Protecting the Integrity of Medicare Act of 2014 - Amends title II (Old Age, Survivors and Disability Insurance) (OASDI) of the Social Security Act (SSA) to direct the Secretary of Health and Human Services (HHS) to establish cost-effective procedures to ensure that: (1) a Social Security account number (or any derivative) is not displayed, coded, or embedded on the Medicare card issued to an individual entitled to benefits under part A (Hospital Insurance) of SSA title XVIII (Medicare) or enrolled under Medicare part B (Supplementary Medical Insurance); and (2) any other identifier displayed on such card is not identifiable as a Social Security account number (or any derivative).
Directs the Secretary to establish procedures to ensure that Medicare payment is not made for items and services furnished to an individual incarcerated, deceased, or otherwise ineligible and not lawfully present in the United States.
Directs the Secretary, if cost-effective and technologically viable, to consider appropriate measures to implement use of electronic Medicare beneficiary and provider cards.
Extends the Medicare durable medical equipment (DME) face-to-face encounter documentation requirement to include physician assistants, practitioners, or specialists as well as physicians (as under current law).
Requires each Medicare administrative contractor to establish an improper payment outreach and education program for service providers and suppliers in order to reduce improper Medicare payments.
Requires the Secretary to develop a plan to revise the incentive program under the Health Insurance Portability and Accountability Act of 1996 to encourage greater participation by individuals to report fraud and abuse in the Medicare program.
Directs the Secretary to require a claim for a covered Medicare part D (Voluntary Prescription Drug Benefit Program) drug for an individual enrolled in a prescription drug plan (PDP) or in a Medicare Advantage Prescription Drug (MA-PD) plan to include a valid prescriber National Provider Identifier.
Gives Medicare beneficiaries the option to receive the Medicare Summary Notice (explanation of benefits) electronically.
Directs the Secretary to: (1) apply competitive procedures to selection of a Medicare administrative contractor at least once every 10 years (currently once every 5 years); and (3) study and, as appropriate, specify incentives for states to work with the Secretary under the Medicare-Medicaid Data Match Program to protect the federal and state share of expenditures.
Authorizes a PDP sponsor to establish a drug management program for at-risk beneficiaries.
Directs the Secretary to authorize Medicare drug integrity contractors (MEDICs) to accept directly an individual's prescription and necessary medical records from pharmacies, prescription drug plans, and physicians in order for MEDICs to provide information relevant to determining whether the individual is an at-risk beneficiary.
Directs the Secretary to issue a clarification or modification with respect to the application of the Common Rule (governing the protection of human subjects in research) to activities involving clinical data registries.
Amends SSA title XI to eliminate civil monetary penalties for inducements to physicians to limit services that are not medically necessary.
Directs the Secretary to report to Congress on options for amending existing Medicare fraud and abuse laws and regulations to permit gainsharing or similar arrangements between physicians and hospitals that would otherwise be subject to penalties.
Modifies the Medicare home health surety bond condition of participation requirement.
Directs the Secretary to: (1) implement a process for medical review of spinal subluxation services by a chiropractor, and (2) develop educational and training programs to improve the ability of chiropractors to document services in a manner that demonstrates they are reasonable and necessary.
Applies Medicare competitive bidding to vacuum erection systems, and requires the Secretary to phase-in a national mail order program for such devices.
Requires the Secretary to: (1) revise the testing in New Jersey, Pennsylvania, and South Carolina of a model of prior authorization for repetitive scheduled non-emergent ambulance transport to cover specified additional states; and (2) apply the prior authorization program to all states.
Directs the Secretary to submit a plan to Congress for including in the annual report of the Comprehensive Error Rate Testing (CERT) programs data on services (other than medical visits) paid under the physician fee schedule where the fee schedule amount exceeds $250 and where the error rate exceeds 20%.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5780 Introduced in House (IH)]
113th CONGRESS
2d Session
H. R. 5780
To amend title XVIII of the Social Security Act to improve the
integrity of the Medicare program, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
December 2, 2014
Mr. Brady of Texas (for himself, Mr. McDermott, Mr. Camp, Mr. Levin,
Mr. Rangel, Mr. Lewis, Mr. Sam Johnson of Texas, Mr. Blumenauer, Mr.
Pascrell, Mr. Gerlach, Mr. Boustany, Mr. Buchanan, Mr. Roskam, Mr.
Reed, Mrs. Black, Mr. Griffin of Arkansas, Mr. Kelly of Pennsylvania,
Mr. Renacci, and Mr. Van Hollen) 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 amend title XVIII of the Social Security Act to improve the
integrity of the Medicare program, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Protecting the
Integrity of Medicare Act of 2014''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Prohibition of inclusion of Social Security account numbers on
Medicare cards.
Sec. 3. Preventing wrongful Medicare payments for items and services
furnished to incarcerated individuals,
individuals not lawfully present, and
deceased individuals.
Sec. 4. Consideration of measures regarding Medicare beneficiary smart
cards.
Sec. 5. Modifying medicare durable medical equipment face-to-face
encounter documentation requirement.
Sec. 6. Reducing improper Medicare payments.
Sec. 7. Improving senior Medicare patrol and fraud reporting rewards.
Sec. 8. Requiring valid prescriber National Provider Identifiers on
pharmacy claims.
Sec. 9. Option to receive Medicare Summary Notice electronically.
Sec. 10. Renewal of MAC contracts.
Sec. 11. Study on pathway for incentives to States for State
participation in medicaid data match
program.
Sec. 12. Programs to prevent prescription drug abuse under Medicare
part D.
Sec. 13. Guidance on application of Common Rule to clinical data
registries.
Sec. 14. Eliminating certain civil money penalties; gainsharing study
and report.
Sec. 15. Modification of Medicare home health surety bond condition of
participation requirement.
Sec. 16. Oversight of Medicare coverage of manual manipulation of the
spine to correct subluxation.
Sec. 17. Limiting payment amount under Medicare program for vacuum
erection systems.
Sec. 18. National expansion of prior authorization model for repetitive
scheduled non-emergent ambulance transport.
Sec. 19. Repealing duplicative Medicare secondary payor provision.
Sec. 20. Plan for expanding data in annual CERT report.
Sec. 21. Rule of construction.
SEC. 2. PROHIBITION OF INCLUSION OF SOCIAL SECURITY ACCOUNT NUMBERS ON
MEDICARE CARDS.
(a) In General.--Section 205(c)(2)(C) of the Social Security Act
(42 U.S.C. 405(c)(2)(C)) is amended--
(1) by moving clause (x), as added by section 1414(a)(2) of
the Patient Protection and Affordable Care Act, 6 ems to the
left;
(2) by redesignating clause (x), as added by section
2(a)(1) of the Social Security Number Protection Act of 2010,
and clause (xi) as clauses (xi) and (xii), respectively; and
(3) by adding at the end the following new clause:
``(xiii) The Secretary of Health and Human Services, in
consultation with the Commissioner of Social Security, shall establish
cost-effective procedures to ensure that a Social Security account
number (or derivative thereof) is not displayed, coded, or embedded on
the Medicare card issued to an individual who is entitled to benefits
under part A of title XVIII or enrolled under part B of title XVIII and
that any other identifier displayed on such card is not identifiable as
a Social Security account number (or derivative thereof).''.
