Value Based Insurance Design for Better Care Act of 2014 or the VBID for Better Care Act of 2014 - Directs the Secretary of Health and Human Services (HHS) to establish a three-year demonstration program to test the use of value-based insurance design methodologies under the eligible Medicare plans offered by Medicare Advantage organizations under part C (Medicare+Choice) of title XVIII (Medicare) of the Social Security Act.
Defines "value-based insurance design methodology" as one for identifying specific prescription medications, and clinical services reimbursable under Medicare, for which copayments, coinsurance, or both should be reduced or eliminated because of the high-value and effectiveness of these medications and services for specific chronic clinical conditions (as approved by the Secretary).
Directs the Secretary to expand the demonstration program to implement, on a permanent basis, those components beneficial to Medicare beneficiaries and the Medicare program, unless a required evaluation of the program states that it: (1) increases expenditures under Medicare with respect to participating beneficiaries, or (2) decreases the quality of health care services furnished to such beneficiaries.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5183 Introduced in House (IH)]
113th CONGRESS
2d Session
H. R. 5183
To establish a demonstration program requiring the utilization of
Value-Based Insurance Design to demonstrate that reducing the
copayments or coinsurance charged to Medicare beneficiaries for
selected high-value prescription medications and clinical services can
increase their utilization and ultimately improve clinical outcomes and
lower health care expenditures.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 23, 2014
Mrs. Black (for herself and Mr. Blumenauer) introduced the following
bill; which was referred to the Committee on Ways and Means, and in
addition to the Committee on Energy and 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 establish a demonstration program requiring the utilization of
Value-Based Insurance Design to demonstrate that reducing the
copayments or coinsurance charged to Medicare beneficiaries for
selected high-value prescription medications and clinical services can
increase their utilization and ultimately improve clinical outcomes and
lower health care expenditures.
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 ``Value Based Insurance Design for
Better Care Act of 2014'' or the ``VBID for Better Care Act of 2014''.
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) A growing body of evidence demonstrates that increases
in patient-level financial barriers (including deductibles,
copayments, and coinsurance) for high-value medical services
(such as prescription medications, clinician visits, diagnostic
tests, and procedures) systematically reduce their use. Savings
attributable to cost-related decreased utilization of specific
services may lead to an increase in total medical expenditures
due to increased use of other related clinical services, such
as hospitalizations and emergency room visits.
(2) Empirical research studies demonstrate that reductions
in beneficiary out-of-pocket expenses for high-value
prescription medications and clinical services can mitigate the
adverse health and financial consequences attributable to cost-
related decreased utilization of high-value services.
(3) Financial barriers to prescription medications and
clinical services that are deemed to be high-value should be
reduced or eliminated to increase their use.
(4) Value-Based Insurance Design is a methodology that
adjusts patient out-of-pocket costs for prescription
medications and clinical services according to the clinical
value--not exclusively the cost. Value-Based Insurance Design
is based on the concept of clinical nuance that recognizes--
(A) prescription medications and clinical services
differ in the clinical benefit provided; and
(B) the clinical benefit derived from a specific
prescription medication or clinical service depends on
the clinical situation, the provider, and where the
care is delivered.
(5) The current ``one-size-fits-all'' copayment or
coinsurance design for prescription medications and clinical
services provided under the Medicare program does not recognize
the well-established value differences in health outcomes
produced by various medical interventions.
(6) The establishment by Medicare of copayment and
coinsurance requirements using Value-Based Insurance Design
methodologies will improve patient-centered health outcomes,
enhance personal responsibility, and afford a more efficient
use of taxpayer dollars.
SEC. 3. DEMONSTRATION PROGRAM.
(a) In General.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') shall establish a 3-year
demonstration program to test the use of value-based insurance design
methodologies (as defined in subsection (c)(1)) under eligible Medicare
Advantage plans offered by Medicare Advantage organizations under part
C of title XVIII of the Social Security Act (42 U.S.C. 1395w-21 et
seq.).
(b) Demonstration Program Design.--
(1) Selection of ma region and eligible medicare advantage
plans.--The Secretary shall--
(A) select at least two MA regions (as defined in
section 1858(a)(2) of the Social Security Act (42
U.S.C. 1395w-27a(a)(2))) with respect to which to
conduct the demonstration program under this section;
and
(B) approve eligible Medicare Advantage plans to
participate in such demonstration program.
