Authorizes the Secretary, for items and services furnished on or after January 1, 2003, to adjust the amount of the payments made under Medicare to such health care providers in order to encourage their provision of services in a medically appropriate manner and to discourage significant deviations in underservice or overservice from generally accepted norms of medical practice.
Amends Medicare part C (Medicare+Choice) to provide for adjustment in Medicare+Choice payment rates to overpaid counties.
Provides that for a contract year consisting of a calendar year beginning on or after January 1, 2000, for which the Secretary has determined there is an overpaid payment area, the Secretary shall adjust the annual per capita rate of payment for specified Medicare+Choice payment areas to increase the blended capitation rate applicable to such areas under Medicare+Choice blended capitation rates by the aggregate amount of reductions in payments attributable to this Act.
Directs the Secretary to: (1) provide for coverage of outpatient prescription drugs to eligible Medicare beneficiaries and to provide for such coverage by entering into agreements with eligible organizations to furnish such coverage; (2) provide coverage of outpatient prescription drugs to such a beneficiary for a specified period beginning when such beneficiary loses coverage of outpatient prescription drugs under the Medicare+Choice plan in which they are enrolled; and (3) impose specified cost-sharing requirements under coverage of outpatient prescription drugs.
Establishes in the Federal Supplementary Medical Insurance Trust Fund under Medicare the Emergency Reserve Outpatient Prescription Drug Account, consisting of specified amounts deposited in the Trust Fund, including amounts attributable to reductions in provider overpayments, to pay for outpatient prescription drugs.
[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3086 Introduced in House (IH)]
106th CONGRESS
1st Session
H. R. 3086
To direct the Secretary of Health and Human Services to make changes in
payment methodologies under the Medicare Program under title XVIII of
the Social Security Act, and to provide for short-term coverage of
outpatient prescription drugs to Medicare beneficiaries who lose drug
coverage under Medicare+Choice plans.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
October 14, 1999
Mrs. Thurman (for herself and Mr. McDermott) introduced the following
bill; which was referred to the Committee on Ways and Means, and in
addition to the Committee on Commerce, for a period to be subsequently
determined by the Speaker, in each case for consideration of such
provisions as fall within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To direct the Secretary of Health and Human Services to make changes in
payment methodologies under the Medicare Program under title XVIII of
the Social Security Act, and to provide for short-term coverage of
outpatient prescription drugs to Medicare beneficiaries who lose drug
coverage under Medicare+Choice plans.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Medicare Benefit Equity and
Emergency Access to Prescription Drugs Act of 1999''.
SEC. 2. FINDINGS.
Congress finds as follows:
(1) American taxpayers should receive equal Medicare
services regardless of place of residence.
(2) Medicare managed care plans play a fundamental role in
the health of our Nation's seniors, often providing coordinated
care and access to pharmaceuticals. The loss of Medicare
managed care plans and their services can be devastating to our
Nation's Medicare-eligible seniors.
(3) For the second consecutive year, Medicare managed care
plans are abandoning hundreds of thousands of medicare
beneficiaries. The most recent announcement of plan
cancellations means that within the past two years, 734,000 of
the Nation's 6,200,000 Medicare beneficiaries enrolled in
managed care plans will have been dropped from those plans.
(4) In 1999, Medicare managed care plan withdrawals
affected nearly 407,000 Medicare beneficiaries, and 51,276
beneficiaries in 79 counties were left with no other Medicare
managed care option.
(5) Beginning January 2000, another 327,000 enrollees will
need to find alternative coverage, and 79,000 of these Medicare
managed care participants will have no other Medicare+Choice
plan available.
(6) Medicare beneficiaries who have lost their managed care
option can enroll in Medicare fee-for-service; however,
Medicare fee-for-service does not currently provide
comprehensive outpatient pharmaceutical coverage.
(7) While all beneficiaries pay the same medicare part B
premium as other program participants, Medicare beneficiaries
regularly pay managed care plans varied amounts and receive
very unequal services and benefits.
(8) A growing body of data suggests that medical practice
and Medicare spending vary substantially among the Nation's
hospital referral regions, even after adjustments for
differences in regional prices and illness rates, but there is
little evidence that greater spending brings better health.
(9) By adjusting Medicare reimbursement payment rates
(adjusted for age, sex, severity of illness, etc.,) and
lowering Medicare reimbursement payment to providers and
regions where there are more costly patterns of practice
without better health outcomes, Congress can provide more
equitable and efficient health care for our Nation's 39,000,000
Medicare beneficiaries.
(10) Such a strategy will encourage a more responsible
practice of medicine at the lowest cost to the taxpayer and
Medicare beneficiary, and will free resources for improvements
to the medicare program.
SEC. 3. MEDICARE CLINICAL PRACTICE AND PAYMENT PATTERN ADJUSTMENT.
(a) Establishment of Practice Profiles.--
(1) In general.--By not later than January 1, 2002, the
Secretary of Health and Human Services shall establish clinical
profiles of the practice and payment patterns of health care
providers (including both institutional providers and health
care professionals) furnishing items and services under the
medicare program under title XVIII of the Social Security Act
in order to determine how their practice and payment patterns
compare to each other on a local, State, and national basis. In
establishing such profiles, the Secretary shall take into
account differences in the case mix and severity of patients
served by such providers and shall take into account, to the
extent practicable, the medical outcomes resulting from such
practices.
