in the demonstration would
enroll beneficiaries who are eligible for the low-income
subsidy under Part D and who are unable to perform two or more
activities of daily living.
The demonstration would begin no later than January 1, 2016
and would last three years. An independent evaluation will be
required to determine whether the demonstration has reduced
hospitalization (or re-hospitalizations), Medicaid nursing home
facility stays, and spend down of income and assets for
purposes of becoming eligible for Medicaid. $3 million is made
available for the demonstration and $500,000 is available for
the evaluation.
SEC. 251. APPLYING CMMI WAIVER AUTHORITY TO PACE IN ORDER TO FOSTER
INNOVATIONS
Present Law
Section 3021 of the ACA created the CMMI within CMS. CMMI
is tasked with testing innovative payment and delivery system
reforms that improve quality or reduce costs. In order to test
innovations under CMMI, the Secretary is permitted to waive
requirements in titles XI and XVIII of the SSA but only three
specific portions of title XI: 1902(a)(1), 1902(a)(13), and
1903(m)(2)(A)(iii). CMMI is not permitted to waive the Medicaid
requirements of the Programs of All-Inclusive Care for the
Elderly (PACE) program.
The PACE program is a provider-based program that serves
frail, elderly Medicare and Medicaid beneficiaries. PACE
providers receive separate payments from Medicare and Medicaid
and provide both Medicare and Medicaid services. The
eligibility to receive services from a PACE provider is more
stringent than Medicare and Medicaid eligibility standards.
Individuals eligible to enroll must: (1) be 55 years of age or
older, (2) require the level of care for nursing home coverage
under a state Medicaid program, and (3) reside in the service
area of a PACE program.
The Committee Bill
The Committee Bill provides the Secretary the authority to
waive applicable Medicaid requirements of the PACE program in
order to conduct demonstration projects through CMMI that
involve PACE. The Committee Bill prohibits the Secretary from
waiving the requirement to offer items and services covered
under Medicare (1934(b)(1)(A)) and the requirements regarding
enrollment in and disenrollment from PACE programs (1934(c)(5))
as part of a CMMI demonstration.
SEC. 252. IMPROVE AND MODERNIZE MEDICAID DATA SYSTEMS AND REPORTING
Present Law
Current law includes data system requirements applicable to
states and the Secretary; however, current law does not
specifically require the Secretary to submit a Medicaid data
systems strategic plan to Congress. Under section 4735 of the
BBA states were required to submit Medicaid data to CMS using
the Medicaid Statistical Information System (MSIS), thus
creating some common data definitions and standards. More
recently, section 6405 of the ACA strengthened this provision
by requiring states to include data elements the Secretary
determines necessary for program integrity, program oversight,
and administration, including managed care encounter data.
Each state has its own MSIS which it uses to process claims
and monitor service use, but CMS maintains a national MSIS for
all states. MSIS is the only nationwide Medicaid eligibility
and claims database, although CMS is developing other data
systems to help monitor and assist states in administering the
Medicaid program. The GAO and the HHS OIG have identified MSIS
data shortcomings such as inaccuracies, insufficient data for
conducting program integrity functions, redundancy, and
outdated information. CMS initiated a pilot, call Transformed-
MSIS (T-MSIS), in March 2011 as a continuation of past MSIS
improvement efforts. CMS indicated that it plans to transition
all states to T-MSIS by July 1, 2014. In a March 2011 report,
the Medicaid and CHIP Payment Advisory Commission recommended
that CMS implement a strategic plan to address redundancies and
gaps in Medicaid data.
Committee Bill
The Committee Bill directs the Secretary to implement a
strategic plan to increase the usefulness of data about state
Medicaid programs reported by states to CMS. The strategic plan
would address redundancies and gaps in Medicaid data systems
and reporting through improvements to, and modernization of,
computer and data systems. Areas for improvement under the plan
would include the following: (1) the reporting of encounter
data by managed care plans; (2) the timeliness and quality of
reported data, including enrollment data; (3) the consistency
of data reported from multiple sources; and (4) information
about state program policies. Within a year of enactment of the
Committee Bill, the Secretary is required to submit a report to
Congress on the status of the implementation of the strategic
plan.
SEC. 253. FAIRNESS IN MEDICAID SUPPLEMENTAL TRUSTS
Present Law
The Omnibus Budget Reconciliation Act of 1993 (OBRA93; P.L.