(b) Implementation.--In implementing clause (xiii) of section
205(c)(2)(C) of the Social Security Act (42 U.S.C. 405(c)(2)(C)), as
added by subsection (a)(3), the Secretary of Health and Human Services
shall do the following:
(1) In general.--Establish a cost-effective process that
involves the least amount of disruption to, as well as
necessary assistance for, Medicare beneficiaries and health
care providers, such as a process that provides such
beneficiaries with access to assistance through a toll-free
telephone number and provides outreach to providers.
(2) Consideration of medicare beneficiary identified.--
Consider implementing a process, similar to the process
involving Railroad Retirement Board beneficiaries, under which
a Medicare beneficiary identifier which is not a Social
Security account number (or derivative thereof) is used
external to the Department of Health and Human Services and is
convertible over to a Social Security account number (or
derivative thereof) for use internal to such Department and the
Social Security Administration.
(c) Funding for Implementation.--For purposes of implementing the
provisions of and the amendments made by this section, the Secretary of
Health and Human Services shall provide for the following transfers
from the Federal Hospital Insurance Trust Fund under section 1817 of
the Social Security Act (42 U.S.C. 1395i) and from the Federal
Supplementary Medical Insurance Trust Fund established under section
1841 of such Act (42 U.S.C. 1395t), in such proportions as the
Secretary determines appropriate:
(1) To the Centers for Medicare & Medicaid Program
Management Account, transfers of the following amounts:
(A) For fiscal year 2015, $65,000,000, to be made
available through fiscal year 2018.
(B) For each of fiscal years 2016 and 2017,
$53,000,000, to be made available through fiscal year
2018.
(C) For fiscal year 2018, $48,000,000, to be made
available until expended.
(2) To the Social Security Administration Limitation on
Administration Account, transfers of the following amounts:
(A) For fiscal year 2015, $27,000,000, to be made
available through fiscal year 2018.
(B) For each of fiscal years 2016 and 2017,
$22,000,000, to be made available through fiscal year
2018.
(C) For fiscal year 2018, $27,000,000, to be made
available until expended.
(3) To the Railroad Retirement Board Limitation on
Administration Account, the following amount:
(A) For fiscal year 2015, $3,000,000, to be made
available until expended.
(d) Effective Date.--
(1) In general.--Clause (xiii) of section 205(c)(2)(C) of
the Social Security Act (42 U.S.C. 405(c)(2)(C)), as added by
subsection (a)(3), shall apply with respect to Medicare cards
issued on and after an effective date specified by the
Secretary of Health and Human Services, but in no case shall
such effective date be later than the date that is four years
after the date of the enactment of this Act.
(2) Reissuance.--The Secretary shall provide for the
reissuance of Medicare cards that comply with the requirements
of such clause not later than four years after the effective
date specified by the Secretary under paragraph (1).
SEC. 3. PREVENTING WRONGFUL MEDICARE PAYMENTS FOR ITEMS AND SERVICES
FURNISHED TO INCARCERATED INDIVIDUALS, INDIVIDUALS NOT
LAWFULLY PRESENT, AND DECEASED INDIVIDUALS.
(a) Requirement for the Secretary To Establish Policies and Claims
Edits Relating to Incarcerated Individuals, Individuals Not Lawfully
Present, and Deceased Individuals.--Section 1874 of the Social Security
Act (42 U.S.C. 1395kk) is amended by adding at the end the following
new subsection:
``(f) Requirement for the Secretary To Establish Policies and
Claims Edits Relating to Incarcerated Individuals, Individuals Not
Lawfully Present, and Deceased Individuals.--The Secretary shall
establish and maintain procedures, including procedures for using
claims processing edits, updating eligibility information to improve
provider accessibility, and conducting recoupment activities such as
through recovery audit contractors, in order to ensure that payment is
not made under this title for items and services furnished to an
individual who is one of the following:
``(1) An individual who is incarcerated.
``(2) An individual who is not lawfully present in the
United States and who is not eligible for coverage under this
title.
``(3) A deceased individual.''.
(b) Report.--Not later than 18 months after the date of the
enactment of this section, and periodically thereafter as determined
necessary by the Office of Inspector General of the Department of
Health and Human Services, such Office shall submit to Congress a
report on the activities described in subsection (f) of section 1874 of
the Social Security Act (42 U.S.C. 1395kk), as added by subparagraph
(a), that have been conducted since such date of enactment.
SEC. 4. CONSIDERATION OF MEASURES REGARDING MEDICARE BENEFICIARY SMART
CARDS.
To the extent the Secretary of Health and Human Services determines
that it is cost effective and technologically viable to use electronic
Medicare beneficiary and provider cards (such as cards that use smart
card technology, including an embedded and secure integrated circuit
chip), as presented in the Government Accountability Office report
required by the conference report accompanying the Consolidated
Appropriations Act, 2014 (Public Law 113-76), the Secretary shall
consider such measures as determined appropriate by the Secretary to
implement such use of such cards for beneficiary and provider use under
title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). In the
case that the Secretary considers measures under the preceding
sentence, the Secretary shall submit to the Committees on Ways and
Means and on Energy and Commerce of the House of Representatives, and
to the Committee on Finance of the Senate, a report outlining the
considerations undertaken by the Secretary under such sentence.
SEC. 5. MODIFYING MEDICARE DURABLE MEDICAL EQUIPMENT FACE-TO-FACE
ENCOUNTER DOCUMENTATION REQUIREMENT.
(a) In General.--Section 1834(a)(11)(B)(ii) of the Social Security
Act (42 U.S.C. 1395m(a)(11)(B)(ii)) is amended--
(1) by striking ``the physician documenting that''; and
(2) by striking ``has had a face-to-face encounter'' and
inserting ``documenting such physician, physician assistant,
practitioner, or specialist has had a face-to-face encounter''.
(b) Implementation.--Notwithstanding any other provision of law,
the Secretary of Health and Human Services may implement the amendments
made by subsection (a) by program instruction or otherwise.
SEC. 6. REDUCING IMPROPER MEDICARE PAYMENTS.
(a) Medicare Administrative Contractor Improper Payment Outreach
and Education Program.--
(1) In general.--Section 1874A of the Social Security Act
(42 U.S.C. 1395kk-1) is amended--
(A) in subsection (a)(4)--
(i) by redesignating subparagraph (G) as
subparagraph (H); and
(ii) by inserting after subparagraph (F)
the following new subparagraph:
``(G) Improper payment outreach and education
program.--Having in place an improper payment outreach
and education program described in subsection (h).'';
and
(B) by adding at the end the following new
subsection:
``(h) Improper Payment Outreach and Education Program.--
``(1) In general.--In order to reduce improper payments
under this title, each medicare administrative contractor shall
establish and have in place an improper payment outreach and
education program under which the contractor, through outreach,
education, training, and technical assistance or other
activities, shall provide providers of services and suppliers
located in the region covered by the contract under this
section with the information described in paragraph (2). The
activities described in the preceding sentence shall be
conducted on a regular basis.
