SGR Repeal and Medicare Beneficiary Access Act of 2013 - Amends title XVIII (Medicare) of the Social Security Act (SSA) to: (1) end and remove sustainable growth rate (SGR) methodology from the determination of annual conversion factors in the formula for payment for physicians' services, (2) freeze the update to the single conversion factor at 0.5% for 2014 through 2018 and at 0.00% for 2019 through 2023, and (3) establish an update of 1% for health professionals participating in alternative payment models (APMs) and an update of 0.5% for all other health professionals after 2023.
Directs the Medicare Payment Advisory Commission (MEDPAC) to report to Congress on the relationship between: (1) physician and other health professional utilization and expenditures (and their rate of increase) of items and services for which Medicare payment is made; and (2) total utilization and expenditures (and their rate of increase) under Medicare parts A (Hospital Insurance), B (Supplementary Medical Insurance), and D (Voluntary Prescription Drug Benefit Program). Requires a separate report on the 2014-2018 update to physicians' services under Medicare
Revises and consolidates components of the three specified existing performance incentive programs into a merit-based incentive payment (MIP) system the Secretary of Health and Human Services (HHS) is directed to establish, under which MIP-eligible professionals (excluding most APM participants) receive annual payment increases or decreases based on their performance.
Requires specified incentive payments to eligible APM participants.
Directs the Secretary to make available on the Physician Compare website certain information, including information regarding the performance of MIP-eligible professionals.
Requires the Comptroller General (GAO) to evaluate the VBP program.
Requires the Secretary to study the application of federal fraud prevention laws related to APMs.
Directs the Secretary to draft a plan for development of quality measures to assess professionals, including non-patient-facing professionals.
Requires the Secretary to establish new Healthcare Common Procedure Coding System (HCPCS) codes for chronic care management services.
Directs the Secretary to conduct an education and outreach campaign to inform professionals who furnish items and services under Medicare part B and part B enrollees of the benefits of chronic care management services.
Authorizes the Secretary to: (1) collect and use information on the resources directly or indirectly related to physicians' services in the determination of relative values under the fee schedule; and (2) establish or adjust practice expense relative values using cost, charge, or other data from suppliers or service providers.
Revises and expands factors for identification of potentially misvalued codes. Sets an annual target for relative value adjustments for misvalued services. Phases-in significant relative value unit (RVU) reductions.
Directs the Secretary to establish a program to promote the use of appropriate use evidence-based criteria for applicable imaging services furnished in an applicable setting by ordering professionals and furnishing professionals.
Expands the kinds of uses of Medicare data available to qualified entities for quality improvement activities.
Directs the Secretary to provide Medicare data to qualified clinical data registries to facilitate quality improvement or patient safety.
Allows continuing renewals of any two-year period for which a physician or practitioner opts out of the Medicare claims process under a private contract with a beneficiary.
Declares it a national objective to achieve widespread exchange of health information through interoperable certified electronic health records (EHR) technology nationwide by December 31, 2017. Directs the Secretary to establish related metrics.
Requires meaningful EHR professionals and hospitals to demonstrate that they have not knowingly and willfully taken any action to limit or restrict the compatibility or interoperability of the certified EHR technology.
Directs GAO to study specified telehealth and remote patient monitoring services.
Modifies extensions and other requirements pertaining to the work geographic adjustment as well as Medicare payment for therapy services and ambulance services.
Revises requirements for: (1) the Medicare-dependent hospital (MDH) program, (2) the Medicare inpatient hospital payment adjustment for low-volume hospitals, as well as (3) specialized Medicare Advantage (MA) plans for special needs individuals.
Amends SSA title XIX (Medicaid) to extend the qualifying individual (QI) program, the transitional medical assistance (TMA) program, and express lane program eligibility.
Amends SSA title XI with respect to continue funding for pediatric quality measures.
Amends the Public Health Service Act to extend certain special diabetes programs.
Extends the abstinence education grant program, the personal responsibility education program, and family-to-family health information centers.
Extends the health workforce demonstration project for low-income individuals under SSA title XX.
Requires each Medicare administrative contractor to establish an improper payment outreach and education program to give service providers and suppliers information on payment errors with a view to reducing improper Medicare payments.
Revises requirements for a Medicaid fraud control unit's authority to investigate and prosecute complaints of abuse and neglect of patients in home and community-based settings.
Authorizes the HHS Inspector General to receive and retain 3% of all amounts collected pursuant to civil debt collection and administrative enforcement actions related to false claims or frauds involving the Medicare or Medicaid program.
Requires valid prescriber National Provider Identifiers on pharmacy claims against prescription drug plans (PDPs).
Directs the Secretary to establish a Commission on Improving Patient Directed Health Care.
Expands the definition of inpatient hospital services for certain cancer hospitals.
Directs the Secretary to provide for the development of one or more quality measures under Medicare to accurately communicate the existence and provide for the transfer of patient health information and patient care preferences when an individual transitions from a hospital to return home or move to other post-acute care settings.
Specifies that the minimum level of supervision with respect to outpatient therapeutic critical access hospital services shall be general supervision.
Requires state licensure of bidding entities under the competitive acquisition program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).
Recognizes attending physician assistants as attending physicians to serve hospice patients under Medicare.
Directs the Secretary to conduct remote patient monitoring pilot projects.
Requires the Secretary to establish a Community-Based Institutional Special Needs Plan demonstration project to prevent and delay institutionalization under Medicaid among targeted low-income Medicare beneficiaries.
Directs the Secretary to implement a strategic plan to increase the usefulness of data about Medicaid programs reported by states to the Centers for Medicare and Medicaid Services.
Includes podiatrists as physicians under the Medicaid program.
Modifies Medicare requirements for inclusion of diabetic shoes under medical and other health services.
Directs the Secretary to: (1) publish criteria for a clinic to be certified by a state as a certified community behavioral health clinic, (2) award states planning grants to develop proposals to participate in time-limited related demonstration programs, and (3) select states to participate in such programs.
Requires the Secretary to report annually to Congress on payment adjustments to disproportionate share hospitals (DSHs) in order to provide Congress with information relevant to determining an appropriate level of overall funding for such adjustments during and after a certain period in which aggregate reductions in DSH allotments to states are required.
Amends the Patient Protection and Affordable Care Act and the Internal Revenue Code (IRC) to repeal the requirement that individuals maintain minimal essential health care coverage beginning in 2014, subject to a specified tax penalty for failing to do so (individual mandate). Requires the IRC to be applied and administered as if such requirement had never been enacted.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[S. 2122 Placed on Calendar Senate (PCS)]
Calendar No. 330
113th CONGRESS
2d Session
S. 2122
To amend titles XVIII and XIX of the Social Security Act to repeal the
Medicare sustainable growth rate and to improve Medicare and Medicaid
payments, and for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
March 12, 2014
Mr. Hatch (for himself, Mr. McConnell, and Mr. Cornyn) introduced the
following bill; which was read the first time
March 13, 2014
Read the second time and placed on the calendar
_______________________________________________________________________
A BILL
To amend titles XVIII and XIX of the Social Security Act to repeal the
Medicare sustainable growth rate and to improve Medicare and Medicaid
payments, 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 ``Responsible
Medicare SGR Repeal and Beneficiary Access Improvement Act of 2014''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--MEDICARE PAYMENT FOR PHYSICIANS' SERVICES
Sec. 101. Repealing the sustainable growth rate (SGR) and improving
Medicare payment for physicians' services.
Sec. 102. Priorities and funding for measure development.
Sec. 103. Encouraging care management for individuals with chronic care
needs.
Sec. 104. Ensuring accurate valuation of services under the physician
fee schedule.
Sec. 105. Promoting evidence-based care.
Sec. 106. Empowering beneficiary choices through access to information
on physicians' services.
Sec. 107. Expanding availability of Medicare data.
Sec. 108. Reducing administrative burden and other provisions.
TITLE II--EXTENSIONS
Subtitle A--Medicare Extensions
Sec. 201. Work geographic adjustment.
Sec. 202. Medicare payment for therapy services.
Sec. 203. Medicare ambulance services.
Sec. 204. Revision of the Medicare-dependent hospital (MDH) program.
Sec. 205. Revision of Medicare inpatient hospital payment adjustment
for low-volume hospitals.
Sec. 206. Specialized Medicare Advantage plans for special needs
individuals.
Sec. 207. Reasonable cost reimbursement contracts.
Sec. 208. Quality measure endorsement and selection.