(2) Dissemination of information.--The Secretary shall
establish a method for disseminating summary information to the
public on the clinical profiles established under paragraph
(1). No information that identifies (or permits the
identification of) an individual patient shall be disseminated.
(b) Authority To Make Payment Adjustments.--For items and services
furnished on or after January 1, 2003, the Secretary of Health and
Human Services may adjust the amount of the payments made under the
medicare program to such health care providers in order to encourage
their provision of services in a medically appropriate manner and to
discourage significant deviations in underservice or overservice from
generally accepted norms of medical practice. Such adjustments shall be
made on the basis of provider profiles established under subsection (a)
and shall be made only after--
(1) taking into account variations among providers in the
case mix and severity of patients served; and
(2) the Secretary determines that discouraging particular
patterns of overservice will not adversely affect outcomes or
quality of care.
(c) Schedule To Reduce Overpayments.--
(1) In general.--For items and services furnished on or
after January 1, 2004, the Secretary shall annually reduce
overpayments to providers by five percent of the overpayment
amount (as defined in paragraph (2)). Such reduction shall be
administered through a percentage reduction in the providers'
applicable payment methodology.
(2) Overpayment amount defined.--In this subsection, the
term ``overpayment amount'' means a health care provider's
payment profile minus the median national payment profiles for
similar health care providers, adjusted for variations in case
mix and severity of patients served.
SEC. 4. ADJUSTMENT IN MEDICARE+CHOICE PAYMENT RATES TO OVERPAID
COUNTIES.
(a) In General.--Section 1853(c)(1)(C) of the Social Security Act
(42 U.S.C. 1395w-23(c)(1)(C)) is amended--
(1) in clause (ii), by striking ``For a subsequent year,''
and inserting ``Subject to clause (iii), for a subsequent
year,''; and
(2) by adding at the end the following new clause:
``(iii) In the case of a year beginning
after 1999 for which the Secretary determines
there is an overpaid payment area (as defined
in paragraph (8)), the following:
``(I) In the case of such overpaid
payment area, 100.5 percent of the
annual Medicare+Choice capitation rate
under this paragraph for the area for
the previous year.
``(II) In the case of a payment
area that is not an overpaid payment
area, 102 percent of the annual
Medicare+Choice capitation rate under
this paragraph for the area for the
previous year.''.
(b) Overpaid Payment Area Defined.--Section 1853(c) of such Act (42
U.S.C. 1395w-23(c)) is amended by adding at the end the following new
paragraph:
``(8) Overpaid payment area defined.--For purposes of
paragraph (1)(C)(iii), the term `overpaid payment area' means a
Medicare+Choice payment area for a year for which the annual
per capita rate of payment for such area exceeds the mean of
the annual per capita rates of payments for all Medicare+Choice
payment areas for that year by more than two standard
deviations, such mean determined without regard to the number
of Medicare beneficiaries in such payment areas.''.
(c) Allocation of Savings to Underpaid Counties.--For a contract
year consisting of a calendar year beginning on or after January 1,
2000, for which the Secretary of Health and Human Services has
determined there is an overpaid payment area (as defined in section
1853(c)(8)), as added by subsection (b), the Secretary shall adjust the
annual per capita rate of payment for Medicare+Choice payment areas
described in section 1853(c)(1)(C)(iii)(II), as added by subsection
(a), to increase the blended capitation rate applicable to such areas
under section 1853(c)(1)(A) (in such pro rata manner as the Secretary
determines appropriate) by an aggregate amount equal to the aggregate
amount of reductions in payments attributable to section
1853(c)(1)(C)(iii)(I), as added by subsection (a).
SEC. 5. PROVISION OF EMERGENCY OUTPATIENT PRESCRIPTION DRUG COVERAGE
FOR MEDICARE BENEFICIARIES LOSING DRUG COVERAGE UNDER
MEDICARE+CHOICE PLANS.
(a) Temporary Coverage of Outpatient Prescription Drugs for
Medicare Beneficiaries Losing Prescription Drug Coverage Under
Medicare+Choice Plans.--
(1) In general.--The Secretary of Health and Human Services
shall provide for coverage of outpatient prescription drugs to
eligible Medicare beneficiaries under this section. The
Secretary shall provide for such coverage by entering into
agreements with eligible organizations to furnish such
coverage.
(2) Term of emergency coverage.--The Secretary shall
provide coverage of outpatient prescription drugs to an
eligible Medicare beneficiary under this section for the 18-
month period beginning on the date the eligible Medicare
beneficiary loses coverage of outpatient prescription drugs
under the Medicare+Choice plan in which the beneficiary is
enrolled.
(3) Cost-sharing.--The Secretary shall impose the following
cost-sharing requirements under coverage of outpatient
prescription drugs furnished under this section:
(A) Benefits under this section shall not begin
until the eligible medicare beneficiary has met a $50
deductible.