103-66) established two trusts that are commonly utilized by
individuals with disabilities to maintain assets while not
endangering their eligibility for public benefits.
Specifically, section 1396p(d)(4)(A) and section 1396p(d)(4)(C)
of the SSA, known as section (d)(4)(A) and (d)(4)(C) trusts
respectively, exempt the assets held therein from counting for
purposes of Medicaid and Supplemental Security Income
eligibility. A section (d)(4)(C) trust may be created by a
parent, grandparent, legal guardian, or individuals themselves,
and is held and managed by a third-party for the benefit of the
individual with a disability. However, a section (d)(4)(A)
trust may be created only by the parent, grandparent, legal, or
a court, not individuals themselves.
Committee Bill
The Committee Bill would allow an individual with a
disability, who otherwise qualifies for a section (d)(4)(A)
trust, to create the trust independently.
SEC. 254. HELPING ENSURE LIFE- AND LIMB-SAVING ACCESS TO PODIATRIC
PHYSICIANS
Present Law
For the purposes of Medicaid, a physician is a doctor of
medicine or osteopathy legally authorized to practice medicine
and surgery by the state in which he or she practices. The
definition does not include doctors of podiatric medicine. As a
result, foot and ankle care services provided by a podiatrist
are considered an optional benefit and are not covered by all
state plans.
Under Medicare, extra-depth shoes with inserts or custom
molded shoes with inserts for an individual with diabetes must
meet a number of conditions in order to be considered covered
services. The individual's managing physician must document
that the individual has peripheral neuropathy with evidence of
callus formation, a history of pre-ulcerative calluses, a
history of previous ulceration, foot deformity, or previous
amputation, or poor circulation. Additionally, the physician
must certify that the individual needs such shoes under a
comprehensive plan of care related to the diabetic condition. A
podiatrist or other qualified physician must prescribe the
particular type of shoes. The shoes must be fit and furnished
by a podiatrist or other qualified individual (such as a
pedorthist or orthotist, as established by the Secretary) who
is not the physician certifying the need for the shoes.
However, the physician certifying the need for shoes can also
fit and furnish them if the Secretary finds that the physician
is the only such qualified individual in the area.
Committee Bill
Effective upon the date of enactment, the Committee Bill
would amend Medicaid's definition of physician under section
1905(a)(5)(A) to include a doctor of podiatric medicine as
defined under section 1861(r) of Medicare. The Committee Bill
allows states requiring legislation to comply with the change
additional time to do so.
Effective for items and services furnished on or after
January 1, 2015, extra-depth shoes with inserts or custom
molded shoes with inserts for an individual with diabetes would
have to meet a different set of conditions in order to be
considered covered services. The physician managing the
individual's diabetic condition would have to:
(1) Document that the individual has diabetes,
(2) Certify that the individual is under a
comprehensive plan of care related to a diabetic
condition, and
(3) Document agreement with the prescribing
podiatrist or other qualified physician that the shoes
are medically necessary.
Additionally, the therapeutic shoes would have to be
prescribed by a podiatrist or other qualified physician who:
(1) Examines the individual and determines the
medical necessity for the individual to receive the
therapeutic shoes, and
(2) Communicates in writing to the individual's
managing physician that therapeutic shoes are medically
necessary as well as findings that the individual has
peripheral neuropathy with evidence of callus
formation, a history of pre-ulcerative calluses, a
history of previous ulceration, foot deformity,
previous amputation, or poor circulation.
The shoes would be fit and furnished by a podiatrist or
other qualified individual (such as a pedorthist or orthotist,
as established by the Secretary) who is not the physician
certifying the need for the shoes. However, the physician
certifying the need for the shoes would also be able to fit and
furnish them if the Secretary finds that the physician is the
only such qualified individual in the area.
SEC. 255. DEMONSTRATION PROGRAM TO IMPROVE COMMUNITY MENTAL HEALTH
SERVICES
Present Law
Under current law, CMS and the Substance Abuse and Mental
Health Services Administration (SAMHSA) collaborate on several
issues. Both the CMS Administrator and the SAMHSA Administrator
sit on the Task Force on Aging Research. The Secretary, acting
through the SAMHSA Administrator, is required to promote the
coordination of programs relevant to individuals with mental
illness or substance abuse, in part through liaisons with CMS.