Sec. 209. Permanent extension of funding outreach and assistance for
low-income programs.
Subtitle B--Medicaid and Other Extensions
Sec. 211. Qualifying individual program.
Sec. 212. Transitional Medical Assistance.
Sec. 213. Express lane eligibility.
Sec. 214. Pediatric quality measures.
Sec. 215. Special diabetes programs.
Subtitle C--Human Services Extensions
Sec. 221. Abstinence education grants.
Sec. 222. Personal responsibility education program.
Sec. 223. Family-to-family health information centers.
Sec. 224. Health workforce demonstration project for low-income
individuals.
TITLE III--MEDICARE AND MEDICAID PROGRAM INTEGRITY
Sec. 301. Reducing improper Medicare payments.
Sec. 302. Authority for Medicaid fraud control units to investigate and
prosecute complaints of abuse and neglect
of Medicaid patients in home and community-
based settings.
Sec. 303. Improved use of funds received by the HHS Inspector General
from oversight and investigative
activities.
Sec. 304. Preventing and reducing improper Medicare and Medicaid
expenditures.
TITLE IV--OTHER PROVISIONS
Sec. 401. Commission on Improving Patient Directed Health Care.
Sec. 402. Expansion of the definition of inpatient hospital services
for certain cancer hospitals.
Sec. 403. Quality measures for certain post-acute care providers
relating to notice and transfer of patient
health information and patient care
preferences.
Sec. 404. Criteria for medically necessary, short inpatient hospital
stays.
Sec. 405. Transparency of reasons for excluding additional procedures
from the Medicare ambulatory surgical
center (ASC) approved list.
Sec. 406. Supervision in critical access hospitals.
Sec. 407. Requiring State licensure of bidding entities under the
competitive acquisition program for certain
durable medical equipment, prosthetics,
orthotics, and supplies (DMEPOS).
Sec. 408. Recognition of attending physician assistants as attending
physicians To serve hospice patients.
Sec. 409. Remote patient monitoring pilot projects.
Sec. 410. Community-Based Institutional Special Needs Plan
Demonstration Program.
Sec. 411. Applying CMMI waiver authority to PACE in order to foster
innovations.
Sec. 412. Improve and modernize Medicaid data systems and reporting.
Sec. 413. Fairness in Medicaid supplemental needs trusts.
Sec. 414. Helping Ensure Life- and Limb-Saving Access to Podiatric
Physicians.
Sec. 415. Demonstration programs to improve community mental health
services.
Sec. 416. Annual Medicaid DSH report.
Sec. 417. Implementation.
TITLE V--RESTORING INDIVIDUAL LIBERTY
Sec. 501. Restoring individual liberty.
TITLE I--MEDICARE PAYMENT FOR PHYSICIANS' SERVICES
SEC. 101. REPEALING THE SUSTAINABLE GROWTH RATE (SGR) AND IMPROVING
MEDICARE PAYMENT FOR PHYSICIANS' SERVICES.
(a) Stabilizing Fee Updates.--
(1) Repeal of sgr payment methodology.--Section 1848 of the
Social Security Act (42 U.S.C. 1395w-4) is amended--
(A) in subsection (d)--
(i) in paragraph (1)(A), by inserting ``or
a subsequent paragraph'' after ``paragraph
(4)''; and
(ii) in paragraph (4)--
(I) in the heading, by inserting
``and ending with 2013'' after ``years
beginning with 2001''; and
(II) in subparagraph (A), by
inserting ``and ending with 2013''
after ``a year beginning with 2001'';
and
(B) in subsection (f)--
(i) in paragraph (1)(B), by inserting
``through 2013'' after ``of each succeeding
year''; and
(ii) in paragraph (2), in the matter
preceding subparagraph (A), by inserting ``and
ending with 2013'' after ``beginning with
2000''.
(2) Update of rates for april through december of 2014,
2015, and subsequent years.--Subsection (d) of section 1848 of
the Social Security Act (42 U.S.C. 1395w-4) is amended by
striking paragraph (15) and inserting the following new
paragraphs:
``(15) Update for 2014 through 2018.--The update to the
single conversion factor established in paragraph (1)(C) for
2014 and each subsequent year through 2018 shall be 0.5
percent.
``(16) Update for 2019 through 2023.--The update to the
single conversion factor established in paragraph (1)(C) for
2019 and each subsequent year through 2023 shall be zero
percent.
``(17) Update for 2024 and subsequent years.--The update to
the single conversion factor established in paragraph (1)(C)
for 2024 and each subsequent year shall be--
``(A) for items and services furnished by a
qualifying APM participant (as defined in section
1833(z)(2)) for such year, 1.0 percent; and
``(B) for other items and services, 0.5 percent.''.
(3) MedPAC reports.--
(A) Initial report.--Not later than July 1, 2016,
the Medicare Payment Advisory Commission shall submit
to Congress a report on the relationship between--
(i) physician and other health professional
utilization and expenditures (and the rate of
increase of such utilization and expenditures)
of items and services for which payment is made
under section 1848 of the Social Security Act
(42 U.S.C. 1395w-4); and
(ii) total utilization and expenditures
(and the rate of increase of such utilization
and expenditures) under parts A, B, and D of
title XVIII of such Act.
Such report shall include a methodology to describe
such relationship and the impact of changes in such
physician and other health professional practice and
service ordering patterns on total utilization and
expenditures under parts A, B, and D of such title.
(B) Final report.--Not later than July 1, 2020, the
Medicare Payment Advisory Commission shall submit to
Congress a report on the relationship described in
subparagraph (A), including the results determined from
applying the methodology included in the report
submitted under such subparagraph.
(C) Report on update to physicians' services under
medicare.--Not later than July 1, 2018, the Medicare
Payment Advisory Commission shall submit to Congress a
report on--
(i) the payment update for professional
services applied under the Medicare program
under title XVIII of the Social Security Act
for the period of years 2014 through 2018;
(ii) the effect of such update on the
efficiency, economy, and quality of care
provided under such program;
(iii) the effect of such update on ensuring
a sufficient number of providers to maintain
access to care by Medicare beneficiaries; and
(iv) recommendations for any future payment
updates for professional services under such
program to ensure adequate access to care is
maintained for Medicare beneficiaries.
(b) Consolidation of Certain Current Law Performance Programs With
New Merit-Based Incentive Payment System.--
(1) EHR meaningful use incentive program.--
(A) Sunsetting separate meaningful use payment
adjustments.--Section 1848(a)(7)(A) of the Social
Security Act (42 U.S.C. 1395w-4(a)(7)(A)) is amended--
(i) in clause (i), by striking ``2015 or
any subsequent payment year'' and inserting
``2015, 2016, or 2017'';
(ii) in clause (ii)--
(I) in the matter preceding
subclause (I), by striking ``Subject to
clause (iii), for'' and inserting
``For''; and
(II) in subclause (III), by
striking ``and each subsequent year'';
and
(iii) by striking clause (iii).
(B) Continuation of meaningful use determinations
for mips.--Section 1848(o)(2) of the Social Security
Act (42 U.S.C. 1395w-4(o)(2)) is amended--
(i) in subparagraph (A), in the matter
preceding clause (i)--
(I) by striking ``For purposes of
paragraph (1), an'' and inserting
``An''; and
(II) by inserting ``, or pursuant
to subparagraph (D) for purposes of
subsection (q), for a performance
period under such subsection for a
year'' after ``under such subsection
for a year''; and
(ii) by adding at the end the following new
subparagraph:
``(D) Continued application for purposes of mips.--
With respect to 2018 and each subsequent payment year,
the Secretary shall, for purposes of subsection (q) and
in accordance with paragraph (1)(F) of such subsection,
determine whether an eligible professional who is a
MIPS eligible professional (as defined in subsection
(q)(1)(C)) for such year is a meaningful EHR user under
this paragraph for the performance period under
subsection (q) for such year.''.
(2) Quality reporting.--
(A) Sunsetting separate quality reporting
incentives.--Section 1848(a)(8)(A) of the Social
Security Act (42 U.S.C. 1395w-4(a)(8)(A)) is amended--
(i) in clause (i), by striking ``2015 or
any subsequent year'' and inserting ``2015,
2016, or 2017''; and
(ii) in clause (ii)(II), by striking ``and
each subsequent year'' and inserting ``and
2017''.