``(2) Information to be provided through activities.--The
information to be provided under such payment outreach and
education program shall include information the Secretary
determines to be appropriate which may include the following
information:
``(A) A list of the providers' or suppliers' most
frequent and expensive payment errors over the last
quarter.
``(B) Specific instructions regarding how to
correct or avoid such errors in the future.
``(C) A notice of new topics that have been
approved by the Secretary for audits conducted by
recovery audit contractors under section 1893(h).
``(D) Specific instructions to prevent future
issues related to such new audits.
``(E) Other information determined appropriate by
the Secretary.
``(3) Priority.--A medicare administrative contractor shall
give priority to activities under such program that will reduce
improper payments that are one or more of the following:
``(A) Are for items and services that have the
highest rate of improper payment.
``(B) Are for items and service that have the
greatest total dollar amount of improper payments.
``(C) Are due to clear misapplication or
misinterpretation of Medicare policies.
``(D) Are clearly due to common and inadvertent
clerical or administrative errors.
``(E) Are due to other types of errors that the
Secretary determines could be prevented through
activities under the program.
``(4) Information on improper payments from recovery audit
contractors.--
``(A) In general.--In order to assist medicare
administrative contractors in carrying out improper
payment outreach and education programs, the Secretary
shall provide each contractor with a complete list of
the types of improper payments identified by recovery
audit contractors under section 1893(h) with respect to
providers of services and suppliers located in the
region covered by the contract under this section. Such
information shall be provided on a time frame the
Secretary determines appropriate which may be on a
quarterly basis.
``(B) Information.--The information described in
subparagraph (A) shall include information such as the
following:
``(i) Providers of services and suppliers
that have the highest rate of improper
payments.
``(ii) Providers of services and suppliers
that have the greatest total dollar amounts of
improper payments.
``(iii) Items and services furnished in the
region that have the highest rates of improper
payments.
``(iv) Items and services furnished in the
region that are responsible for the greatest
total dollar amount of improper payments.
``(v) Other information the Secretary
determines would assist the contractor in
carrying out the program.
``(5) Communications.--Communications with providers of
services and suppliers under an improper payment outreach and
education program are subject to the standards and requirements
of subsection (g).''.
(b) Use of Certain Funds Recovered by RACs.--Section 1893(h) of the
Social Security Act (42 U.S.C. 1395ddd(h)) is amended--
(1) in paragraph (2), by inserting ``or section
1874(h)(6)'' after ``paragraph (1)(C)''; and
(2) by adding at the end the following new paragraph:
``(10) Use of certain recovered funds.--
``(A) In general.--After application of paragraph
(1)(C), the Secretary shall retain a portion of the
amounts recovered by recovery audit contractors for
each year under this section which shall be available
to the program management account of the Centers for
Medicare & Medicaid Services for purposes of, subject
to subparagraph (B), carrying out sections 1833(z),
1834(l)(16), and 1874A(a)(4)(G), carrying out section
16(b) of the Protecting the Integrity of Medicare Act
of 2014, and implementing strategies (such as claims
processing edits) to help reduce the error rate of
payments under this title. The amounts retained under
the preceding sentence shall not exceed an amount equal
to 15 percent of the amounts recovered under this
subsection, and shall remain available until expended.
``(B) Limitation.--Except for uses that support
claims processing (including edits) or system
functionality for detecting fraud, amounts retained
under subparagraph (A) may not be used for
technological-related infrastructure, capital
investments, or information systems.
``(C) No reduction in payments to recovery audit
contractors.--Nothing in subparagraph (A) shall reduce
amounts available for payments to recovery audit
contractors under this subsection.''.
SEC. 7. IMPROVING SENIOR MEDICARE PATROL AND FRAUD REPORTING REWARDS.
(a) In General.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') shall develop a plan to
revise the incentive program under section 203(b) of the Health
Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1395b-
5(b)) to encourage greater participation by individuals to report fraud
and abuse in the Medicare program. Such plan shall include
recommendations for--
(1) ways to enhance rewards for individuals reporting under
the incentive program, including rewards based on information
that leads to an administrative action; and
(2) extending the incentive program to the Medicaid
program.
(b) Public Awareness and Education Campaign.--The plan developed
under subsection (a) shall also include recommendations for the use of
the Senior Medicare Patrols authorized under section 411 of the Older
Americans Act of 1965 (42 U.S.C. 3032) to conduct a public awareness
and education campaign to encourage participation in the revised
incentive program under subsection (a).
(c) Submission of Plan.--Not later than 180 days after the date of
enactment of this Act, the Secretary shall submit to Congress the plan
developed under subsection (a).
SEC. 8. REQUIRING VALID PRESCRIBER NATIONAL PROVIDER IDENTIFIERS ON
PHARMACY CLAIMS.
Section 1860D-4(c) of the Social Security Act (42 U.S.C. 1395w-
104(c)) is amended by adding at the end the following new paragraph:
``(4) Requiring valid prescriber national provider
identifiers on pharmacy claims.--
``(A) In general.--For plan year 2016 and
subsequent plan years, the Secretary shall require a
claim for a covered part D drug for a part D eligible
individual enrolled in a prescription drug plan under
this part or an MA-PD plan under part C to include a
prescriber National Provider Identifier that is
determined to be valid under the procedures established
under subparagraph (B)(i).
``(B) Procedures.--
``(i) Validity of prescriber national
provider identifiers.--The Secretary, in
consultation with appropriate stakeholders,
shall establish procedures for determining the
validity of prescriber National Provider
Identifiers under subparagraph (A).
``(ii) Informing beneficiaries of reason
for denial.--The Secretary shall establish
procedures to ensure that, in the case that a
claim for a covered part D drug of an
individual described in subparagaph (A) is
denied because the claim does not meet the
requirements of this paragraph, the individual
is properly informed at the point of service of
the reason for the denial.
``(C) Report.--Not later than January 1, 2018, the
Inspector General of the Department of Health and Human
Services shall submit to Congress a report on the
effectiveness of the procedures established under
subparagraph (B)(i).''.
SEC. 9. OPTION TO RECEIVE MEDICARE SUMMARY NOTICE ELECTRONICALLY.
(a) In General.--Section 1806 of the Social Security Act (42 U.S.C.
1395b-7) is amended by adding at the end the following new subsection:
``(c) Format of Statements From Secretary.--
``(1) Electronic option beginning in 2016.--Subject to
paragraph (2), for statements described in subsection (a) that
are furnished for a period in 2016 or a subsequent year, in the
case that an individual described in subsection (a) elects, in
accordance with such form, manner, and time specified by the
Secretary, to receive such statement in an electronic format,
such statement shall be furnished to such individual for each
period subsequent to such election in such a format and shall
not be mailed to the individual.
``(2) Limitation on revocation option.--
``(A) In general.--Subject to subparagraph (B), the
Secretary may determine a maximum number of elections
described in paragraph (1) by an individual that may be
revoked by the individual.
``(B) Minimum of one revocation option.--In no case
may the Secretary determine a maximum number under
subparagraph (A) that is less than one.