The duties of the Director of SAMHSA's Center for Substance
Abuse Treatment include collaborating with the CMS
Administrator to promote integration of substance abuse
treatment into the mainstream of the health care system. The
Secretary is required to ensure that CMS, SAMHSA, and other
agencies coordinate the planning, funding, and implementation
of federal HIV programs.
There is no statutory definition of a behavioral health
clinic; however, statutory requirements do exist for three
similar types of facilities, each in the context of a specific
program (e.g., a grant or Medicare Part B). The first is a
mental health center, which must provide: services principally
to individuals residing in geographically defined service
areas; a series of specified outpatient services; 24-hour
emergency care services; day treatment, partial hospitalization
services, or psychosocial rehabilitation services; and
screening for patients being considered for admission to state
mental health facilities. Such services must be provided to any
individual residing or employed in the service area, regardless
of ability to pay; services must be available and accessible
promptly, as appropriate and in a manner which preserves human
dignity and assures continuity and high quality care. The
second is a community mental health center, which also provides
the services specified above for mental health centers; in
addition they must meet applicable state licensing or
certification requirements and provide at least 40 percent of
their services to individuals who are not Medicare
beneficiaries. The third is an emergency mental health center,
which must serve as a central receiving point for individuals
in need of emergency mental health services; provide necessary
mental health treatment or a referral for such treatment;
purchase any necessary equipment; and provide any necessary
training to the medical staff. Such centers may also establish
and train a mobile crisis intervention team.
States establish and administer their Medicaid programs and
determine the type, amount, duration, and scope of covered
services within broad federal guidelines. For example, states
must cover certain mandatory benefits and may choose to cover
optional benefits listed in Medicaid statute. In general,
Medicaid covered services must meet a ``statewideness''
requirement whereby states must provide the same amount,
duration and scope of coverage for a given benefit throughout
the entire state.
Federal Medicaid statute does not specify the exact types
of mental health services that can be reimbursed. However, all
state Medicaid programs cover some mental health services,
whether through state plan services, the Early and Periodic
Screening, Diagnostic and Testing benefit, or waiver programs.
Medicaid reimbursement is available for mental health services
under various Medicaid service categories, including: physician
services, inpatient and outpatient hospital services, clinics,
rehabilitative services, inpatient psychiatric hospital
services for individuals under age 21, and prescription drugs.
Examples of services in these categories include counseling,
therapy, medication management, psychiatrist services, licensed
clinical social work services, peer supports, and substance
abuse treatment. Individuals may receive services in their
homes, other residences, schools, or medical institutions, if
necessary.
The federal government and the states jointly finance
Medicaid. The federal government reimburses states for a
portion of each state's Medicaid program costs. The federal
government's share of most Medicaid expenditures is established
by the FMAP rate. A state's share of program spending for
Medicaid is equal to 100 percent minus the FMAP. CHIP is also
jointly financed by the federal government and the states using
a matching scheme. The federal government pays a larger share
for CHIP than it does for Medicaid. The enhanced FMAP (E-FMAP)
for CHIP means a state's share of expenditures is 30 percent
lower than under the regular FMAP.
Federal laws and regulations govern the time and manner in
which state Medicaid agencies pay providers. For most Medicaid
providers, states develop their own methodologies for making
Medicaid payments (e.g., they may pay providers by FFS, on a
capitated basis, or under a combination of both). Federally
qualified health centers (FQHCs) and rural health clinics
(RHCs), which provide health care services to populations in
areas where access to physician care has been limited, are
unique in Medicaid in that federal statute specifies their
reimbursement methodology referred to as a prospective payment
system (PPS). Since January 2002, the law requires that each
existing FQHC/RHC is entitled to a payment amount per visit
equal to the amount for the previous fiscal year increased by
the percentage increase in the Medicare Economic Index (MEI)
for primary care services, and adjusted to take into account
any change in the scope of services furnished.