(B) Continuation of quality measures and processes
for mips.--Section 1848 of the Social Security Act (42
U.S.C. 1395w-4) is amended--
(i) in subsection (k), by adding at the end
the following new paragraph:
``(9) Continued application for purposes of mips and for
certain professionals volunteering to report.--The Secretary
shall, in accordance with subsection (q)(1)(F), carry out the
provisions of this subsection--
``(A) for purposes of subsection (q); and
``(B) for eligible professionals who are not MIPS
eligible professionals (as defined in subsection
(q)(1)(C)) for the year involved.''; and
(ii) in subsection (m)--
(I) by redesignating paragraph (7)
added by section 10327(a) of Public Law
111-148 as paragraph (8); and
(II) by adding at the end the
following new paragraph:
``(9) Continued application for purposes of mips and for
certain professionals volunteering to report.--The Secretary
shall, in accordance with subsection (q)(1)(F), carry out the
processes under this subsection--
``(A) for purposes of subsection (q); and
``(B) for eligible professionals who are not MIPS
eligible professionals (as defined in subsection
(q)(1)(C)) for the year involved.''.
(3) Value-based payments.--
(A) Sunsetting separate value-based payments.--
Clause (iii) of section 1848(p)(4)(B) of the Social
Security Act (42 U.S.C. 1395w-4(p)(4)(B)) is amended to
read as follows:
``(iii) Application.--The Secretary shall
apply the payment modifier established under
this subsection for items and services
furnished on or after January 1, 2015, but
before January 1, 2018, with respect to
specific physicians and groups of physicians
the Secretary determines appropriate. Such
payment modifier shall not be applied for items
and services furnished on or after January 1,
2018.''.
(B) Continuation of value-based payment modifier
measures for mips.--Section 1848(p) of the Social
Security Act (42 U.S.C. 1395w-4(p)) is amended--
(i) in paragraph (2), by adding at the end
the following new subparagraph:
``(C) Continued application for purposes of mips.--
The Secretary shall, in accordance with subsection
(q)(1)(F), carry out subparagraph (B) for purposes of
subsection (q).''; and
(ii) in paragraph (3), by adding at the end
the following: ``With respect to 2018 and each
subsequent year, the Secretary shall, in
accordance with subsection (q)(1)(F), carry out
this paragraph for purposes of subsection
(q).''.
(c) Merit-Based Incentive Payment System.--
(1) In general.--Section 1848 of the Social Security Act
(42 U.S.C. 1395w-4) is amended by adding at the end the
following new subsection:
``(q) Merit-Based Incentive Payment System.--
``(1) Establishment.--
``(A) In general.--Subject to the succeeding
provisions of this subsection, the Secretary shall
establish an eligible professional Merit-based
Incentive Payment System (in this subsection referred
to as the `MIPS') under which the Secretary shall--
``(i) develop a methodology for assessing
the total performance of each MIPS eligible
professional according to performance standards
under paragraph (3) for a performance period
(as established under paragraph (4)) for a
year;
``(ii) using such methodology, provide for
a composite performance score in accordance
with paragraph (5) for each such professional
for each performance period; and
``(iii) use such composite performance
score of the MIPS eligible professional for a
performance period for a year to determine and
apply a MIPS adjustment factor (and, as
applicable, an additional MIPS adjustment
factor) under paragraph (6) to the professional
for the year.
``(B) Program implementation.--The MIPS shall apply
to payments for items and services furnished on or
after January 1, 2018.
``(C) MIPS eligible professional defined.--
``(i) In general.--For purposes of this
subsection, subject to clauses (ii) and (iv),
the term `MIPS eligible professional' means--
``(I) for the first and second
years for which the MIPS applies to
payments (and for the performance
period for such first and second year),
a physician (as defined in section
1861(r)), a physician assistant, nurse
practitioner, and clinical nurse
specialist (as such terms are defined
in section 1861(aa)(5)), and a
certified registered nurse anesthetist
(as defined in section 1861(bb)(2)) and
a group that includes such
professionals; and
``(II) for the third year for which
the MIPS applies to payments (and for
the performance period for such third
year) and for each succeeding year (and
for the performance period for each
such year), the professionals described
in subclause (I) and such other
eligible professionals (as defined in
subsection (k)(3)(B)) as specified by
the Secretary and a group that includes
such professionals.
``(ii) Exclusions.--For purposes of clause
(i), the term `MIPS eligible professional' does
not include, with respect to a year, an
eligible professional (as defined in subsection
(k)(3)(B)) who--
``(I) is a qualifying APM
participant (as defined in section
1833(z)(2));
``(II) subject to clause (vii), is
a partial qualifying APM participant
(as defined in clause (iii)) for the
most recent period for which data are
available and who, for the performance
period with respect to such year, does
not report on applicable measures and
activities described in paragraph
(2)(B) that are required to be reported
by such a professional under the MIPS;
or
``(III) for the performance period
with respect to such year, does not
exceed the low-volume threshold
measurement selected under clause (iv).
``(iii) Partial qualifying apm
participant.--For purposes of this
subparagraph, the term `partial qualifying APM
participant' means, with respect to a year, an
eligible professional for whom the Secretary
determines the minimum payment percentage (or
percentages), as applicable, described in
paragraph (2) of section 1833(z) for such year
have not been satisfied, but who would be
considered a qualifying APM participant (as
defined in such paragraph) for such year if--
``(I) with respect to 2018 and
2019, the reference in subparagraph (A)
of such paragraph to 25 percent was
instead a reference to 20 percent;
``(II) with respect to 2020 and
2021--
``(aa) the reference in
subparagraph (B)(i) of such
paragraph to 50 percent was
instead a reference to 40
percent; and
``(bb) the references in
subparagraph (B)(ii) of such
paragraph to 50 percent and 25
percent of such paragraph were
instead references to 40
percent and 20 percent,
respectively; and
``(III) with respect to 2022 and
subsequent years--
``(aa) the reference in
subparagraph (C)(i) of such
paragraph to 75 percent was
instead a reference to 50
percent; and
``(bb) the references in
subparagraph (C)(ii) of such
paragraph to 75 percent and 25
percent of such paragraph were
instead references to 50
percent and 20 percent,
respectively.
``(iv) Selection of low-volume threshold
measurement.--The Secretary shall select a low-
volume threshold to apply for purposes of
clause (ii)(III), which may include one or more
or a combination of the following:
``(I) The minimum number (as
determined by the Secretary) of
individuals enrolled under this part
who are treated by the eligible
professional for the performance period
involved.
``(II) The minimum number (as
determined by the Secretary) of items
and services furnished to individuals
enrolled under this part by such
professional for such performance
period.
``(III) The minimum amount (as
determined by the Secretary) of allowed
charges billed by such professional
under this part for such performance
period.
``(v) Treatment of new medicare enrolled
eligible professionals.--In the case of a
professional who first becomes a Medicare
enrolled eligible professional during the
performance period for a year (and had not
previously submitted claims under this title
such as a person, an entity, or a part of a
physician group or under a different billing
number or tax identifier), such professional
shall not be treated under this subsection as a
MIPS eligible professional until the subsequent
year and performance period for such subsequent
year.
``(vi) Clarification.--In the case of items
and services furnished during a year by an
individual who is not a MIPS eligible
professional (including pursuant to clauses
(ii) and (v)) with respect to a year, in no
case shall a MIPS adjustment factor (or
additional MIPS adjustment factor) under
paragraph (6) apply to such individual for such
year.
``(vii) Partial qualifying apm participant
clarifications.--
``(I) Treatment as mips eligible
professional.--In the case of an
eligible professional who is a partial
qualifying APM participant, with
respect to a year, and who for the
performance period for such year
reports on applicable measures and
activities described in paragraph
(2)(B) that are required to be reported
by such a professional under the MIPS,
such eligible professional is
considered to be a MIPS eligible
professional with respect to such year.
``(II) Not eligible for qualifying
apm participant payments.--In no case
shall an eligible professional who is a
partial qualifying APM participant,
with respect to a year, be considered a
qualifying APM participant (as defined
in paragraph (2) of section 1833(z))
for such year or be eligible for the
additional payment under paragraph (1)
of such section for such year.
``(D) Application to group practices.--
``(i) In general.--Under the MIPS:
``(I) Quality performance
category.--The Secretary shall
establish and apply a process that
includes features of the provisions of
subsection (m)(3)(C) for MIPS eligible
professionals in a group practice with
respect to assessing performance of
such group with respect to the
performance category described in
clause (i) of paragraph (2)(A).