(2) Start of demonstration.--The demonstration program
shall begin with respect to the first plan year beginning after
the date on which at least two eligible Medicare Advantage
plans have been approved by the Secretary in at least one MA
region selected under paragraph (1).
(3) Eligible medicare advantage plans.--For purposes of
this section, the term ``eligible Medicare Advantage plan''
means a Medicare Advantage plan under part C of title XVIII of
the Social Security Act (42 U.S.C. 1395w-21 et seq.) that meets
the following requirements:
(A) The plan is an MA regional plan (as defined in
paragraph (4) of section 1859(b) of such Act (42 U.S.C.
1395w-28(b))) or MA local plan (as defined in paragraph
(5) of such section) offered in the MA region selected
under paragraph (1)(A).
(B) The plan has--
(i) a quality rating under section
1853(n)(4) of such Act (42 U.S.C. 1395w-
23(n)(4)) of 4 stars or higher based on the
most recent data available for such year;
(ii) in the case of a specialized MA plan
for special needs individuals, as defined in
subsection (b)(6)(A) of section 1859(b)(6)(A)
of such Act (42 U.S.C. 1395w-28(b)(6)(A)),
received a multi-year approval by the National
Committee for Quality Assurance under
subsection (f)(7) of such section; or
(iii) at least 20 percent of the population
to whom the plan is offered consists of subsidy
eligible individuals (as defined in section
1860D-14(a)(3)(A) of the Social Security Act
(42 U.S.C. 1395w-114(a)(3)(A))).
(c) Value-Based Insurance Design Methodologies.--
(1) Definition.--For purposes of this section, the term
``value-based insurance design methodology'' means a
methodology for identifying specific prescription medications,
and clinical services that are reimbursable under title XVIII
of the Social Security Act, for which copayments, coinsurance,
or both should be reduced or eliminated because of the high-
value and effectiveness of such medications and services for
specific chronic clinical conditions (as approved by the
Secretary).
(2) Use of methodologies to reduce copayments and
coinsurance.--A Medicare Advantage organization offering an
eligible Medicare Advantage plan selected to participate under
the demonstration program, for each plan year for which the
plan is so selected and using value-based insurance design
methodologies--
(A) shall identify each prescription medication and
clinical service covered under such plan for which the
amount of the copayment or coinsurance should be
reduced or eliminated, with respect to the management
of specific chronic clinical conditions (as specified
by the Secretary) of MA eligible individuals (as
defined in section 1851(a)(3) of the Social Security
Act (42 U.S.C. 1395w-21(a)(3))) enrolled under such
plans, for such plan year; and
(B) may, for such plan year, reduce or eliminate
copayments, coinsurance, or both for such prescription
medication and clinical services so identified with
respect to the management of such conditions of such
individuals--
(i) if such reduction or elimination is
evidence-based, for the purpose of encouraging
such individuals in such plan to use such
prescription medications and clinical services
(such as preventive care, primary care,
specialty visits, diagnostic tests, procedures,
and durable medical equipment) with respect to
such conditions; and
(ii) for the purpose of encouraging such
individuals in such plan to use health care
providers that such organization has identified
with respect to such plan year.
(3) Prohibition of increases of copayments and
coinsurance.--In no case may any Medicare Advantage plan
participating in the demonstration program increase, for any
plan year for which the plan is so participating, the amount of
copayments or coinsurance for any item or service covered under
such plan for purposes of discouraging the use of such item or
service.
(d) Report on Implementation.--
(1) In general.--Not later than 1 year after the date on
which the demonstration program under this section begins under
subsection (b)(2), the Secretary shall submit to Congress a
report on the status of the implementation of the demonstration
program.
(2) Elements.--The report required by paragraph (1) shall,
with respect to eligible Medicare Advantage plans participating
in the demonstration program for the first plan year of such
program, include the following:
(A) A list of each medication and service
identified pursuant to subsection (c)(2)(A) for such
plan with respect to such plan year.