For entities first qualifying as FQHCs and RHCs after 2000,
the per visit payments begin in the first year that the center
or clinic attains qualification and are based on 100 percent of
the costs incurred during that year and the rates established
for similar centers or clinics with similar caseloads in the
same or adjacent geographic areas. In the absence of such
similar centers or clinics, the methodology is based on that
used for developing rates for established FQHCs or RHCs or such
methodology or reasonable specifications as established by the
Secretary. For each fiscal year thereafter, per visit payments
for all FQHCs and RHCs are equal to amounts for the preceding
fiscal year increased by the percentage increase in the MEI
applicable to primary care services for that fiscal year, and
adjusted for any increase or decrease in the scope of services
furnished during that fiscal year. Under managed care
contracts, states must make supplemental payments to the center
or clinic equal to the difference between contracted amounts
and the cost-based amounts. States are allowed to establish
alternative payment methods but only when payments are at least
equal to the amounts that would otherwise be provided under the
PPS.
Committee Bill
The Committee Bill establishes a five-year demonstration
program for up to ten states, setting new criteria for
community behavioral health providers and allowing them to be
reimbursed for a broad range of services. The Secretary, in
coordination with the Administrator of SAMHSA, would award
planning grants to the selected states.
To be eligible, states would be required to submit an
application to the Secretary, conduct a financial assessment,
comply with any other requirements as established by the
Secretary, and certify that the behavioral health providers
under the demonstration program meet certain specified criteria
for certified clinics. States would also have to certify that
providers of community mental health services meet new criteria
and offer specific behavioral health services. Those services
would then be reimbursed under Medicaid using a PPS based on
the PPS for FQHCs under section 1902(bb) of the SSA. Those
services would also be eligible for an enhanced federal match
rate as defined under section 2105(b). In selecting states for
the demonstration, considerations will be made for geographic
diversity of participating states, including representation of
certified clinics in rural and other underserved areas within
those states. The Secretary would be able to waive the Medicaid
statewideness requirement, which would permit states to offer
different service packages in different areas.
The certified clinics would have to provide a number of
services under the new criteria including: (1) crisis
psychiatric services available on a 24-hour basis as well as
psychiatric screenings; (2) evidence-based and integrated
treatment for mental illness, substance abuse, and trauma
including cognitive behavioral therapy, applied behavioral
analysis, and medication management; (3) peer support and
counselor services for individuals and families; and (4)
integrated preventive screenings for diabetes, hypertension,
and cardiovascular disease.
The certified clinics would have to meet a number of
additional requirements under the new criteria, including to:
(1) demonstrate the capacity to comply with behavioral health
and related healthcare quality measures; (2) form linkages or
formal contracts with FQHCs, VA facilities, acute care
hospitals, psychiatric hospitals, and other providers and
social service organizations; and (3) provide outreach,
engagement, and intensive community-based mental healthcare for
members of the armed forces and veterans, particularly in rural
areas.
The Committee Bill authorizes $50 million to be
appropriated to carry out this section.
SEC. 256. ANNUAL MEDICAID DSH REPORT
Present Law
The Medicaid statute requires states make disproportionate
share hospital (DSH) payments to hospitals treating large
numbers of low-income patients. While most federal Medicaid
funding is provided on an open-ended basis, federal Medicaid
DSH funding is capped. Each state receives an annual federal
DSH allotment, which is the maximum amount of federal matching
funds that each state can claim for Medicaid DSH payments. In
FY2013, the federal DSH allotments to states totaled $11.5
billion. Medicaid DSH allotments will be reduced by $1.2
billion in FY2016, $1.8 billion in FY2017, $5 billion in
FY2018, $5.6 billion in FY2019, and $4.0 billion for FY2020
through FY2023. Under current law, in FY2024, states' DSH
allotments will rebound to their pre-2014 reduced levels with
the annual inflation adjustments for FY2014 to FY2024.
Currently, federal statute requires states submit annual
reports identifying each DSH hospital and other information as
the Secretary determines necessary, which includes hospital-
specific information such as Medicaid inpatient utilization
rate and amount of uncompensated care.
Committee Bill
Under the Committee Bill, beginning January 1, 2015, the
Secretary would annually submit a report to Congress on the
Medicaid DSH payments for the purpose of providing Congress
with information relevant to determining an appropriate level
of overall funding for the payment adjustments during and after
2014-2022, the period in which reductions to the DSH allotments
are made.