``(3) Notification.--The Secretary shall ensure that, in
the most cost effective manner and beginning January 1, 2017, a
clear notification of the option to elect to receive statements
described in subsection (a) in an electronic format is made
available, such as through the notices distributed under
section 1804, to individuals described in subsection (a).''.
(b) Encouraged Expansion of Electronic Statements.--To the extent
to which the Secretary of Health and Human Services determines
appropriate, the Secretary shall--
(1) apply an option similar to the option described in
subsection (c)(1) of section 1806 of the Social Security Act
(42 U.S.C. 1395b-7) (relating to the provision of the Medicare
Summary Notice in an electronic format), as added by subsection
(a), to other statements and notifications under title XVIII of
such Act (42 U.S.C. 1395 et seq.); and
(2) provide such Medicare Summary Notice and any such other
statements and notifications on a more frequent basis than is
otherwise required under such title.
SEC. 10. RENEWAL OF MAC CONTRACTS.
(a) In General.--Section 1874A(b)(1)(B) of the Social Security Act
(42 U.S.C. 1395kk-1(b)(1)(B)) is amended by striking ``5 years'' and
inserting ``10 years''.
(b) Application.--The amendments made by subsection (a) shall apply
to contracts entered into on or after, and to contracts in effect as
of, the date of the enactment of this Act.
(c) Contractor Performance Transparency.--Section 1874A(b)(3)(A) of
the Social Security Act (42 U.S.C. 1395kk-1(b)(3)(A)) is amended by
adding at the end the following new clause:
``(iv) Contractor performance
transparency.--To the extent possible without
compromising the process for entering into and
renewing contracts with medicare administrative
contractors under this section, the Secretary
shall make available to the public the
performance of each medicare administrative
contractor with respect to such performance
requirements and measurement standards.''.
SEC. 11. STUDY ON PATHWAY FOR INCENTIVES TO STATES FOR STATE
PARTICIPATION IN MEDICAID DATA MATCH PROGRAM.
Section 1893(g) of the Social Security Act (42 U.S.C. 1395ddd(g))
is amended by adding at the end the following new paragraph:
``(3) Incentives for states.--The Secretary shall study
and, as appropriate, may specify incentives for States to work
with the Secretary for the purposes described in paragraph
(1)(A)(ii). The application of the previous sentence may
include use of the waiver authority described in paragraph
(2).''.
SEC. 12. PROGRAMS TO PREVENT PRESCRIPTION DRUG ABUSE UNDER MEDICARE
PART D.
(a) Drug Management Program for At-Risk Beneficiaries.--
(1) In general.--Section 1860D-4(c) of the Social Security
Act (42 U.S.C. 1395w-10(c)), as amended by section 8, is
further amended by adding at the end the following:
``(5) Drug management program for at-risk beneficiaries.--
``(A) Authority to establish.--A PDP sponsor may
establish a drug management program for at-risk
beneficiaries under which, subject to subparagraph (B),
the PDP sponsor may, in the case of an at-risk
beneficiary for prescription drug abuse who is an
enrollee in a prescription drug plan of such PDP
sponsor, limit such beneficiary's access to coverage
for frequently abused drugs under such plan to
frequently abused drugs that are prescribed for such
beneficiary by a prescriber selected under subparagraph
(D), and dispensed for such beneficiary by a pharmacy
selected under such subparagraph.
``(B) Requirement for notices.--
``(i) In general.--A PDP sponsor may not
limit the access of an at-risk beneficiary for
prescription drug abuse to coverage for
frequently abused drugs under a prescription
drug plan until such sponsor--
``(I) provides to the beneficiary
an initial notice described in clause
(ii) and a second notice described in
clause (iii); and
``(II) verifies with the providers
of the beneficiary that the beneficiary
is an at-risk beneficiary for
prescription drug abuse.
``(ii) Initial notice.--An initial notice
described in this clause is a notice that
provides to the beneficiary--
``(I) notice that the PDP sponsor
has identified the beneficiary as
potentially being an at-risk
beneficiary for prescription drug
abuse;
``(II) information describing all
State and Federal public health
resources that are designed to address
prescription drug abuse to which the
beneficiary has access, including
mental health services and other
counseling services;
``(III) notice of, and information
about, the right of the beneficiary to
appeal such identification under
subsection (h) and the option of an
automatic escalation to external
review;
``(IV) a request for the
beneficiary to submit to the PDP
sponsor preferences for which
prescribers and pharmacies the
beneficiary would prefer the PDP
sponsor to select under subparagraph
(D) in the case that the beneficiary is
identified as an at-risk beneficiary
for prescription drug abuse as
described in clause (iii)(I);
``(V) an explanation of the meaning
and consequences of the identification
of the beneficiary as potentially being
an at-risk beneficiary for prescription
drug abuse, including an explanation of
the drug management program established
by the PDP sponsor pursuant to
subparagraph (A);
``(VI) clear instructions that
explain how the beneficiary can contact
the PDP sponsor in order to submit to
the PDP sponsor the preferences
described in subclause (IV) and any
other communications relating to the
drug management program for at-risk
beneficiaries established by the PDP
sponsor; and
``(VII) contact information for
other organizations that can provide
the beneficiary with assistance
regarding such drug management program
(similar to the information provided by
the Secretary in other standardized
notices provided to part D eligible
individuals enrolled in prescription
drug plans under this part).
``(iii) Second notice.--A second notice
described in this clause is a notice that
provides to the beneficiary notice--
``(I) that the PDP sponsor has
identified the beneficiary as an at-
risk beneficiary for prescription drug
abuse;
``(II) that such beneficiary is
subject to the requirements of the drug
management program for at-risk
beneficiaries established by such PDP
sponsor for such plan;
``(III) of the prescriber and
pharmacy selected for such individual
under subparagraph (D);
``(IV) of, and information about,
the beneficiary's right to appeal such
identification under subsection (h) and
the option of an automatic escalation
to external review;
``(V) that the beneficiary can, in
the case that the beneficiary has not
previously submitted to the PDP sponsor
preferences for which prescribers and
pharmacies the beneficiary would prefer
the PDP sponsor select under
subparagraph (D), submit such
preferences to the PDP sponsor; and
``(VI) that includes clear
instructions that explain how the
beneficiary can contact the PDP
sponsor.
``(iv) Timing of notices.--
``(I) In general.--Subject to
subclause (II), a second notice
described in clause (iii) shall be
provided to the beneficiary on a date
that is not less than 60 days after an
initial notice described in clause (ii)
is provided to the beneficiary.
``(II) Exception.--In the case that
the PDP sponsor, in conjunction with
the Secretary, determines that concerns
identified through rulemaking by the
Secretary regarding the health or
safety of the beneficiary or regarding
significant drug diversion activities
require the PDP sponsor to provide a
second notice described in clause (iii)
to the beneficiary on a date that is
earlier than the date described in
subclause (II), the PDP sponsor may
provide such second notice on such
earlier date.