``(II) Other performance
categories.--The Secretary may
establish and apply a process that
includes features of the provisions of
subsection (m)(3)(C) for MIPS eligible
professionals in a group practice with
respect to assessing the performance of
such group with respect to the
performance categories described in
clauses (ii) through (iv) of such
paragraph.
``(ii) Ensuring comprehensiveness of group
practice assessment.--The process established
under clause (i) shall to the extent
practicable reflect the range of items and
services furnished by the MIPS eligible
professionals in the group practice involved.
``(iii) Clarification.--MIPS eligible
professionals electing to be a virtual group
under paragraph (5)(I) shall not be considered
MIPS eligible professionals in a group practice
for purposes of applying this subparagraph.
``(E) Use of registries.--Under the MIPS, the
Secretary shall encourage the use of qualified clinical
data registries pursuant to subsection (m)(3)(E) in
carrying out this subsection.
``(F) Application of certain provisions.--In
applying a provision of subsection (k), (m), (o), or
(p) for purposes of this subsection, the Secretary
shall--
``(i) adjust the application of such
provision to ensure the provision is consistent
with the provisions of this subsection; and
``(ii) not apply such provision to the
extent that the provision is duplicative with a
provision of this subsection.
``(G) Accounting for risk factors.--
``(i) Risk factors.--Taking into account
the relevant studies conducted and
recommendations made in reports under section
101(f)(1) of the Responsible Medicare SGR
Repeal and Beneficiary Access Improvement Act
of 2014, the Secretary, on an ongoing basis,
shall estimate how an individual's health
status and other risk factors affect quality
and resource use outcome measures and, as
feasible, shall incorporate information from
quality and resource use outcome measurement
(including care episode and patient condition
groups) into the MIPS.
``(ii) Accounting for other factors in
payment adjustments.--Taking into account the
studies conducted and recommendations made in
reports under section 101(f)(1) of the
Responsible Medicare SGR Repeal and Beneficiary
Access Improvement Act of 2014 and other
information as appropriate, the Secretary shall
account for identified factors with an effect
on quality and resource use outcome measures
when determining payment adjustments, composite
performance scores, scores for performance
categories, or scores for measures or
activities under the MIPS.
``(2) Measures and activities under performance
categories.--
``(A) Performance categories.--Under the MIPS, the
Secretary shall use the following performance
categories (each of which is referred to in this
subsection as a performance category) in determining
the composite performance score under paragraph (5):
``(i) Quality.
``(ii) Resource use.
``(iii) Clinical practice improvement
activities.
``(iv) Meaningful use of certified EHR
technology.
``(B) Measures and activities specified for each
category.--For purposes of paragraph (3)(A) and subject
to subparagraph (C), measures and activities specified
for a performance period (as established under
paragraph (4)) for a year are as follows:
``(i) Quality.--For the performance
category described in subparagraph (A)(i), the
quality measures included in the final measures
list published under subparagraph (D)(i) for
such year and the list of quality measures
described in subparagraph (D)(vi) used by
qualified clinical data registries under
subsection (m)(3)(E).
``(ii) Resource use.--For the performance
category described in subparagraph (A)(ii), the
measurement of resource use for such period
under subsection (p)(3), using the methodology
under subsection (r) as appropriate, and, as
feasible and applicable, accounting for the
cost of drugs under part D.
``(iii) Clinical practice improvement
activities.--For the performance category
described in subparagraph (A)(iii), clinical
practice improvement activities (as defined in
subparagraph (C)(v)(III)) under subcategories
specified by the Secretary for such period,
which shall include at least the following:
``(I) The subcategory of expanded
practice access, which shall include
activities such as same day
appointments for urgent needs and after
hours access to clinician advice.
``(II) The subcategory of
population management, which shall
include activities such as monitoring
health conditions of individuals to
provide timely health care
interventions or participation in a
qualified clinical data registry.
``(III) The subcategory of care
coordination, which shall include
activities such as timely communication
of test results, timely exchange of
clinical information to patients and
other providers, and use of remote
monitoring or telehealth.
``(IV) The subcategory of
beneficiary engagement, which shall
include activities such as the
establishment of care plans for
individuals with complex care needs,
beneficiary self-management assessment
and training, and using shared
decision-making mechanisms.
``(V) The subcategory of patient
safety and practice assessment, such as
through use of clinical or surgical
checklists and practice assessments
related to maintaining certification.
``(VI) The subcategory of
participation in an alternative payment
model (as defined in section
1833(z)(3)(C)).
In establishing activities under this clause,
the Secretary shall give consideration to the
circumstances of small practices (consisting of
15 or fewer professionals) and practices
located in rural areas and in health
professional shortage areas (as designated
under section 332(a)(1)(A) of the Public Health
Service Act).
``(iv) Meaningful ehr use.--For the
performance category described in subparagraph
(A)(iv), the requirements established for such
period under subsection (o)(2) for determining
whether an eligible professional is a
meaningful EHR user.
``(C) Additional provisions.--
``(i) Emphasizing outcome measures under
the quality performance category.--In applying
subparagraph (B)(i), the Secretary shall, as
feasible, emphasize the application of outcome
measures.
``(ii) Application of additional system
measures.--The Secretary may use measures used
for a payment system other than for physicians,
such as measures for inpatient hospitals, for
purposes of the performance categories
described in clauses (i) and (ii) of
subparagraph (A). For purposes of the previous
sentence, the Secretary may not use measures
for hospital outpatient departments, except in
the case of emergency physicians.
``(iii) Global and population-based
measures.--The Secretary may use global
measures, such as global outcome measures, and
population-based measures for purposes of the
performance category described in subparagraph
(A)(i).
``(iv) Application of measures and
activities to non-patient-facing
professionals.--In carrying out this paragraph,
with respect to measures and activities
specified in subparagraph (B) for performance
categories described in subparagraph (A), the
Secretary--
``(I) shall give consideration to
the circumstances of professional types
(or subcategories of those types
determined by practice characteristics)
who typically furnish services that do
not involve face-to-face interaction
with a patient; and
``(II) may, to the extent feasible
and appropriate, take into account such
circumstances and apply under this
subsection with respect to MIPS
eligible professionals of such
professional types or subcategories,
alternative measures or activities that
fulfill the goals of the applicable
performance category.
In carrying out the previous sentence, the
Secretary shall consult with professionals of
such professional types or subcategories.
``(v) Clinical practice improvement
activities.--
``(I) Request for information.--In
initially applying subparagraph
(B)(iii), the Secretary shall use a
request for information to solicit
recommendations from stakeholders to
identify activities described in such
subparagraph and specifying criteria
for such activities.
``(II) Contract authority for
clinical practice improvement
activities performance category.--In
applying subparagraph (B)(iii), the
Secretary may contract with entities to
assist the Secretary in--
``(aa) identifying
activities described in
subparagraph (B)(iii);
``(bb) specifying criteria
for such activities; and
``(cc) determining whether
a MIPS eligible professional
meets such criteria.
``(III) Clinical practice
improvement activities defined.--For
purposes of this subsection, the term
`clinical practice improvement
activity' means an activity that
relevant eligible professional
organizations and other relevant
stakeholders identify as improving
clinical practice or care delivery and
that the Secretary determines, when
effectively executed, is likely to
result in improved outcomes.
``(D) Annual list of quality measures available for
mips assessment.--
``(i) In general.--Under the MIPS, the
Secretary, through notice and comment
rulemaking and subject to the succeeding
clauses of this subparagraph, shall, with
respect to the performance period for a year,
establish an annual final list of quality
measures from which MIPS eligible professionals
may choose for purposes of assessment under
this subsection for such performance period.
Pursuant to the previous sentence, the
Secretary shall--
``(I) not later than November 1 of
the year prior to the first day of the
first performance period under the
MIPS, establish and publish in the
Federal Register a final list of
quality measures; and
``(II) not later than November 1 of
the year prior to the first day of each
subsequent performance period, update
the final list of quality measures from
the previous year (and publish such
updated final list in the Federal
Register), by--
``(aa) removing from such
list, as appropriate, quality
measures, which may include the
removal of measures that are no
longer meaningful (such as
measures that are topped out);
``(bb) adding to such list,
as appropriate, new quality
measures; and
``(cc) determining whether
or not quality measures on such
list that have undergone
substantive changes should be
included in the updated list.
``(ii) Call for quality measures.--
``(I) In general.--Eligible
professional organizations and other
relevant stakeholders shall be
requested to identify and submit
quality measures to be considered for
selection under this subparagraph in
the annual list of quality measures
published under clause (i) and to
identify and submit updates to the
measures on such list. For purposes of
the previous sentence, measures may be
submitted regardless of whether such
measures were previously published in a
proposed rule or endorsed by an entity
with a contract under section 1890(a).