(B) The eligible Medicare beneficiary shall pay
coinsurance in the amount of 10 percent.
(4) Payment.--The Secretary shall provide for payment for
such coverage under this section from the Emergency Reserve
Outpatient Prescription Drug Account established under
subsection (b).
(b) Account for Emergency Outpatient Prescription Drug Benefit in
SMI Trust Fund.--
(1) Establishment.--There is hereby established in the
Federal Supplementary Medical Insurance Trust Fund under
section 1841 of the Social Security Act (42 U.S.C. 1395t) an
expenditure account to be known as the ``Emergency Reserve
Outpatient Prescription Drug Account''.
(2) Crediting of funds.--The Managing Trustee shall credit
to the Emergency Reserve Outpatient Prescription Drug Account
such amounts as may be deposited in the Federal Supplementary
Medical Insurance Trust Fund as follows:
(A) Amounts appropriated to the account.
(B) Amounts equal to the annual outstanding balance
of the Health Care Fraud and Abuse Control Account
under section 1817(k) of the Social Security Act (42 U.S.C. 1395i(k))
at the end of each fiscal year that the Secretary determines may be
made available to the Emergency Reserve Outpatient Prescription Drug
Account.
(C) Amounts attributable to reductions in payments
to providers under section 3(c) of this Act.
(3) Use of funds.--Funds credited to the Outpatient
Prescription Drug Account may only be used to pay for
outpatient prescription drugs furnished under this section.
(c) Definitions.--In this section:
(1) Eligible medicare beneficiary.--The term ``eligible
Medicare beneficiary'' means an individual--
(A) who is enrolled in a Medicare+Choice plan under
part C of title XVIII of the Social Security Act;
(B) who requires outpatient prescription drugs for
an extended period of time for the treatment of a
condition, as determined by a physician; and
(C)(i) whose enrollment in such plan is terminated
or may not be renewed for the next contract year
because the plan has been terminated or will not be
offered in such contract year; or
(ii) whose coverage of outpatient prescription
drugs under such plan has been terminated,
significantly reduced, or no longer provides for the
coverage of a particular outpatient prescription drug
required as specified under subparagraph (B).
(2) Covered outpatient drug.--
(A) In general.--Except as provided in subparagraph
(B), the term ``covered outpatient drug'' means any of
the following products:
(i) A drug which may be dispensed only upon
prescription, and--
(I) which is approved for safety
and effectiveness as a prescription
drug under section 505 of the Federal
Food, Drug, and Cosmetic Act;
(II)(aa) which was commercially
used or sold in the United States
before the date of enactment of the
Drug Amendments of 1962 or which is
identical, similar, or related (within
the meaning of section 310.6(b)(1) of
title 21 of the Code of Federal
Regulations) to such a drug, and (bb)
which has not been the subject of a
final determination by the Secretary
that it is a ``new drug'' (within the
meaning of section 201(p) of the
Federal Food, Drug, and Cosmetic Act)
or an action brought by the Secretary
under section 301, 302(a), or 304(a) of
such Act to enforce section 502(f) or
505(a) of such Act; or
(III)(aa) which is described in
section 107(c)(3) of the Drug
Amendments of 1962 and for which the
Secretary has determined there is a
compelling justification for its
medical need, or is identical, similar,
or related (within the meaning of
section 310.6(b)(1) of title 21 of the
Code of Federal Regulations) to such a
drug, and (bb) for which the Secretary
has not issued a notice of an
opportunity for a hearing under section
505(e) of the Federal Food, Drug, and
Cosmetic Act on a proposed order of the
Secretary to withdraw approval of an
application for such drug under such
section because the Secretary has
determined that the drug is less than
effective for all conditions of use
prescribed, recommended, or suggested
in its labeling.
(ii) A biological product which--
(I) may only be dispensed upon
prescription;
(II) is licensed under section 351
of the Public Health Service Act; and
(III) is produced at an
establishment licensed under such
section to produce such product.
(iii) Insulin approved under appropriate
Federal law.
(iv) A prescribed drug or biological
product that would meet the requirements of
clause (i) or (ii) but that is available over-
the-counter in addition to being available upon
prescription.
(B) Exclusion.--The term ``covered outpatient
drug'' does not include any product--
(i) except as provided in subparagraph
(A)(iv), which may be distributed to
individuals without a prescription;
(ii) when furnished as part of, or as
incident to, a diagnostic service or any other
item or service for which payment may be made
under title XVIII of the Social Security Act;
or
(iii) that is a therapeutically equivalent
replacement for a product described in clause
(i) or (ii), as determined by the Secretary.
(3) Eligible organization.--The term ``eligible
organization'' means any organization that the Secretary
determines to be appropriate, including--
(A) pharmaceutical benefit management companies;
(B) wholesale and retail pharmacist delivery
systems;
(C) insurers;
(D) other organizations; or
(E) any combination of the entities described in
subparagraphs (A) through (D).
(4) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Ways and Means, and in addition to the Committee on Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Ways and Means, and in addition to the Committee on Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Ways and Means, and in addition to the Committee on Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Subcommittee on Trade.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Human Resources.
Referred to the Subcommittee on Health and Environment.
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