Each report would have to include: (1) information
regarding changes in the number of uninsured individuals over
time; (2) information on the extent to which hospitals continue
to incur uncompensated care costs; (3) the extent to which
hospitals continue to provide charity care and incur bad debt;
(4) in the first report submitted, a methodology for estimating
the amount of unpaid patient deductibles, copayments, and
coinsurance incurred by hospitals for patients enrolled in
qualified health plans and in subsequent reports, data
regarding such uncompensated care costs collected pursuant to
such methodology; (5) for each state, the difference between
the aggregate amount of uncompensated care costs for all
disproportionate share hospitals and the state's DSH allotment
in the prior year; (6) the extent to which there are certain
vital hospitals that are disproportionately experiencing high
levels of uncompensated care; and (7) any other relevant
information on the appropriate level and allocation of funding
that the Secretary determines appropriate.
SEC. 257. IMPLEMENTATION
Present Law
When Congress enacts legislation, Congress often grants
rulemaking authority to agencies, and agencies use that
authority to set standards and prescribe the details of certain
federal policies and programs. In issuing those regulations,
agencies are generally required to follow a certain set of
procedures that Congress has enacted into law. The most long-
standing and broadly applicable federal rulemaking requirements
are in the Administrative Procedure Act of 1946 (APA, P.L. 79-
404).
In general, the APA requires agencies to issue a notice of
proposed rulemaking (NPRM) prior to issuing a final rule (5
U.S.C. Sec. 553(b)). Under the APA, the NPRM must contain
either the ``terms or substance of the proposed rule'' or ``a
description of the subjects and issues involved.'' The APA
contains some exceptions to that requirement, including
``interpretative rules, general statements of policy, or rules
of agency organization, procedure, or practice''; or ``when the
agency for good cause finds . . . that notice and public
procedure thereon are impracticable, unnecessary, or contrary
to the public interest.''
Following the notice of proposed rulemaking, agencies are
generally required to take comments on the NPRM (5 U.S.C.
Sec. 553(c)). However, the same exceptions apply to the comment
period that apply to the issuance of an NPRM (see above). The
APA does not specify a minimum duration for the comment period.
Unless specified in statute, the agency may determine the
length of a comment period for a given rule, so long as it
gives the public a meaningful opportunity to participate.
Similarly, the APA does not require agencies to issue their
rules under any particular timeline. In many cases, agencies
are required by or permitted under statute to issue rules
without any deadlines.
Section 553(d) of the APA requires that, with some
exceptions, agencies must have a 30-day period following the
publication date of a rule before it can become effective. The
APA's exceptions to that requirement are ``(1) a substantive
rule which grants or recognizes an exemption or relieves a
restriction; (2) interpretative rules and statements of policy;
or (3) as otherwise provided by the agency for good cause found
and published with the rule.''
Committee Bill
The Committee Bill would establish requirements for the
issuance of implementing regulations for any section of the
Bill. The Secretary would be required to, unless otherwise
specified in the Committee Bill: (1) issue a notice of proposed
rulemaking that includes the proposed regulation; (2) provide a
period of not less than 60 calendar days for comments on the
proposed regulation; and (3) publish the final regulation or
take alternative action (such as withdrawing the rule or
proposing a revised rule with a new comment period) on the
proposed regulation, not more than 24 months following
publication of the proposed rule and not less than 30 calendar
days before the effective date of such final regulation.
LIST OF TERMS
ACA: The Patient Protection and Affordable Care Act (P.L. 111-
148); the health care provisions of the Health Care and
Education Reconciliation Act of 2010 (P.L. 111-152)
APA: The Administrative Procedures Act of 1946 (P.L. 79-404)
APM: Alternative payment model
ARRA: The American Recovery and Reinvestment Act of 2009 (P.L.
111-5)
ATRA: The American Taxpayer Relief Act (P.L. 112-240)
BBA: The Balanced Budget Act of 1997 (P.L. 105-33)
BPBA: The Bipartisan Budget Act of 2013 (P.L. 113-67)
CAH: Critical access hospital
CMMI: The Center for Medicare and Medicaid Innovation
CMS: The Centers for Medicare and Medicaid Services
C-SNP: Medicare Advantage special needs plan for individuals
with specific, severe or disabling chronic conditions
DRA: The Deficit Reduction Act of 2005 (P.L. 109-171)
D-SNP: Medicare Advantage special needs plan for individuals
who are eligible for Medicare and Medicaid
EHR: Electronic health record
ERISA: Employee Retirement Insurance Security Act of 1974 (P.L.