``(C) At-risk beneficiary for prescription drug
abuse.--
``(i) In general.--For purposes of this
paragraph, the term `at-risk beneficiary for
prescription drug abuse' means a part D
eligible individual who is not an exempted
individual described in clause (ii) and--
``(I) who is identified through the
use of guidelines developed by the
Secretary in consultation with PDP
sponsors and other stakeholders
described in section 12(f)(2)(A) of the
Protecting the Integrity of Medicare
Act of 2014; or
``(II) with respect to whom the PDP
sponsor of a prescription drug plan,
upon enrolling such individual in such
plan, received notice from the
Secretary that such individual was
identified under this paragraph to be
an at-risk beneficiary for prescription
drug abuse under the prescription drug
plan in which such individual was most
recently previously enrolled and such
identification has not been terminated
under subparagraph (F).
``(ii) Exempted individual described.--An
exempted individual described in this clause is
an individual who--
``(I) receives hospice care under
this title; or
``(II) the Secretary elects to
treat as an exempted individual for
purposes of clause (i).
``(D) Selection of prescribers.--
``(i) In general.--With respect to each at-
risk beneficiary for prescription drug abuse
enrolled in a prescription drug plan offered by
such sponsor, a PDP sponsor shall, based on the
preferences submitted to the PDP sponsor by the
beneficiary pursuant to clauses (ii)(IV) and
(iii)(V) of subparagraph (B), select--
``(I) one or more individuals who
are authorized to prescribe frequently
abused drugs (referred to in this
paragraph as `prescribers') who may
write prescriptions for such drugs for
such beneficiary; and
``(II) one or more pharmacies that
may dispense such drugs to such
beneficiary.
``(ii) Reasonable access.--In making the
selection under this subparagraph, a PDP
sponsor shall ensure that the beneficiary
continues to have reasonable access to drugs
described in subparagraph (G), taking into
account geographic location, beneficiary
preference, affordability, and reasonable
travel time.
``(iii) Beneficiary preferences.--
``(I) In general.--If an at-risk
beneficiary for prescription drug abuse
submits preferences for which in-
network prescribers and pharmacies the
beneficiary would prefer the PDP
sponsor select in response to a notice
under subparagraph (B), the PDP sponsor
shall--
``(aa) review such
preferences;
``(bb) select or change the
selection of a prescriber or
pharmacy for the beneficiary
based on such preferences; and
``(cc) inform the
beneficiary of such selection
or change of selection.
``(II) Exception.--In the case that
the PDP sponsor determines that a
change to the selection of a prescriber
or pharmacy under item (bb) by the PDP
sponsor is contributing or would
contribute to prescription drug abuse
or drug diversion by the beneficiary,
the PDP sponsor may change the
selection of a prescriber or pharmacy
for the beneficiary without regard to
the preferences of the beneficiary
described in subclause (I).
``(iv) Confirmation.--Before selecting a
prescriber or pharmacy under this subparagraph,
a PDP sponsor must request and receive
confirmation from the prescriber or pharmacy
acknowledging and accepting that the
beneficiary involved is in the drug management
program for at-risk beneficiaries.
``(E) Terminations and appeals.--The identification
of an individual as an at-risk beneficiary for
prescription drug abuse under this paragraph, a
coverage determination made under a drug management
program for at-risk beneficiaries, and the selection of
a prescriber or pharmacy under subparagraph (D) with
respect to such individual shall be subject to
reconsideration and appeal under subsection (h) and the
option of an automatic escalation to external review to
the extent provided by the Secretary.
``(F) Termination of identification.--
``(i) In general.--The Secretary shall
develop standards for the termination of
identification of an individual as an at-risk
beneficiary for prescription drug abuse under
this paragraph. Under such standards such
identification shall terminate as of the
earlier of--
``(I) the date the individual
demonstrates that the individual is no
longer likely, in the absence of the
restrictions under this paragraph, to
be an at-risk beneficiary for
prescription drug abuse described in
subparagraph (C)(i); or
``(II) the end of such maximum
period of identification as the
Secretary may specify.
``(ii) Rule of construction.--Nothing in
clause (i) shall be construed as preventing a
plan from identifying an individual as an at-
risk beneficiary for prescription drug abuse
under subparagraph (C)(i) after such
termination on the basis of additional
information on drug use occurring after the
date of notice of such termination.
``(G) Frequently abused drug.--For purposes of this
subsection, the term `frequently abused drug' means a
drug that is determined by the Secretary to be
frequently abused or diverted and that is--
``(i) a Controlled Drug Substance in
Schedule CII-CIV;
``(ii) within the same class or category of
drugs as a Controlled Drug Substance in
Schedule CII-CIV; or
``(iii) within another class or category of
drugs that the Secretary determines, in
consultation with the Inspector General of the
Department of Health and Human Services, is at
high risk for diversion or abuse.
``(H) Data disclosure.--In the case of an at-risk
beneficiary for prescription drug abuse whose access to
coverage for frequently abused drugs under a
prescription drug plan has been limited by a PDP
sponsor under this paragraph, such PDP sponsor shall
disclose data, including any necessary individually
identifiable health information, in a form and manner
specified by the Secretary, about the decision to
impose such limitations and the limitations imposed by
the sponsor under this part.
``(I) Education.--The Secretary shall provide
education to enrollees in prescription drug plans of
PDP sponsors and providers regarding the drug
management program for at-risk beneficiaries described
in this paragraph, including education--
``(i) provided by medicare administrative
contractors through the improper payment
outreach and education program described in
section 1874A(h); and
``(ii) through current education efforts
(such as State health insurance assistance
programs described in subsection (a)(1)(A) of
section 119 of the Medicare Improvements for
Patients and Providers Act of 2008 (42 U.S.C.
1395b-3 note)) and materials directed toward
such enrollees.''.
(2) Information for consumers.--Section 1860D-4(a)(1)(B) of
the Social Security Act (42 U.S.C. 1395w-104(a)(1)(B)) is
amended by adding at the end the following:
``(v) The drug management program for at-
risk beneficiaries under subsection (c)(5).''.
(b) Utilization Management Programs.--Section 1860D-4(c) of the
Social Security Act (42 U.S.C. 1395w-104(c)), as amended by subsection
(a) and section 8, is further amended--
(1) in paragraph (1), by inserting after subparagraph (D)
the following new subparagraph:
``(E) A utilization management tool to prevent drug
abuse (as described in paragraph (6)(A)).''; and
(2) by adding at the end the following new paragraph:
``(6) Utilization management tool to prevent drug abuse.--
``(A) In general.--A tool described in this
paragraph is any of the following:
``(i) A utilization tool designed to
prevent the abuse of frequently abused drugs by
individuals and to prevent the diversion of
such drugs at pharmacies.
``(ii) Retrospective utilization review to
identify--
``(I) individuals that receive
frequently abused drugs at a frequency
or in amounts that are not clinically
appropriate; and
``(II) providers of services or
suppliers that may facilitate the abuse
or diversion of frequently abused drugs
by beneficiaries.
``(iii) Consultation with the Contractor
described in subparagraph (B) to verify if an
individual enrolling in a prescription drug
plan offered by a PDP sponsor has been
previously identified by another PDP sponsor as
an individual described in clause (ii)(I).
