Diabetes Prevention Act of 2012 - Amends title XVIII (Medicare) of the Social Security Act to direct the Secretary of Health and Human Services (HHS) to make payments from the Federal Supplementary Medical Insurance Trust Fund to qualified third-party intermediaries for diabetes prevention services furnished to prediabetic Medicare beneficiaries by eligible entities in local communities that are networked and managed by such third-party intermediaries.
[Congressional Bills 112th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6548 Introduced in House (IH)]
112th CONGRESS
2d Session
H. R. 6548
To amend title XVIII of the Social Security Act to provide coverage
under the Medicare program for diabetes prevention services.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 21, 2012
Mr. Shuler (for himself and Mrs. Davis of California) introduced the
following bill; which was referred to the Committee on Energy and
Commerce, and in addition to the Committee on Ways and Means, for a
period to be subsequently determined by the Speaker, in each case for
consideration of such provisions as fall within the jurisdiction of the
committee concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to provide coverage
under the Medicare program for diabetes prevention services.
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 ``Diabetes Prevention Act of 2012''.
SEC. 2. MEDICARE COVERAGE FOR DIABETES PREVENTION SERVICES.
Title XVIII of the Social Security Act is amended by adding at the
end the following new section:
``SEC. 1899B. DIABETES PREVENTION PROGRAM.
``(a) Payments for Diabetes Prevention Services.--
``(1) In general.--Beginning not later than January 1,
2013, the Secretary shall make payments to qualified third-
party intermediaries for diabetes prevention services furnished
to prediabetic Medicare beneficiaries by eligible entities in
local communities that are networked and managed by such third-
party intermediaries, for the purpose of preventing such
beneficiaries from developing diabetes.
``(2) Source.--The payments under paragraph (1) shall be
made from the Federal Supplementary Medical Insurance Trust
Fund.
``(3) Special consideration for the dual eligible
individuals.--In implementing this section, the Secretary of
Health and Human Services shall give special consideration to
the needs of dual eligible individuals (as such term is defined
in section 1915(h)(2)(B)).
``(b) Diabetes Prevention Services and Prediabetic Medicare
Beneficiary Defined.--For purposes of this section:
``(1) Diabetes prevention services.--The term `diabetes
prevention services' means services that--
``(A) are furnished to prediabetic Medicare
beneficiaries by an eligible entity; and
``(B) are components of a diabetes prevention
program that meets the requirements, goals, and
objectives of the National Diabetes Program of the
Centers for Disease Control and Prevention (including
use of the curriculum of such program).
``(2) Prediabetic medicare beneficiary.--The term
`prediabetic Medicare beneficiary' means an individual who is
entitled to benefits under part A, or enrolled for benefits
under part B and who meets criteria that the Secretary may
establish, in consultation with the Director of the Centers for
Disease Control and Prevention. Such criteria shall be similar
to the criteria for participation in the National Diabetes
Program of the Centers for Disease Control and Prevention.
``(c) Eligible Entities.--For purposes of this section:
``(1) In general.--The term `eligible entity' means an
entity (such as a provider of services, physician, or other
health care practitioner, a trained lifestyle coach, community-
based organization, or a health insurance or services company)
that the Secretary determines--
``(A) can appropriately furnish diabetes prevention
services through a diabetes prevention program that
satisfies the requirements of subsection (b)(1)(B);
``(B)(i) has entered into a contract with a
qualified third-party intermediary that meets the
requirements of subsection (e); or
``(ii) is a third-party intermediary and meets the
requirements of subsection (d)(1)(A)(ii); and
``(C) is recognized by the Centers for Disease
Control and Prevention under the Diabetes Prevention
Recognition Program and such recognition has not
expired.
``(2) Trained lifestyle coach.--The term `trained lifestyle
coach' means an individual who has received adequate training,
as determined by the Secretary, in the curriculum of the
National Diabetes Program of the Centers for Disease Control
and Prevention to provide diabetes prevention services.
``(d) Qualified Third-Party Intermediary.--
``(1) In general.--For purposes of this section, the term
`qualified third-party intermediary' means a third-party
intermediary that has entered into a contract with the
Secretary to conduct the following activities:
``(A) Managed network of eligible entities.--The
third-party intermediary--
``(i) has entered into a contract that
meets the requirements of subsection (e) with
one or more eligible entities; or
``(ii) is an eligible entity.