``(II) Eligible professional
organization defined.--In this
subparagraph, the term `eligible
professional organization' means a
professional organization as defined by
nationally recognized multispecialty
boards of certification or equivalent
certification boards.
``(iii) Requirements.--In selecting quality
measures for inclusion in the annual final list
under clause (i), the Secretary shall--
``(I) provide that, to the extent
practicable, all quality domains (as
defined in subsection (s)(1)(B)) are
addressed by such measures; and
``(II) ensure that such selection
is consistent with the process for
selection of measures under subsections
(k), (m), and (p)(2).
``(iv) Peer review.--Before including a new
measure or a measure described in clause
(i)(II)(cc) in the final list of measures
published under clause (i) for a year, the
Secretary shall submit for publication in
applicable specialty-appropriate peer-reviewed
journals such measure and the method for
developing and selecting such measure,
including clinical and other data supporting
such measure.
``(v) Measures for inclusion.--The final
list of quality measures published under clause
(i) shall include, as applicable, measures
under subsections (k), (m), and (p)(2),
including quality measures from among--
``(I) measures endorsed by a
consensus-based entity;
``(II) measures developed under
subsection (s); and
``(III) measures submitted under
clause (ii)(I).
Any measure selected for inclusion in such list
that is not endorsed by a consensus-based
entity shall have a focus that is evidence-
based.
``(vi) Exception for qualified clinical
data registry measures.--Measures used by a
qualified clinical data registry under
subsection (m)(3)(E) shall not be subject to
the requirements under clauses (i), (iv), and
(v). The Secretary shall publish the list of
measures used by such qualified clinical data
registries on the Internet website of the
Centers for Medicare & Medicaid Services.
``(vii) Exception for existing quality
measures.--Any quality measure specified by the
Secretary under subsection (k) or (m),
including under subsection (m)(3)(E), and any
measure of quality of care established under
subsection (p)(2) for the reporting period
under the respective subsection beginning
before the first performance period under the
MIPS--
``(I) shall not be subject to the
requirements under clause (i) (except
under items (aa) and (cc) of subclause
(II) of such clause) or to the
requirement under clause (iv); and
``(II) shall be included in the
final list of quality measures
published under clause (i) unless
removed under clause (i)(II)(aa).
``(viii) Consultation with relevant
eligible professional organizations and other
relevant stakeholders.--Relevant eligible
professional organizations and other relevant
stakeholders, including State and national
medical societies, shall be consulted in
carrying out this subparagraph.
``(ix) Optional application.--The process
under section 1890A is not required to apply to
the selection of measures under this
subparagraph.
``(3) Performance standards.--
``(A) Establishment.--Under the MIPS, the Secretary
shall establish performance standards with respect to
measures and activities specified under paragraph
(2)(B) for a performance period (as established under
paragraph (4)) for a year.
``(B) Considerations in establishing standards.--In
establishing such performance standards with respect to
measures and activities specified under paragraph
(2)(B), the Secretary shall consider the following:
``(i) Historical performance standards.
``(ii) Improvement.
``(iii) The opportunity for continued
improvement.
``(4) Performance period.--The Secretary shall establish a
performance period (or periods) for a year (beginning with the
year described in paragraph (1)(B)). Such performance period
(or periods) shall begin and end prior to the beginning of such
year and be as close as possible to such year. In this
subsection, such performance period (or periods) for a year
shall be referred to as the performance period for the year.
``(5) Composite performance score.--
``(A) In general.--Subject to the succeeding
provisions of this paragraph and taking into account,
as available and applicable, paragraph (1)(G), the
Secretary shall develop a methodology for assessing the
total performance of each MIPS eligible professional
according to performance standards under paragraph (3)
with respect to applicable measures and activities
specified in paragraph (2)(B) with respect to each
performance category applicable to such professional
for a performance period (as established under
paragraph (4)) for a year. Using such methodology, the
Secretary shall provide for a composite assessment
(using a scoring scale of 0 to 100) for each such
professional for the performance period for such year.
In this subsection such a composite assessment for such
a professional with respect to a performance period
shall be referred to as the `composite performance
score' for such professional for such performance
period.
``(B) Incentive to report; encouraging use of
certified ehr technology for reporting quality
measures.--
``(i) Incentive to report.--Under the
methodology established under subparagraph (A),
the Secretary shall provide that in the case of
a MIPS eligible professional who fails to
report on an applicable measure or activity
that is required to be reported by the
professional, the professional shall be treated
as achieving the lowest potential score
applicable to such measure or activity.
``(ii) Encouraging use of certified ehr
technology and qualified clinical data
registries for reporting quality measures.--
Under the methodology established under
subparagraph (A), the Secretary shall--
``(I) encourage MIPS eligible
professionals to report on applicable
measures with respect to the
performance category described in
paragraph (2)(A)(i) through the use of
certified EHR technology and qualified
clinical data registries; and
``(II) with respect to a
performance period, with respect to a
year, for which a MIPS eligible
professional reports such measures
through the use of such EHR technology,
treat such professional as satisfying
the clinical quality measures reporting
requirement described in subsection
(o)(2)(A)(iii) for such year.
``(C) Clinical practice improvement activities
performance score.--
``(i) Rule for accreditation.--A MIPS
eligible professional who is in a practice that
is certified as a patient-centered medical home
or comparable specialty practice pursuant to
subsection (b)(8)(B)(i) with respect to a
performance period shall be given the highest
potential score for the performance category
described in paragraph (2)(A)(iii) for such
period.
``(ii) APM participation.--Participation by
a MIPS eligible professional in an alternative
payment model (as defined in section
1833(z)(3)(C)) with respect to a performance
period shall earn such eligible professional a
minimum score of one-half of the highest
potential score for the performance category
described in paragraph (2)(A)(iii) for such
performance period.
``(iii) Subcategories.--A MIPS eligible
professional shall not be required to perform
activities in each subcategory under paragraph
(2)(B)(iii) or participate in an alternative
payment model in order to achieve the highest
potential score for the performance category
described in paragraph (2)(A)(iii).
``(D) Achievement and improvement.--
``(i) Taking into account improvement.--
Beginning with the second year to which the
MIPS applies, in addition to the achievement of
a MIPS eligible professional, if data
sufficient to measure improvement is available,
the methodology developed under subparagraph
(A)--
``(I) in the case of the
performance score for the performance
category described in clauses (i) and
(ii) of paragraph (2)(A), shall take
into account the improvement of the
professional; and
``(II) in the case of performance
scores for other performance
categories, may take into account the
improvement of the professional.
``(ii) Assigning higher weight for
achievement.--Beginning with the fourth year to
which the MIPS applies, under the methodology
developed under subparagraph (A), the Secretary
may assign a higher scoring weight under
subparagraph (F) with respect to the
achievement of a MIPS eligible professional
than with respect to any improvement of such
professional applied under clause (i) with
respect to a measure, activity, or category
described in paragraph (2).
``(E) Weights for the performance categories.--
``(i) In general.--Under the methodology
developed under subparagraph (A), subject to
subparagraph (F)(i) and clauses (ii) and (iii),
the composite performance score shall be
determined as follows:
``(I) Quality.--
``(aa) In general.--Subject
to item (bb), thirty percent of
such score shall be based on
performance with respect to the
category described in clause
(i) of paragraph (2)(A). In
applying the previous sentence,
the Secretary shall, as
feasible, encourage the
application of outcome measures
within such category.
``(bb) First 2 years.--For
the first and second years for
which the MIPS applies to
payments, the percentage
applicable under item (aa)
shall be increased in a manner
such that the total percentage
points of the increase under
this item for the respective
year equals the total number of
percentage points by which the
percentage applied under
subclause (II)(bb) for the
respective year is less than 30
percent.
``(II) Resource use.--
``(aa) In general.--Subject
to item (bb), thirty percent of
such score shall be based on
performance with respect to the
category described in clause
(ii) of paragraph (2)(A).
``(bb) First 2 years.--For
the first year for which the
MIPS applies to payments, not
more than 10 percent of such
score shall be based on
performance with respect to the
category described in clause
(ii) of paragraph (2)(A). For
the second year for which the
MIPS applies to payments, not
more than 15 percent of such
score shall be based on
performance with respect to the
category described in clause
(ii) of paragraph (2)(A).