93-406)
FFS: Fee-for-service
FIDE-SNP: a subset of D-SNPs that must fully integrate Medicare
and Medicaid benefits, including long-term care services
and supports, and have a contract with the state Medicaid
program among other requirements
FMAP: Federal Medical Assistance Percentage
FOIA: The Freedom of Information Act of 1996 (P.L. 104-231)
FQHC: Federally qualified health center
GAO: Government Accountability Office
GPCI: Geographic practice cost index
HCFAC: Health Care Fraud and Abuse Control Program
HCPCS: Healthcare Common Procedure Coding System
HHS OIG: Office of the Inspector General of the Department of
Health and Human Services
HI: Hospital insurance; benefits of Part A of the Medicare
program
HIPAA: The Health Insurance Portability and Accountability Act
of 1996 (P.L. 104-191)
HOPD: Hospital outpatient department
HPSA: Health professional shortage area
IPPS: Inpatient prospective payment system
I-SNP: Medicare Advantage special needs plan for individuals
who are institutionalized
MA: Medicare Advantage
MAC: Medicare administrative contractor
MCTRJCA: The Middle Class Tax Relief and Job Creation Act of
2012 (P.L. 112-96)
MDH: Medicare dependent hospital
MedPAC: The Medicare Payment Advisory Commission
MEI: Medicare economic index
MIPPA: The Medicare Improvements for Patients and Providers Act
of 2008 (P.L. 110-275)
MMA: The Medicare Prescription Drug, Improvement and
Modernization Act (P.L. 108-173)
MMIS: Medicaid Management Information System
MSIS: Medicaid Statistical Information System
MVPS: Medicare volume performance standard
NCQA: National Committee on Quality Assurance
NDNH: National Directory of New Hires
NPI: National provider identifier
NPRM: Notice of proposed rulemaking
OBRA89: The Omnibus Budget Reconciliation Act of 1989 (P.L.
101-239)
OBRA93: The Omnibus Budget Reconciliation Act of 1993 (P.L.
103-66)
OCSE: Federal Office of Child Support Enforcement
OE: Improper payment outreach and education program
OPPS: Outpatient prospective payment system
PDE: Prescription drug event
PI: Program integrity
PPS: Prospective payment system
PQRS: Physician Quality Reporting System
QE: Qualified entity
RAC: Recovery audit contractor
RBRVS: Recourse-based relative value scale
RHC: Rural health clinic
RUC: The American Medical Association/Specialty Society
Relative Value Scale Update Committee
RVU: Relative value unit
SAMHSA: The Substance Abuse and Mental Health Services
Administration
SGR: The Sustainable Growth Rate
SMI: Supplementary medical insurance; benefits of Part B of the
Medicare program
SNP: Medicare Advantage special needs plan
SSA: The Social Security Act of 1935 (P.L. 74-271)
TIN: Tax identification number
TRHCA: The Tax Relief and Health Care Act of 2006 (P.L. 109-
432)
VBM: Value-based payment modifier
VBP: Value-based performance incentive program
III. BUDGET EFFECTS OF THE BILL
Information Relating to Unfunded Mandates
The statement of unfunded mandates from the Director of the
Congressional Budget Office was not available at the time the
Committee Report was submitted. Pursuant to section 423(f)(2)
of the Unfunded Mandates Act of 1995 (P.L. 104-4) the statement
will be published in the Congressional Record in advance of
floor consideration of the Committee Bill.
Cost Estimate
Pursuant to paragraph 11(a) of the Rule XXVI of the
Standing Rules of the Senate, a Congressional Budget Office
report related to the cost of the Committee Bill must accompany
this report. An estimate of the cost of the Chairman's Mark,
made available to the public on December 10, 2013, is provided.
Because an updated estimate of the cost of the legislation by
the Congressional Budget Office was not available at the time
the report was submitted, it was impracticable to provide an
estimate of the cost of the Committee Bill under paragraph
11(a) of Rule XXVI of the Standing Rules of the Senate. An
estimate of the cost of the Committee Bill will be made
available.