``(B) Tracking, processing, and engagement.--The
third-party intermediary shall--
``(i) if such intermediary has not entered
into a contract described in subparagraph
(A)(i), furnish diabetes prevention services;
``(ii) track, using adequate information
technology systems, the outcomes (including
class attendance and weight loss) of the
diabetes prevention services furnished to
prediabetic Medicare beneficiaries by such
intermediary or by any eligible entity with a
contract with the intermediary under
subparagraph (A)(i);
``(iii) implement business processes to
manage workflow (such as eligibility,
reporting, claims billing, class scheduling,
and enrollment) related to the provision of
diabetes prevention services to prediabetic
Medicare beneficiaries by the intermediary or
eligible entities with contracts with the
intermediary under subparagraph (A)(i);
``(iv) perform various forms of engagement
with, and outreach to, prediabetic Medicare
beneficiaries, including individuals receiving
diabetes prevention services from eligible
entities with contracts with the intermediary
under subparagraph (A)(i);
``(v) comply with all program integrity
requirements established by the Secretary; and
``(vi) perform such other functions as
required by the Secretary through the contract
under this paragraph.
``(C) Claims billing.--The third-party intermediary
will promptly and accurately submit billing information
to the Secretary for diabetes prevention services
furnished to a prediabetic Medicare beneficiary by an
eligible entity with which the third-party intermediary
has a contract under subparagraph (A)(i).
``(D) Outreach to health care providers.--The
third-party intermediary provides outreach and
education for health care providers (as such term is
defined in section 1855(d)(5)) about the availability
of diabetes prevention services and the benefits of
patient participation in such services.
``(E) Reporting on services provided.--The third-
party intermediary shall report to the Secretary the
following information:
``(i) Information on the participation of
prediabetic Medicare beneficiaries in the
diabetes prevention services furnished--
``(I) by each eligible entity with
which such intermediary has a contract
under subparagraph (A)(i); and
``(II) the third-party beneficiary,
if the third-party intermediary is an
eligible entity.
``(ii) Information on the impact of such
participation on such beneficiaries (including
weight loss).
``(iii) Any information required by the
Secretary for purposes of ensuring that the
third-party intermediary is conducting the
oversight required under subsection (e)(5).
``(F) Organizational structure.--The third-party
intermediary meets such requirements for organizational
structure as the Secretary may specify, to ensure that
such third-party intermediary can meet the requirements
of this Act.
``(2) Types of third-party intermediaries.--The term
`third-party intermediary' may include--
``(A) an accountable care organization under
section 1899;
``(B) a technology company;
``(C) a provider of services (as such term is
defined in section 1861(u));
``(D) a health insurance or services company
(including population health or disease management
companies);
``(E) a community-based organization or a network
of community-based organizations;
``(F) a faith-based organization; or
``(G) any other organization that the Secretary
determines is capable of managing a network of eligible
entities and meeting the requirements for a qualified
third-party intermediary under paragraph (1).
``(3) Oversight.--The Secretary shall monitor the third-
party intermediaries to prevent fraud and abuse in the
provision of diabetes prevention services to prediabetic
Medicare beneficiaries.
``(e) Contracts Between Eligible Entities and Third-Party
Intermediaries.--A contract between an eligible entity and a third-
party intermediary meets the requirements of this subsection if the
contract provides for the following:
``(1) Payment for services.--The third-party intermediary
shall provide payment to the eligible entity for diabetes
prevention services furnished to prediabetic Medicare
beneficiaries by such entity.
``(2) Eligibility and enrollment.--The third-party
intermediary shall conduct the following activities (unless the
contract specifically assigns any of these activities to the
eligible entity):
``(A) Determine whether individuals are prediabetic
Medicare beneficiaries who are eligible to receive
diabetes prevention services pursuant to this section.
``(B) Scheduling and enrollment for diabetes
prevention services furnished by the eligible entity.
``(C) Develop and manage a process to assist health
care providers (as such term is defined in section
1855(d)(5)) in referring prediabetic Medicare
beneficiaries to eligible entities for diabetes
prevention services.
``(3) Outreach and customer service for beneficiaries.--The
third-party intermediary shall--
``(A) use a variety of methods to identify
individuals who are likely to be prediabetic Medicare
beneficiaries and inform such beneficiaries of diabetes
prevention services offered by the eligible entity (and
other eligible entities with which such third-party
intermediary has a contract under this subsection); and
``(B) provide customer service and support for
prediabetic Medicare beneficiaries who are seeking or
receiving diabetes prevention services furnished by the
eligible entity.
``(4) Performance.--The third-party intermediary shall
monitor the performance of the eligible entity with respect to
diabetes prevention services furnished to prediabetic Medicare
beneficiaries by such entity and ensure that such performance
is consistent with the requirements of this section.
``(5) Oversight.--The third-party intermediary shall
monitor the eligible entity to prevent fraud and abuse in the
provision of diabetes prevention services to prediabetic
Medicare beneficiaries.