``(III) Clinical practice
improvement activities.--Fifteen
percent of such score shall be based on
performance with respect to the
category described in clause (iii) of
paragraph (2)(A).
``(IV) Meaningful use of certified
ehr technology.--Twenty-five percent of
such score shall be based on
performance with respect to the
category described in clause (iv) of
paragraph (2)(A).
``(ii) Authority to adjust percentages in
case of high ehr meaningful use adoption.--In
any year in which the Secretary estimates that
the proportion of eligible professionals (as
defined in subsection (o)(5)) who are
meaningful EHR users (as determined under
subsection (o)(2)) is 75 percent or greater,
the Secretary may reduce the percent applicable
under clause (i)(IV), but not below 15 percent.
If the Secretary makes such reduction for a
year, subject to subclauses (I)(bb) and
(II)(bb) of clause (i), the percentages
applicable under one or more of subclauses (I),
(II), and (III) of clause (i) for such year
shall be increased in a manner such that the
total percentage points of the increase under
this clause for such year equals the total
number of percentage points reduced under the
preceding sentence for such year.
``(F) Certain flexibility for weighting performance
categories, measures, and activities.--Under the
methodology under subparagraph (A), if there are not
sufficient measures and clinical practice improvement
activities applicable and available to each type of
eligible professional involved, the Secretary shall
assign different scoring weights (including a weight of
0)--
``(i) which may vary from the scoring
weights specified in subparagraph (E), for each
performance category based on the extent to
which the category is applicable to the type of
eligible professional involved; and
``(ii) for each measure and activity
specified under paragraph (2)(B) with respect
to each such category based on the extent to
which the measure or activity is applicable and
available to the type of eligible professional
involved.
``(G) Resource use.--Analysis of the performance
category described in paragraph (2)(A)(ii) shall
include results from the methodology described in
subsection (r)(5), as appropriate.
``(H) Inclusion of quality measure data from other
payers.--In applying subsections (k), (m), and (p) with
respect to measures described in paragraph (2)(B)(i),
analysis of the performance category described in
paragraph (2)(A)(i) may include data submitted by MIPS
eligible professionals with respect to items and
services furnished to individuals who are not
individuals entitled to benefits under part A or
enrolled under part B.
``(I) Use of voluntary virtual groups for certain
assessment purposes.--
``(i) In general.--In the case of MIPS
eligible professionals electing to be a virtual
group under clause (ii) with respect to a
performance period for a year, for purposes of
applying the methodology under subparagraph
(A)--
``(I) the assessment of performance
provided under such methodology with
respect to the performance categories
described in clauses (i) and (ii) of
paragraph (2)(A) that is to be applied
to each such professional in such group
for such performance period shall be
with respect to the combined
performance of all such professionals
in such group for such period; and
``(II) the composite score provided
under this paragraph for such
performance period with respect to each
such performance category for each such
MIPS eligible professional in such
virtual group shall be based on the
assessment of the combined performance
under subclause (I) for the performance
category and performance period.
``(ii) Election of practices to be a
virtual group.--The Secretary shall, in
accordance with clause (iii), establish and
have in place a process to allow an individual
MIPS eligible professional or a group practice
consisting of not more than 10 MIPS eligible
professionals to elect, with respect to a
performance period for a year, for such
individual MIPS eligible professional or all
such MIPS eligible professionals in such group
practice, respectively, to be a virtual group
under this subparagraph with at least one other
such individual MIPS eligible professional or
group practice making such an election. Such a
virtual group may be based on geographic areas
or on provider specialties defined by
nationally recognized multispecialty boards of
certification or equivalent certification
boards and such other eligible professional
groupings in order to capture classifications
of providers across eligible professional
organizations and other practice areas or
categories.
``(iii) Requirements.--The process under
clause (ii)--
``(I) shall provide that an
election under such clause, with
respect to a performance period, shall
be made before or during the beginning
of such performance period and may not
be changed during such performance
period;
``(II) shall provide that a
practice described in such clause, and
each MIPS eligible professional in such
practice, may elect to be in no more
than one virtual group for a
performance period; and
``(III) may provide that a virtual
group may be combined at the tax
identification number level.
``(6) MIPS payments.--
``(A) MIPS adjustment factor.--Taking into account
paragraph (1)(G), the Secretary shall specify a MIPS
adjustment factor for each MIPS eligible professional
for a year. Such MIPS adjustment factor for a MIPS
eligible professional for a year shall be in the form
of a percent and shall be determined--
``(i) by comparing the composite
performance score of the eligible professional
for such year to the performance threshold
established under subparagraph (D)(i) for such
year;
``(ii) in a manner such that the adjustment
factors specified under this subparagraph for a
year result in differential payments under this
paragraph reflecting that--
``(I) MIPS eligible professionals
with composite performance scores for
such year at or above such performance
threshold for such year receive zero or
positive incentive payment adjustment
factors for such year in accordance
with clause (iii), with such
professionals having higher composite
performance scores receiving higher
adjustment factors; and
``(II) MIPS eligible professionals
with composite performance scores for
such year below such performance
threshold for such year receive
negative payment adjustment factors for
such year in accordance with clause
(iv), with such professionals having
lower composite performance scores
receiving lower adjustment factors;
``(iii) in a manner such that MIPS eligible
professionals with composite scores described
in clause (ii)(I) for such year, subject to
clauses (i) and (ii) of subparagraph (F),
receive a zero or positive adjustment factor on
a linear sliding scale such that an adjustment
factor of 0 percent is assigned for a score at
the performance threshold and an adjustment
factor of the applicable percent specified in
subparagraph (B) is assigned for a score of
100; and
``(iv) in a manner such that--
``(I) subject to subclause (II),
MIPS eligible professionals with
composite performance scores described
in clause (ii)(II) for such year
receive a negative payment adjustment
factor on a linear sliding scale such
that an adjustment factor of 0 percent
is assigned for a score at the
performance threshold and an adjustment
factor of the negative of the
applicable percent specified in
subparagraph (B) is assigned for a
score of 0; and
``(II) MIPS eligible professionals
with composite performance scores that
are equal to or greater than 0, but not
greater than \1/4\ of the performance
threshold specified under subparagraph
(D)(i) for such year, receive a
negative payment adjustment factor that
is equal to the negative of the
applicable percent specified in
subparagraph (B) for such year.
``(B) Applicable percent defined.--For purposes of
this paragraph, the term `applicable percent' means--
``(i) for 2018, 4 percent;
``(ii) for 2019, 5 percent;
``(iii) for 2020, 7 percent; and
``(iv) for 2021 and subsequent years, 9
percent.
``(C) Additional mips adjustment factors for
exceptional performance.--
``(i) In general.--In the case of a MIPS
eligible professional with a composite
performance score for a year at or above the
additional performance threshold under
subparagraph (D)(ii) for such year, in addition
to the MIPS adjustment factor under
subparagraph (A) for the eligible professional
for such year, subject to the availability of
funds under clause (ii), the Secretary shall
specify an additional positive MIPS adjustment
factor for such professional and year. Such
additional MIPS adjustment factors shall be
determined by the Secretary in a manner such
that professionals having higher composite
performance scores above the additional
performance threshold receive higher additional
MIPS adjustment factors.
``(ii) Additional funding pool.--For 2018
and each subsequent year through 2023, there is
appropriated from the Federal Supplementary
Medical Insurance Trust Fund $500,000,000 for
MIPS payments under this paragraph resulting
from the application of the additional MIPS
adjustment factors under clause (i).
``(D) Establishment of performance thresholds.--
``(i) Performance threshold.--For each year
of the MIPS, the Secretary shall compute a
performance threshold with respect to which the
composite performance score of MIPS eligible
professionals shall be compared for purposes of
determining adjustment factors under
subparagraph (A) that are positive, negative,
and zero. Such performance threshold for a year
shall be the mean or median (as selected by the
Secretary) of the composite performance scores
for all MIPS eligible professionals with
respect to a prior period specified by the
Secretary. The Secretary may reassess the
selection under the previous sentence every 3
years.
``(ii) Additional performance threshold for
exceptional performance.--In addition to the
performance threshold under clause (i), for
each year of the MIPS, the Secretary shall
compute an additional performance threshold for
purposes of determining the additional MIPS
adjustment factors under subparagraph (C)(i).
For each such year, the Secretary shall apply
either of the following methods for computing
such additional performance threshold for such
a year:
``(I) The threshold shall be the
score that is equal to the 25th
percentile of the range of possible
composite performance scores above the
performance threshold with respect to
the prior period described in clause
(i).