ADDITIONAL CLARIFICATIONS PROVIDED BY THE STAFF OF THE SENATE FINANCE
COMMITTEE
ENCOURAGING CARE MANAGEMENT FOR INDIVIDUALS WITH CHRONIC CARE NEEDS
There is a discrepancy between the Chairman's Mark
and the legislative text of S. 1871, the SGR Repeal and
Medicare Beneficiary Access Improvement Act. Page 27 of the
Chairman's Mark states that applicable providers eligible to
receive payments for chronic care management include doctors of
medicine and osteopathy, doctors of dental surgery and dental
medicine, doctors of podiatry and optometry, and chiropractors.
This was arrived at by inadvertently listing all of the health
care professionals defined in section 1861(r) of the SSA.
However, the correct citation is section 1861(r)(1), and that
mistake was corrected in the legislative text, which references
section 1861(r)(1). The legislative text is correct in defining
those physician types that are eligible to receive payments for
chronic care management as doctors of medicine and osteopathy
because those are the two categories of professionals who can
provide these services contemplated in the provision.
The legislative text contains the correct definition of
applicable providers eligible to receive chronic care
management payments. In addition to doctors of medicine and
osteopathy, the legislation specifies that nurse practitioners,
clinical nurse specialists, and physician assistants are also
applicable providers. Professionals receiving chronic care
management payments would be accountable for coordinating a
patient's care across the spectrum of health care settings. For
this reason, the legislation specifies that only one provider
can receive this payment for a given patient. Additionally,
providers would have to practice in a patient-centered medical
home or comparable specialty practice to receive the payment.
REQUIRING STATE LICENSURE OF BIDDING ENTITIES UNDER THE COMPETITIVE
ACQUISITION PROGRAM FOR CERTAIN DURABLE MEDICAL EQUIPMENT, PROSTHETICS,
ORTHOTICS, AND SUPPLIES (DMEPOS)
An amendment submitted by Senator Roberts and
Senator Thune was modified, accepted, and reflected in the
Committee Bill as section 247.
IV. VOTES OF THE COMMITTEE
In compliance with paragraph 7(b) of Rule XXVI of the
Standing Rules of the Senate, the Committee states that, with a
majority and quorum present, the ``SGR Repeal and Medicare
Beneficiary Access Improvement Act of 2013'' was amended and
ordered favorably reported as follows:
The Committee on Finance met on December 12, 2013 to
consider an original bill entitled, ``SGR Repeal and Medicare
Beneficiary Access Improvement Act of 2013.''
The Chairman's Mark was modified and amended as follows:
Amendment 8, Wyden/Isakson 1
The Better Care, Lower Cost Delivery System for Medicare
Beneficiaries with Multiple Chronic Conditions.
Amendment withdrawn.
Amendment 89, Roberts/Casey 1
Expansion of MTM Targeted Beneficiary.
Amendment withdrawn.
Amendment 119, Thune/Enzi 3
Requiring Interoperability in the Meaningful Use Program by
2017.
Amendment withdrawn.
Amendment 45, Menendez/Brown 9
To make the Family-to-Family Health Information Centers and the
Maternal, Infant and Early Childhood Visitation program
permanent.
Amendment withdrawn.
Amendment 126, Isakson 1
Demonstration Project to Test Physician Private Contracting in
Medicare.
Amendment withdrawn.
Amendment 49, Carper/Toomey/Brown 4
Improvements to Medicare Procedures to Prevent Fraudulent
Diversion and Medically Unnecessary or Unsafe Use of
Prescription Drugs.
Amendment withdrawn.
Amendment 32, Nelson/Schumer/Stabenow/Menendez/Casey 1
Residency Physician Shortage Reduction.
Amendment withdrawn.
Amendment 56, Cardin/Portman 4
To encourage the use of efficient dispensing techniques for
long-term care pharmacies.
Amendment withdrawn.
Amendment 105, Cornyn 1
Protect seniors from a board of 15 bureaucrats empowered to
make substantial changes to the Medicare without full
transparency and accountability.
Amendment withdrawn.
Amendment 61, Bennet/Cornyn/Isakson 1
To incentivize states to achieve reductions in future health
care cost growth while improving quality.
Amendment withdrawn.
Amendment 135, Toomey/Carper/Cornyn 1
Standard of Care Protection.
Amendment withdrawn.
Amendment 67, Casey/Rockefeller/Brown/Wyden 1
Performance Bonus Payment to Offset Additional Medicaid and
CHIP Enrollment Costs Resulting from Enrollment and
Retention Efforts.