``(6) Audits.--
``(A) In general.--The third-party intermediary may
conduct audits of the eligible entity to ensure--
``(i) that such entity--
``(I) is providing diabetes
prevention services that meet the
requirements, goals, and objectives of
the National Diabetes Program of the
Centers for Disease Control and
Prevention; and
``(II) is complying with the
requirements of subsection (g) (related
to privacy);
``(ii) that individuals receiving diabetes
prevention services for which payment is made
pursuant to a contract under this section to
the eligible entity are prediabetic Medicare
beneficiaries; and
``(iii) that the claims for payment
submitted by the eligible entity to the third-
party intermediary are accurate and comply with
the requirements of the contract under this
subsection.
``(B) Access.--The eligible entity shall provide
the third-party intermediary with access to information
necessary to complete the audits under subparagraph
(A).
``(f) Payments for Diabetes Prevention Program Services.--
``(1) In general.--Under the contract under subsection
(d)(1) the Secretary shall agree to make payments to the third-
party intermediary for diabetes prevention services furnished
to prediabetic Medicare beneficiaries by eligible entities with
contracts with such third-party intermediary (or in the case of
a third-party intermediary that is an eligible entity, diabetes
prevention services furnished to such beneficiaries by such
third-party intermediary).
``(2) Amount of payment for 2013.--With respect to diabetes
prevention program services furnished to a prediabetic Medicare
beneficiary, the amount of payment made under paragraph (1) for
2013 is the sum of any of the following amounts that are
applicable to such beneficiary:
``(A) $100 for the enrollment of such individual in
a diabetes prevention program that meets the
requirements, goals, and objectives of the National
Diabetes Program of the Centers for Disease Control and
Prevention (including use of the curriculum of such
program) and is provided by an eligible entity with
which the third-party intermediary has a contract under
subsection (e) or by the third-party intermediary
directly, if the third-party intermediary is an
eligible entity.
``(B) $150 for any such individual who attends at
least 4 class sessions, as specified in such
curriculum.
``(C) $200 for any such individual who attends at
least 9 class sessions (including the 4 class sessions
described in subparagraph (B)), as specified in such
curriculum.
``(D) $120 for any such individual who--
``(i) attends all of the sessions described
in subparagraphs (B) and (C); and
``(ii) loses at least 5 percent of the
individual's total body weight during the time
period that begins on the date of the first
such session attended by such individual, and
ends 60 days after the completion of the last
such session attended by such individual.
``(E) An additional $40 for any individual who
meets the requirements of subparagraph (D)(i) and who
loses at least 9 percent of total body weight during
the time period described in subparagraph (D)(ii).
``(3) Payment amounts for 2014 and subsequent years.--For
2014 and subsequent years, with respect to diabetes prevention
program services furnished to a prediabetic Medicare
beneficiary, the amount of payment under this subsection shall
be the amount payable under this subsection in the previous
year, increased by an appropriate amount, as determined by the
Secretary, to account for inflation. The amount of such
increase shall not be less than the percentage change in the
Consumer Price Index for all urban consumers (U.S. city
average) for such year.
``(g) Privacy and Security Requirements.--Each eligible entity and
third-party intermediary shall, to the extent such entity or
intermediary handles individually identifiable health information
related to furnishing diabetes prevention services under this section,
be treated as a covered entity for purposes of the application of the
provisions of (and regulations promulgated under) part C of title XI,
section 264(c) of the Health Insurance Portability and Accountability
Act of 1996 (42 U.S.C. 1320d-2 note), and subtitle D of title XIII of
the American Recovery and Reinvestment Act of 2009.
``(h) No Cost Sharing.--No premium, deductible, coinsurance, or
other cost-sharing requirement shall apply to any diabetes prevention
service furnished to a prediabetic Medicare beneficiary under this
section.
``(i) Evaluation and Report to Congress.--
``(1) Evaluation.--The Secretary shall conduct an
evaluation on the coverage of diabetes prevention services
under this title. Such evaluation shall include the analysis
of--
``(A) the impact of the provision of such coverage
on Medicare beneficiaries, including the impact on
various populations, such as individuals who are dual
eligible individuals (as such term is defined in
section 1915(h)(2)(B)), and the impact of the provision
of such coverage on health disparities;
``(B) the rate at which physicians refer
prediabetic Medicare beneficiaries to eligible entities
and third-party intermediaries providing such diabetes
prevention services;
``(C) the rate at which Medicare beneficiaries
access such services and the awareness of Medicare
beneficiaries of coverage for such services under this
title;
``(D) the health outcomes resulting from the
participation of prediabetic Medicare beneficiaries in
diabetes prevention services under this title;
``(E) recommendations for important program
integrity protections related to the payment for
diabetes prevention services under this title; and
``(F) other topics determined appropriate by the
Secretary.
``(2) Report.--Not later than January 1, 2018, the
Secretary shall submit to Congress a report that contains--
``(A) the results of the evaluation conducted under
paragraph (1); and
``(B) recommendations for any legislative or
administration actions that the Secretary determines
appropriate.''.
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Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
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