``(II) The threshold shall be the
score that is equal to the 25th
percentile of the actual composite
performance scores for MIPS eligible
professionals with composite
performance scores at or above the
performance threshold with respect to
the prior period described in clause
(i).
``(iii) Special rule for initial 2 years.--
With respect to each of the first two years to
which the MIPS applies, the Secretary shall,
prior to the performance period for such years,
establish a performance threshold for purposes
of determining MIPS adjustment factors under
subparagraph (A) and a threshold for purposes
of determining additional MIPS adjustment
factors under subparagraph (C)(i). Each such
performance threshold shall--
``(I) be based on a period prior to
such performance periods; and
``(II) take into account--
``(aa) data available with
respect to performance on
measures and activities that
may be used under the
performance categories under
subparagraph (2)(B); and
``(bb) other factors
determined appropriate by the
Secretary.
``(E) Application of mips adjustment factors.--In
the case of items and services furnished by a MIPS
eligible professional during a year (beginning with
2018), the amount otherwise paid under this part with
respect to such items and services and MIPS eligible
professional for such year, shall be multiplied by--
``(i) 1, plus
``(ii) the sum of--
``(I) the MIPS adjustment factor
determined under subparagraph (A)
divided by 100, and
``(II) as applicable, the
additional MIPS adjustment factor
determined under subparagraph (C)(i)
divided by 100.
``(F) Aggregate application of mips adjustment
factors.--
``(i) Application of scaling factor.--
``(I) In general.--With respect to
positive MIPS adjustment factors under
subparagraph (A)(ii)(I) for eligible
professionals whose composite
performance score is above the
performance threshold under
subparagraph (D)(i) for such year,
subject to subclause (II), the
Secretary shall increase or decrease
such adjustment factors by a scaling
factor in order to ensure that the
budget neutrality requirement of clause
(ii) is met.
``(II) Scaling factor limit.--In no
case may be the scaling factor applied
under this clause exceed 3.0.
``(ii) Budget neutrality requirement.--
``(I) In general.--Subject to
clause (iii), the Secretary shall
ensure that the estimated amount
described in subclause (II) for a year
is equal to the estimated amount
described in subclause (III) for such
year.
``(II) Aggregate increases.--The
amount described in this subclause is
the estimated increase in the aggregate
allowed charges resulting from the
application of positive MIPS adjustment
factors under subparagraph (A) (after
application of the scaling factor
described in clause (i)) to MIPS
eligible professionals whose composite
performance score for a year is above
the performance threshold under
subparagraph (D)(i) for such year.
``(III) Aggregate decreases.--The
amount described in this subclause is
the estimated decrease in the aggregate
allowed charges resulting from the
application of negative MIPS adjustment
factors under subparagraph (A) to MIPS
eligible professionals whose composite
performance score for a year is below
the performance threshold under
subparagraph (D)(i) for such year.
``(iii) Exceptions.--
``(I) In the case that all MIPS
eligible professionals receive
composite performance scores for a year
that are below the performance
threshold under subparagraph (D)(i) for
such year, the negative MIPS adjustment
factors under subparagraph (A) shall
apply with respect to such MIPS
eligible professionals and the budget
neutrality requirement of clause (ii)
shall not apply for such year.
``(II) In the case that, with
respect to a year, the application of
clause (i) results in a scaling factor
equal to the maximum scaling factor
specified in clause (i)(II), such
scaling factor shall apply and the
budget neutrality requirement of clause
(ii) shall not apply for such year.
``(iv) Additional incentive payment
adjustments.--In specifying the MIPS additional
adjustment factors under subparagraph (C)(i)
for each applicable MIPS eligible professional
for a year, the Secretary shall ensure that the
estimated increase in payments under this part
resulting from the application of such
additional adjustment factors for MIPS eligible
professionals in a year shall be equal (as
estimated by the Secretary) to the additional
funding pool amount for such year under
subparagraph (C)(ii).
``(7) Announcement of result of adjustments.--Under the
MIPS, the Secretary shall, not later than 30 days prior to
January 1 of the year involved, make available to MIPS eligible
professionals the MIPS adjustment factor (and, as applicable,
the additional MIPS adjustment factor) under paragraph (6)
applicable to the eligible professional for items and services
furnished by the professional for such year. The Secretary may
include such information in the confidential feedback under
paragraph (12).
``(8) No effect in subsequent years.--The MIPS adjustment
factors and additional MIPS adjustment factors under paragraph
(6) shall apply only with respect to the year involved, and the
Secretary shall not take into account such adjustment factors
in making payments to a MIPS eligible professional under this
part in a subsequent year.
``(9) Public reporting.--
``(A) In general.--The Secretary shall, in an
easily understandable format, make available on the
Physician Compare Internet website of the Centers for
Medicare & Medicaid Services the following:
``(i) Information regarding the performance
of MIPS eligible professionals under the MIPS,
which--
``(I) shall include the composite
score for each such MIPS eligible
professional and the performance of
each such MIPS eligible professional
with respect to each performance
category; and
``(II) may include the performance
of each such MIPS eligible professional
with respect to each measure or
activity specified in paragraph (2)(B).
``(ii) The names of eligible professionals
in eligible alternative payment models (as
defined in section 1833(z)(3)(D)) and, to the
extent feasible, the names of such eligible
alternative payment models and performance of
such models.
``(B) Disclosure.--The information made available
under this paragraph shall indicate, where appropriate,
that publicized information may not be representative
of the eligible professional's entire patient
population, the variety of services furnished by the
eligible professional, or the health conditions of
individuals treated.
``(C) Opportunity to review and submit
corrections.--The Secretary shall provide for an
opportunity for a professional described in
subparagraph (A) to review, and submit corrections for,
the information to be made public with respect to the
professional under such subparagraph prior to such
information being made public.
``(D) Aggregate information.--The Secretary shall
periodically post on the Physician Compare Internet
website aggregate information on the MIPS, including
the range of composite scores for all MIPS eligible
professionals and the range of the performance of all
MIPS eligible professionals with respect to each
performance category.
``(10) Consultation.--The Secretary shall consult with
stakeholders in carrying out the MIPS, including for the
identification of measures and activities under paragraph
(2)(B) and the methodologies developed under paragraphs (5)(A)
and (6) and regarding the use of qualified clinical data
registries. Such consultation shall include the use of a
request for information or other mechanisms determined
appropriate.
``(11) Technical assistance to small practices and
practices in health professional shortage areas.--
``(A) In general.--The Secretary shall enter into
contracts or agreements with appropriate entities (such
as quality improvement organizations, regional
extension centers (as described in section 3012(c) of
the Public Health Service Act), or regional health
collaboratives) to offer guidance and assistance to
MIPS eligible professionals in practices of 15 or fewer
professionals (with priority given to such practices
located in rural areas, health professional shortage
areas (as designated under in section 332(a)(1)(A) of
such Act), and medically underserved areas, and
practices with low composite scores) with respect to--
``(i) the performance categories described
in clauses (i) through (iv) of paragraph
(2)(A); or
``(ii) how to transition to the
implementation of and participation in an
alternative payment model as described in
section 1833(z)(3)(C).
``(B) Funding for implementation.--
``(i) In general.--For purposes of
implementing subparagraph (A), the Secretary
shall provide for the transfer from the Federal
Supplementary Medical Insurance Trust Fund
established under section 1841 to the Centers
for Medicare & Medicaid Services Program
Management Account of $40,000,000 for each of
fiscal years 2015 through 2019. Amounts
transferred under this subparagraph for a
fiscal year shall be available until expended.
``(ii) Technical assistance.--Of the
amounts transferred pursuant to clause (i) for
each of fiscal years 2015 through 2019, not
less than $10,000,000 shall be made available
for each such year for technical assistance to
small practices in health professional shortage
areas (as so designated) and medically
underserved areas.
``(12) Feedback and information to improve performance.--
``(A) Performance feedback.--
``(i) In general.--Beginning July 1, 2016,
the Secretary--
``(I) shall make available timely
(such as quarterly) confidential
feedback to MIPS eligible professionals
on the performance of such
professionals with respect to the
performance categories under clauses
(i) and (ii) of paragraph (2)(A); and
``(II) may make available
confidential feedback to each such
professional on the performance of such
professional with respect to the
performance categories under clauses
(iii) and (iv) of such paragraph.