``(B) Reporting.--A PDP sponsor offering a
prescription drug plan in a State shall submit to the
Secretary and the Medicare drug integrity contractor
with which the Secretary has entered into a contract
under section 1893 with respect to such State a report,
on a monthly basis, containing information on--
``(i) any provider of services or supplier
described in subparagraph (A)(ii)(II) that is
identified by such plan sponsor during the 30-
day period before such report is submitted; and
``(ii) the name and prescription records of
individuals described in paragraph (5)(C).''.
(c) Expanding Activities of Medicare Drug Integrity Contractors
(MEDICs).--Section 1893 of the Social Security Act (42 U.S.C. 1395ddd)
is amended by adding at the end the following new subsection:
``(j) Expanding Activities of Medicare Drug Integrity Contractors
(MEDICs).--
``(1) Access to information.--Under contracts entered into
under this section with Medicare drug integrity contractors,
the Secretary shall authorize such contractors to directly
accept prescription and necessary medical records from entities
such as pharmacies, prescription drug plans, and physicians
with respect to an individual in order for such contractors to
provide information relevant to the determination of whether
such individual is an at-risk beneficiary for prescription drug
abuse, as defined in section 1860D-4(c)(5)(C).
``(2) Requirement for acknowledgment of referrals.--If a
PDP sponsor refers information to a contractor described in
paragraph (1) in order for such contractor to assist in the
determination described in such paragraph, the contractor
shall--
``(A) acknowledge to the PDP sponsor receipt of the
referral; and
``(B) in the case that any PDP sponsor contacts the
contractor requesting to know the determination by the
contractor of whether or not an individual has been
determined to be an individual described such
paragraph, shall inform such PDP sponsor of such
determination on a date that is not later than 15 days
after the date on which the PDP sponsor contacts the
contractor.
``(3) Making data available to other entitiessect.--
``(A) In general.--For purposes of carrying out
this subsection, subject to subparagraph (B), the
Secretary shall authorize MEDICs to respond to requests
for information from PDP sponsors, State prescription
drug monitoring programs, and other entities delegated
by PDP sponsors using available programs and systems in
the effort to prevent fraud, waste, and abuse.
``(B) HIPAA compliant information only.--
Information may only be disclosed by a MEDIC under
subparagraph (A) if the disclosure of such information
is permitted under the Federal regulations (concerning
the privacy of individually identifiable health
information) promulgated under section 264(c) of the
Health Insurance Portability and Accountability Act of
1996 (42 U.S.C. 1320d-2 note).''.
(d) Treatment of Certain Complaints for Purposes of Quality or
Performance Assessment.--Section 1860D-42 of the Social Security Act
(42 U.S.C. 1395w-152) is amended by adding at the end the following new
subsection:
``(d) Treatment of Certain Complaints for Purposes of Quality or
Performance Assessment.--In conducting a quality or performance
assessment of a PDP sponsor, the Secretary shall develop or utilize
existing screening methods for reviewing and considering complaints
that are received from enrollees in a prescription drug plan offered by
such PDP sponsor and that are complaints regarding the lack of access
by the individual to prescription drugs due to a drug management
program for at-risk beneficiaries.''.
(e) GAO Studies and Reports.--
(1) Studies.--The Comptroller General of the United States
shall conduct a study on each of the following:
(A) The implementation of the amendments made by
this section.
(B) The effectiveness of the at-risk beneficiaries
for prescription drug abuse drug management programs
authorized by section 1860D-4(c)(5) of the Social
Security Act (42 U.S.C. 1395w-10(c)(5)), as added by
subsection (a)(1), including an analysis of--
(i) the impediments, if any, that impair
the ability of individuals described in
subparagraph (C) of such section 1860D-4(c)(5)
to access clinically appropriate levels of
prescription drugs; and
(ii) the types of--
(I) individuals who, in the
implementation of such section, are
determined to be individuals described
in such subparagraph; and
(II) prescribers and pharmacies
that are selected under subparagraph
(D) of such section.
(2) Reports.--Not later than January 1, 2016, the
Comptroller General of the United States shall begin work, with
respect to each study described in paragraph (1), on a report
that describes the result of such study. Upon the completion of
each such report, such Comptroller General shall submit the
report to each of the committees described in paragraph (3).
(3) Committees described.--The committees described in this
paragraph are the following:
(A) The Committee on Ways and Means of the House of
Representatives.
(B) The Committee on Energy and Commerce of the
House of Representatives.
(C) The Committee on Finance of the Senate.
(D) The Committee on Health, Education, Labor, and
Pensions of the Senate.
(E) The Special Committee on Aging of the Senate.
(f) Effective Date.--
(1) In general.--The amendments made by this section shall
apply to prescription drug plans for plan years beginning on or
after January 1, 2017.
(2) Stakeholder meetings prior to effective date.--
(A) In general.--Not later than January 1, 2016,
the Secretary shall convene stakeholders, including
individuals entitled to benefits under part A of title
XVIII of the Social Security Act or enrolled under part
B of such title of such Act, advocacy groups
representing such individuals, clinicians, plan
sponsors, and entities delegated by plan sponsors, for
input regarding the topics described in subparagraph
(B).
(B) Topics described.--The topics described in this
subparagraph are the topics of--
(i) ensuring affordability and
accessibility to prescription drugs for
enrollees in prescription drug plans of PDP
sponsors who are at-risk beneficiaries for
prescription drug abuse (as defined in
paragraph (5)(C) of section 1860D-4(c) of the
Social Security Act (42 U.S.C. 1395w-10(c)));
(ii) the use of an expedited appeals
process under which such an enrollee may appeal
an identification of such enrollee as an at-
risk beneficiary for prescription drug abuse
under such paragraph (similar to the processes
established under the Medicare Advantage
program under part C of title XVIII of the
Social Security Act that allow an automatic
escalation to external review of claims
submitted under such part);
(iii) the types of enrollees that should be
treated as exempted individuals, as described
in clause (ii) of such paragraph;
(iv) the manner in which terms and
definitions in paragraph (5) of such section
1860D-4(c) should be applied, such as the use
of clinical appropriateness in determining
whether an enrollee is an at-risk beneficiary
for prescription drug abuse as defined in
subparagraph (C) of such paragraph (5);
(v) the information to be included in the
notices described in subparagraph (B) of such
section and the standardization of such
notices; and
(vi) with respect to a PDP sponsor that
establishes a drug management program for at-
risk beneficiaries under such paragraph (5),
the responsibilities of such PDP sponsor with
respect to the implementation of such program.
(C) Rulemaking.--The Secretary shall promulgate
regulations based on the input gathered pursuant to
subparagraph (A).
SEC. 13. GUIDANCE ON APPLICATION OF COMMON RULE TO CLINICAL DATA
REGISTRIES.
Not later than one year after the date of the enactment of this
section, the Secretary of Health and Human Services shall issue a
clarification or modification with respect to the application of
subpart A of part 46 of title 45, Code of Federal Regulations,
governing the protection of human subjects in research (and commonly
known as the ``Common Rule''), to activities, including quality
improvement activities, involving clinical data registries, including
entities that are qualified clinical data registries pursuant to
section 1848(m)(3)(E) of the Social Security Act (42 U.S.C. 1395w-
4(m)(3)(E)).