Amendment withdrawn.
Amendment 99, Enzi 3
An amendment to require the Department of Health and Human
Services (HHS) and the Centers for Medicare and Medicaid
Services (CMS) to seek public comment on whether proposed
Medicare payment policies will increase or decrease the
consolidation of health care providers.
Amendment withdrawn.
Amendment 74, Grassley/Bennett/Toomey/Nelson/Portman/
Rockefeller/Casey/Brown/Cantwell 5
Coordinated Care for Medically Complex Children.
Amendment withdrawn.
Amendment 102, Enzi 6
An amendment to modernize the Medicare benefit through
bipartisan, common-sense reforms.
Amendment withdrawn.
Amendment 10, Wyden/Isakson/Carper/Grassley 3
An Amendment to Improve Medicare Advantage Risk Adjustment.
Amendment withdrawn.
Amendment 16, Wyden/Portman/Carper/Enzi 9
An Amendment to Include S. 1228: Medicare Better Health Rewards
Program Act of 2013.
Amendment withdrawn.
Amendment 132, Portman/Brown/Stabenow 1
Health Coverage Tax Credit Extension.
Amendment withdrawn.
Amendment 26, Stabenow/Casey 2
To clarify payments for drugs under Medicare Part B by
excluding prompt pay discounts from Average Sales Price.
Amendment withdrawn.
Amendment 90, Roberts/Enzi 2
Clarification of 96 Hour Rule for Critical Access Hospital
Conditions of Participation.
Amendment withdrawn.
Amendment 66, Bennet/Cornyn 6
To better inform taxpayers about their individual Medicare
contributions and benefits by including information in a
yearly statement they already receive about Social
Security.
Amendment withdrawn.
Amendment 134, Portman 3
Amendment to Improve Coordination in Behavioral Health
Information Technology.
Amendment withdrawn.
Amendment 27, Stabenow 3
To postpone the rebasing of home health payments to allow for
further evaluation.
Amendment withdrawn.
Amendment 129, Isakson 4
Strike Extension of Health Workforce Demonstration Project.
Amendment withdrawn.
Amendment 137, Toomey/Casey 3
Preserving Access to Orphan Drugs.
Amendment withdrawn.
Amendment 52, Carper/Grassley 7
Increasing Patient Medication Education and Adherence.
Amendment withdrawn.
Amendment 70, Grassley/Wyden 1
Transition to Independence Medicaid Demonstration.
Amendment withdrawn.
Amendment 79, Grassley/Rockefeller/Carper 10
Prevention of Diabesity Amendment.
Amendment withdrawn.
Amendment 69, Casey/Crapo 3
Delay of CMS CY14 HOPPS Final Rule Implementation of Skin
Substitute Bundling for Advanced Therapeutic Wound Healing
Products.
Amendment withdrawn.
Amendment 25, Stabenow/Grassley 1
To improve quality, and expand access to community mental
health services.
Approved by voice vote.
Amendment 18, Schumer/Grassley 1
Rural Hospital Access Act.
Approved by unanimous voice vote.
Amendment 118, Thune/Casey/Enzi 2
To provide a demonstration project on remote patient monitoring
(RPM) in the Medicare program to ensure seniors can remain
in their homes longer and to prevent hospital readmissions.
Approved by unanimous voice vote.
Amendment 82, Grassley 13
Full GPCI Permanence.
Approved by unanimous voice vote.
Amendment 4, Rockefeller/Brown/Casey 4
Transitional Medical Assistance Substitution and Improvement.
Approved by voice vote.
Amendment 21, Schumer/Grassley/Cardin/Stabenow 4
Helping Ensure Life- and Limb-Saving Access to Podiatric
Physicians (HELLPP) Act.
Approved by voice vote.
Amendment 120, Thune/Rockefeller 4
Providing Additional Technical Assistance to Small Rural
Practices in the Value Based Performance (VBP) Program
Approved by unanimous voice vote.
The Chairman's Mark, as amended, was ordered favorably reported
by a voice vote.
V. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED
In the opinion of the Committee, in order to expedite the
business of the Senate, it is necessary to dispense with the
requirements of paragraph 12 of Rule XXVI of the Standing Rules
of the Senate (relating to the showing of changes in existing
law made by the bill as reported by the Committee).