(B) For each such medication or service so
identified, the amount of the copayment or coinsurance
required under such plan with respect to such plan year
for such medication or service and the amount of the
reduction of such copayment or coinsurance from the
previous plan year.
(C) For each provider identified pursuant to
subsection (c)(2)(B)(ii) for such plan with respect to
such plan year, a statement of the amount of the
copayment or coinsurance required under such plan with
respect to such plan year and the amount of the
reduction of such copayment or coinsurance from the
previous plan year.
(e) Review and Assessment of Utilization of Value-Based Insurance
Design Methodologies.--
(1) In general.--The Secretary shall enter into a contract
or agreement with an independent, non-biased entity having
expertise in value-based insurance design methodologies to
review and assess the implementation of the demonstration
program under this section. The review and assessment shall
include the following:
(A) An assessment of the utilization of value-based
insurance design methodologies by Medicare Advantage
plans participating under such program.
(B) An analysis of whether reducing or eliminating
the copayment or coinsurance for each medication and
clinical service identified pursuant to subsection
(c)(2)(A) resulted in increased adherence to medication
regimens, increased service utilization, improvement in
quality metrics, better health outcomes, and enhanced
beneficiary experience.
(C) An analysis of the extent to which costs to
Medicare Advantage plans under part C of title XVIII of
the Social Security Act participating in the
demonstration program is less than costs to Medicare
Advantage plans under such part that are not
participating in the demonstration program.
(D) An analysis of whether reducing or eliminating
the copayment or coinsurance for providers identified
pursuant to subsection (c)(2)(B)(ii) resulted in
improvement in quality metrics, better health outcomes,
and enhanced beneficiary experience.
(E) An analysis, for each provider so identified,
the extent to which costs to Medicare Advantage plans
under part C of title XVIII of the Social Security Act
participating in the demonstration program is less than
costs to Medicare Advantage plans under such part that
are not participating in the demonstration program.
(F) Such other matters, as the Secretary considers
appropriate.
(2) Report.--The contract or agreement entered into under
paragraph (1) shall require such entity to submit to the
Secretary a report on the review and assessment conducted by
the entity under such paragraph in time for the inclusion of
the results of such report in the report required by paragraph
(3).
(3) Report to congress.--Not later than 3 years after the
date on which the demonstration program begins under subsection
(b)(2), the Secretary shall submit to Congress a report on the
review and assessment of the demonstration program conducted
under this subsection. The report shall include the following:
(A) A description of the results of the review and
assessment included in the report submitted pursuant to
paragraph (2).
(B) Such recommendations as the Secretary considers
appropriate for enhancing the utilization of the
methodologies applied under the demonstration program
to all Medicare Advantage plans under part C of title
XVIII of the Social Security Act so as to reduce
copayments and coinsurance under such plans paid by
Medicare beneficiaries for high-value prescription
medications and clinical services for which coverage is
provided under such plans and to otherwise improve the
quality of health care provided under such plans.
(f) Expansion of Demonstration Program.--The Secretary shall expand
the demonstration program, pursuant to notice and comment rulemaking,
to implement, on a permanent basis, the components of the demonstration
program that are beneficial to Medicare beneficiaries and the Medicare
program, unless the report under subsection (d) or (e)(3) contains an
evaluation that the demonstration program--
(1) increases expenditures under title XVIII with respect
to Medicare beneficiaries participating in the demonstration
program; or
(2) decreases the quality of health care services furnished
to such Medicare beneficiaries participating in the
demonstration program.
(g) Waiver Authority.--The Secretary may waive such provisions of
titles XI and XVIII of the Social Security Act as may be necessary to
carry out the demonstration program under this section.
(h) Implementation Funding.--For purposes of carrying out the
demonstration program under this section, the Secretary shall provide
for the transfer from the Federal Hospital Insurance Trust Fund under
section 1817 of the Social Security Act (42 U.S.C. 1395i) and the
Federal Supplementary Insurance Trust Fund under section 1841 of the
Social Security Act (42 U.S.C. 1395t), including the Medicare
Prescription Drug Account in such Trust Fund, in such proportion as
determined appropriate by the Secretary, of such sums as may be
necessary.
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Introduced in House
Introduced in House
Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and 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 Energy and 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 Health.
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