SEC. 14. ELIMINATING CERTAIN CIVIL MONEY PENALTIES; GAINSHARING STUDY
AND REPORT.
(a) Eliminating Civil Money Penalties for Inducements to Physicians
To Limit Services That Are Not Medically Necessary.--
(1) In general.--Section 1128A(b)(1) of the Social Security
Act (42 U.S.C. 1320a-7a(b)(1)) is amended by inserting
``medically necessary'' after ``reduce or limit''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to payments made on or after the date of the
enactment of this Act.
(b) Gainsharing Study and Report.--Not later than 12 months after
the date of the enactment of this Act, the Secretary of Health and
Human Services, in consultation with the Inspector General of the
Department of Health and Human Services, shall submit to Congress a
report with options for amending existing fraud and abuse laws in, and
regulations related to, titles XI and XVIII of the Social Security Act
(42 U.S.C. 301 et seq.), through exceptions, safe harbors, or other
narrowly targeted provisions, to permit gainsharing arrangements that
otherwise would be subject to the civil money penalties described in
paragraphs (1) and (2) of section 1128A(b) of such Act (42 U.S.C.
1320a-7a(b)), or similar arrangements between physicians and hospitals,
and that improve care while reducing waste and increasing efficiency.
The report shall--
(1) consider whether such provisions should apply to
ownership interests, compensation arrangements, or other
relationships;
(2) describe how the recommendations address
accountability, transparency, and quality, including how best
to limit inducements to stint on care, discharge patients
prematurely, or otherwise reduce or limit medically necessary
care; and
(3) consider whether a portion of any savings generated by
such arrangements (as compared to an historical benchmark or
other metric specified by the Secretary to determine the impact
of delivery and payment system changes under such title XVIII
on expenditures made under such title) should accrue to the
Medicare program under title XVIII of the Social Security Act.
SEC. 15. MODIFICATION OF MEDICARE HOME HEALTH SURETY BOND CONDITION OF
PARTICIPATION REQUIREMENT.
Section 1861(o)(7) of the Social Security Act (42 U.S.C.
1395x(o)(7)) is amended to read as follows:
``(7) provides the Secretary with a surety bond--
``(A) in a form specified by the Secretary and in
an amount that is not less than the minimum of $50,000;
and
``(B) that the Secretary determines is commensurate
with the volume of payments to the home health agency;
and''.
SEC. 16. OVERSIGHT OF MEDICARE COVERAGE OF MANUAL MANIPULATION OF THE
SPINE TO CORRECT SUBLUXATION.
(a) In General.--Section 1833 of the Social Security Act (42 U.S.C.
1395l) is amended by adding at the end the following new subsection:
``(z) Medical Review of Spinal Subluxation Services.--
``(1) In general.--The Secretary shall implement a process
for the medical review (as described in paragraph (2)) of
treatment by a chiropractor described in section 1861(r)(5) by
means of manual manipulation of the spine to correct a
subluxation (as described in such section) of an individual who
is enrolled under this part and apply such process to such
services furnished on or after January 1, 2017, focusing on
services such as--
``(A) services furnished by a such a chiropractor
whose pattern of billing is aberrant compared to peers;
and
``(B) services furnished by such a chiropractor
who, in a prior period, has a services denial
percentage in the 85th percentile or greater, taking
into consideration the extent that service denials are
overturned on appeal.
``(2) Medical review.--
``(A) Prior authorization medical review.--
``(i) In general.--Subject to clause (ii),
the Secretary shall use prior authorization
medical review for services described in
paragraph (1) that are furnished to an
individual by a chiropractor described in
section 1861(r)(5) that are part of an episode
of treatment that includes more than 12
services. For purposes of the preceding
sentence, an episode of treatment shall be
determined by the underlying cause that
justifies the need for services, such as a
diagnosis code.
``(ii) Ending application of prior
authorization medical review.--The Secretary
shall end the application of prior
authorization medical review under clause (i)
to services described in paragraph (1) by such
a chiropractor if the Secretary determines that
the chiropractor has a low denial rate under
such prior authorization medical review. The
Secretary may subsequently reapply prior
authorization medical review to such
chiropractor if the Secretary determines it to
be appropriate and the chiropractor has, in the
time period subsequent to the determination by
the Secretary of a low denial rate with respect
to the chiropractor, furnished such services
described in paragraph (1).
``(iii) Early request for prior
authorization review permitted.--Nothing in
this subsection shall be construed to prevent
such a chiropractor from requesting prior
authorization for services described in
paragraph (1) that are to be furnished to an
individual before the chiropractor furnishes
the twelfth such service to such individual for
an episode of treatment.
``(B) Type of review.--The Secretary may use pre-
payment review or post-payment review of services
described in section 1861(r)(5) that are not subject to
prior authorization medical review under subparagraph
(A).
``(C) Relationship to law enforcement activities.--
The Secretary may determine that medical review under
this subsection does not apply in the case where
potential fraud may be involved.
``(3) No payment without prior authorization.--With respect
to a service described in paragraph (1) for which prior
authorization medical review under this subsection applies, the
following shall apply:
``(A) Prior authorization determination.--The
Secretary shall make a determination, prior to the
service being furnished, of whether the service would
or would not meet the applicable requirements of
section 1862(a)(1)(A).
``(B) Denial of payment.--Subject to paragraph (5),
no payment may be made under this part for the service
unless the Secretary determines pursuant to
subparagraph (A) that the service would meet the
applicable requirements of such section 1862(a)(1)(A).
``(4) Submission of information.--A chiropractor described
in section 1861(r)(5) may submit the information necessary for
medical review by fax, by mail, or by electronic means. The
Secretary shall make available the electronic means described
in the preceding sentence as soon as practicable.
``(5) Timeliness.--If the Secretary does not make a prior
authorization determination under paragraph (3)(A) within 14
business days of the date of the receipt of medical
documentation needed to make such determination, paragraph
(3)(B) shall not apply.
``(6) Application of limitation on beneficiary liability.--
Where payment may not be made as a result of the application of
paragraph (2)(B), section 1879 shall apply in the same manner
as such section applies to a denial that is made by reason of
section 1862(a)(1).
``(7) Review by contractors.--The medical review described
in paragraph (2) may be conducted by medicare administrative
contractors pursuant to section 1874A(a)(4)(G) or by any other
contractor determined appropriate by the Secretary that is not
a recovery audit contractor.
``(8) Multiple services.--The Secretary shall, where
practicable, apply the medical review under this subsection in
a manner so as to allow an individual described in paragraph
(1) to obtain, at a single time rather than on a service-by-
service basis, an authorization in accordance with paragraph
(3)(A) for multiple services.
``(9) Construction.--With respect to a service described in
paragraph (1) that has been affirmed by medical review under
this subsection, nothing in this subsection shall be construed
to preclude the subsequent denial of a claim for such service
that does not meet other applicable requirements under this
Act.
``(10) Implementation.--
``(A) Authority.--The Secretary may implement the
provisions of this subsection by interim final rule
with comment period.
``(B) Administration.--Chapter 35 of title 44,
United States Code, shall not apply to medical review
under this subsection.''.
(b) Improving Documentation of Services.--
(1) In general.--The Secretary of Health and Human Services
shall, in consultation with stakeholders (including the
American Chiropractic Association) and representatives of
medicare administrative contractors (as defined in section
1874A(a)(3)(A) of the Social Security Act (42 U.S.C. 1395kk-
1(a)(3)(A))), develop educational and training programs to
improve the ability of chiropractors to provide documentation
to the Secretary of services described in section 1861(r)(5) in
a manner that demonstrates that such services are, in
accordance with section 1862(a)(1) of such Act (42 U.S.C.
1395y(a)(1)), reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the functioning of
a malformed body member.
(2) Timing.--The Secretary shall make the educational and
training programs described in paragraph (1) publicly available
not later than January 1, 2016.
(3) Funding.--The Secretary shall use funds made available
under section 1893(h)(10) of the Social Security Act (42 U.S.C.
1395ddd(h)(10)), as added by section 6, to carry out this
subsection.
(c) GAO Study and Report.--
(1) Study.--The Comptroller General of the United States
shall conduct a study on the effectiveness of the process for
medical review of services furnished as part of a treatment by
means of manual manipulation of the spine to correct a
subluxation implemented under subsection (z) of section 1833 of
the Social Security Act (42 U.S.C. 1395l), as added by
subsection (a). Such study shall include an analysis of--
(A) aggregate data on--
(i) the number of individuals,
chiropractors, and claims for services subject
to such review; and
(ii) the number of reviews conducted under
such section; and
(B) the outcomes of such reviews.
(2) Report.--Not later than four years after the date of
enactment of this Act, the Comptroller General shall submit to
Congress a report containing the results of the study conducted
under paragraph (1), including recommendations for such
legislation and administrative action with respect to the
process for medical review implemented under subsection (z) of
section 1833 of the Social Security Act (42 U.S.C. 1395l) as
the Comptroller General determines appropriate.
SEC. 17. LIMITING PAYMENT AMOUNT UNDER MEDICARE PROGRAM FOR VACUUM
ERECTION SYSTEMS.
(a) Inclusion in Program.--Section 1847(a)(2) of the Social
Security Act (42 U.S.C. 1395w-3(a)(2)) is amended by adding at the end
the following new subparagraph:
``(D) Vacuum erection systems.--Vacuum erection
systems covered as prosthetic devices described in
section 1861(s)(8) for which payment would otherwise be
made under section 1834(h).''.
(b) National Mail Order Program.--Section 1847(a)(1)(D) of the
Social Security Act (42 U.S.C. 1395w-3(a)(1)(D)) is amended by adding
at the end the following new clause:
``(iv) National mail order program for
vacuum erection systems.--The Secretary shall
phase in a national mail order program under
this section for vacuum erection systems
described in paragraph (2)(D). The first round
of competition for such program shall occur in
2016, with contracts taking effect after the
competition is completed. Chapter 35 of title
44, United States Code (commonly referred to as
the `Paperwork Reduction Act of 1995') shall
not apply to the first round competition for
such program.''.
SEC. 18. NATIONAL EXPANSION OF PRIOR AUTHORIZATION MODEL FOR REPETITIVE
SCHEDULED NON-EMERGENT AMBULANCE TRANSPORT.
(a) Initial Expansion.--
(1) In general.--In implementing the model described in
paragraph (2) proposed to be tested under subsection (b) of
section 1115A of the Social Security Act (42 U.S.C. 1315a), the
Secretary of Health and Human Services shall revise the testing
under subsection (b) of such section to cover, effective
January 1, 2016, States located in medicare administrative
contractor (MAC) regions L and 11 (consisting of Delaware, the
District of Columbia, Maryland, New Jersey, Pennsylvania, North
Carolina, South Carolina, West Virginia, and Virginia).
(2) Model described.--The model described in this paragraph
is the testing of a model of prior authorization for repetitive
scheduled non-emergent ambulance transport proposed to be
carried out in New Jersey, Pennsylvania, and South Carolina.
(3) Funding.--The Secretary shall allocate funds made
available under section 1115A(f)(1)(B) of the Social Security
Act (42 U.S.C. 1315a(f)(1)(B)) to carry out this subsection.
(b) National Expansion.--Section 1834(l) of the Social Security Act
(42 U.S.C. 1395m(l)) is amended by adding at the end the following new
paragraph:
``(16) Prior authorization for repetitive scheduled non-
emergency ambulance transports.--
``(A) In general.--Beginning January 1, 2017, the
Secretary shall apply the prior authorization program
described in subparagraph (B) to all States.
``(B) Program described.--The prior authorization
program described in this subparagraph is a prior
authorization program for repetitive scheduled
ambulance services consisting of non-emergency basic
life support services involving transport of an
individual furnished other than on an emergency basis.
In carrying out the program, the Secretary shall
determine in advance of the provision of items and
services related to the provision of such an ambulance
service whether payment for such items or services may
not be made because the item or service is not covered
or because of the application of section 1862(a)(1).
``(C) Implementation.--The program described in
subparagraph (B) shall be implemented in a manner that
is consistent with the terms and conditions for the
testing of a model of prior authorization for
repetitive scheduled non-emergent ambulance transport
proposed by the Centers for Medicare & Medicaid
Services to be implemented in New Jersey, Pennsylvania,
and South Carolina under section 1115A.
``(D) Funding.--The Secretary shall use funds made
available under section 1893(h)(10) to carry out this
paragraph.''.
SEC. 19. REPEALING DUPLICATIVE MEDICARE SECONDARY PAYOR PROVISION.
(a) In General.--Section 1862(b)(5) of the Social Security Act (42
U.S.C. 1395y(b)(5)) is amended by inserting at the end the following
new subparagraph:
``(E) End date.--The provisions of this paragraph
shall not apply to information required to be provided
on or after July 1, 2016.''.
(b) Effective Date.--The amendment made by subsection (a) shall
take effect on the date of the enactment of this Act and shall apply to
information required to be provided on or after January 1, 2016.
SEC. 20. PLAN FOR EXPANDING DATA IN ANNUAL CERT REPORT.
Not later than March 25, 2015, the Secretary of Health and Human
Services shall submit to the Committee on Finance of the Senate, and to
the Committees on Energy and Commerce and on Ways and Means of the
House of Representatives--
(1) a plan for including, in the annual report of the
Comprehensive Error Rate Testing (CERT) program, data on
services (or groupings of services) (other than medical visits)
paid under the physician fee schedule under section 1848 of the
Social Security Act (42 U.S.C. 1395w-4) where the fee schedule
amount is in excess of 250 dollars and where the error rate is
in excess of 20 percent; and
(2) to the extent practicable by such date, specific
examples of services described in paragraph (1).
SEC. 21. RULE OF CONSTRUCTION.
Except as explicitly provided in this Act, nothing in this Act,
including the amendments made by this Act, shall be construed as
preventing the use of notice and comment rulemaking in the
implementation of the provisions of, and the amendments made by, this
Act.
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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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