``(ii) Mechanisms.--The Secretary may use
one or more mechanisms to make feedback
available under clause (i), which may include
use of a web-based portal or other mechanisms
determined appropriate by the Secretary. With
respect to the performance category described
in paragraph (2)(A)(i), feedback under this
subparagraph shall, to the extent an eligible
professional chooses to participate in a data
registry for purposes of this subsection
(including registries under subsections (k) and
(m)), be provided based on performance on
quality measures reported through the use of
such registries. With respect to any other
performance category described in paragraph
(2)(A), the Secretary shall encourage provision
of feedback through qualified clinical data
registries as described in subsection
(m)(3)(E)).
``(iii) Use of data.--For purposes of
clause (i), the Secretary may use data, with
respect to a MIPS eligible professional, from
periods prior to the current performance period
and may use rolling periods in order to make
illustrative calculations about the performance
of such professional.
``(iv) Disclosure exemption.--Feedback made
available under this subparagraph shall be
exempt from disclosure under section 552 of
title 5, United States Code.
``(v) Receipt of information.--The
Secretary may use the mechanisms established
under clause (ii) to receive information from
professionals, such as information with respect
to this subsection.
``(B) Additional information.--
``(i) In general.--Beginning July 1, 2017,
the Secretary shall make available to each MIPS
eligible professional information, with respect
to individuals who are patients of such MIPS
eligible professional, about items and services
for which payment is made under this title that
are furnished to such individuals by other
suppliers and providers of services, which may
include information described in clause (ii).
Such information may be made available under
the previous sentence to such MIPS eligible
professionals by mechanisms determined
appropriate by the Secretary, which may include
use of a web-based portal. Such information may
be made available in accordance with the same
or similar terms as data are made available to
accountable care organizations participating in
the shared savings program under section 1899,
including a beneficiary opt-out.
``(ii) Type of information.--For purposes
of clause (i), the information described in
this clause, is the following:
``(I) With respect to selected
items and services (as determined
appropriate by the Secretary) for which
payment is made under this title and
that are furnished to individuals, who
are patients of a MIPS eligible
professional, by another supplier or
provider of services during the most
recent period for which data are
available (such as the most recent
three-month period), such as the name
of such providers furnishing such items
and services to such patients during
such period, the types of such items
and services so furnished, and the
dates such items and services were so
furnished.
``(II) Historical data, such as
averages and other measures of the
distribution if appropriate, of the
total, and components of, allowed
charges (and other figures as
determined appropriate by the
Secretary).
``(13) Review.--
``(A) Targeted review.--The Secretary shall
establish a process under which a MIPS eligible
professional may seek an informal review of the
calculation of the MIPS adjustment factor applicable to
such eligible professional under this subsection for a
year. The results of a review conducted pursuant to the
previous sentence shall not be taken into account for
purposes of paragraph (6) with respect to a year (other
than with respect to the calculation of such eligible
professional's MIPS adjustment factor for such year or
additional MIPS adjustment factor for such year) after
the factors determined in subparagraph (A) and
subparagraph (C) of such paragraph have been determined
for such year.
``(B) Limitation.--Except as provided for in
subparagraph (A), there shall be no administrative or
judicial review under section 1869, section 1878, or
otherwise of the following:
``(i) The methodology used to determine the
amount of the MIPS adjustment factor under
paragraph (6)(A) and the amount of the
additional MIPS adjustment factor under
paragraph (6)(C)(i) and the determination of
such amounts.
``(ii) The establishment of the performance
standards under paragraph (3) and the
performance period under paragraph (4).
``(iii) The identification of measures and
activities specified under paragraph (2)(B) and
information made public or posted on the
Physician Compare Internet website of the
Centers for Medicare & Medicaid Services under
paragraph (9).
``(iv) The methodology developed under
paragraph (5) that is used to calculate
performance scores and the calculation of such
scores, including the weighting of measures and
activities under such methodology.''.
(2) GAO reports.--
(A) Evaluation of eligible professional mips.--Not
later than October 1, 2019, and October 1, 2022, the
Comptroller General of the United States shall submit
to Congress a report evaluating the eligible
professional Merit-based Incentive Payment System under
subsection (q) of section 1848 of the Social Security
Act (42 U.S.C. 1395w-4), as added by paragraph (1).
Such report shall--
(i) examine the distribution of the
composite performance scores and MIPS
adjustment factors (and additional MIPS
adjustment factors) for MIPS eligible
professionals (as defined in subsection
(q)(1)(c) of such section) under such program,
and patterns relating to such scores and
adjustment factors, including based on type of
provider, practice size, geographic location,
and patient mix;
(ii) provide recommendations for improving
such program;
(iii) evaluate the impact of technical
assistance funding under section 1848(q)(11) of
the Social Security Act, as added by paragraph
(1), on the ability of professionals to improve
within such program or successfully transition
to an alternative payment model (as defined in
section 1833(z)(3) of the Social Security Act,
as added by subsection (e)), with priority for
such evaluation given to practices located in
rural areas, health professional shortage areas
(as designated in section 332(a)(1)(a) of the
Public Health Service Act), and medically
underserved areas; and
(iv) provide recommendations for optimizing
the use of such technical assistance funds.
(B) Study to examine alignment of quality measures
used in public and private programs.--
(i) In general.--Not later than 18 months
after the date of the enactment of this Act,
the Comptroller General of the United States
shall submit to Congress a report that--
(I) compares the similarities and
differences in the use of quality
measures under the original Medicare
fee-for-service program under parts A
and B of title XVIII of the Social
Security Act, the Medicare Advantage
program under part C of such title,
selected State Medicaid programs under
title XIX of such Act, and private
payer arrangements; and
(II) makes recommendations on how
to reduce the administrative burden
involved in applying such quality
measures.
(ii) Requirements.--The report under clause
(i) shall--
(I) consider those measures
applicable to individuals entitled to,
or enrolled for, benefits under such
part A, or enrolled under such part B
and individuals under the age of 65;
and
(II) focus on those measures that
comprise the most significant component
of the quality performance category of
the eligible professional MIPS
incentive program under subsection (q)
of section 1848 of the Social Security
Act (42 U.S.C. 1395w-4), as added by
paragraph (1).
(C) Study on role of independent risk managers.--
Not later than January 1, 2016, the Comptroller General
of the United States shall submit to Congress a report
examining whether entities that pool financial risk for
physician practices, such as independent risk managers,
can play a role in supporting physician practices,
particularly small physician practices, in assuming
financial risk for the treatment of patients. Such
report shall examine barriers that small physician
practices currently face in assuming financial risk for
treating patients, the types of risk management
entities that could assist physician practices in
participating in two-sided risk payment models, and how
such entities could assist with risk management and
with quality improvement activities. Such report shall
also include an analysis of any existing legal barriers
to such arrangements.
(D) Study to examine rural and health professional
shortage area alternative payment models.--Not later
than October 1, 2020, and October 1, 2022, the
Comptroller General of the United States shall submit
to Congress a report that examines the transition of
professionals in rural areas, health professional
shortage areas (as designated in section 332(a)(1)(A)
of the Public Health Service Act), or medically
underserved areas to an alternative payment model (as
defined in section 1833(z)(3) of the Social Security
Act, as added by subsection (e)). Such report shall
make recommendations for removing administrative
barriers to practices, including small practices
consisting of 15 or fewer professionals, in rural
areas, health professional shortage areas, and
medically underserved areas to participation in such
models.
(3) 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 transfer of $80,000,000 from the Supplementary
Medical Insurance Trust Fund established under section 1841 of
the Social Security Act (42 U.S.C. 1395t) to the Centers for
Medicare & Medicaid Program Management Account for each of the
fiscal years 2014 through 2018. Amounts transferred under this
paragraph shall be available until expended.
(d) Improving Quality Reporting for Composite Scores.--
(1) Changes for group reporting option.--
(A) In general.--Section 1848(m)(3)(C)(ii) of the
Social Security Act (42 U.S.C. 1395w-4(m)(3)(C)(ii)) is
amended by inserting ``and, for 2015 and subsequent
years, may provide'' after ``shall provide''.
(B) Clarification of qualified clinical data
registry reporting to group practices.--Section
1848(m)(3)(D) of the Social Security Act (42 U.S.C.
1395w-4(m)(3)(D)) is amended by inserting ``and, for
2015 and subsequent years, subparagraph (A) or (C)''
after ``subparagraph (A)''.
(2) Changes for multiple reporting periods and alternative
criteria for satisfactory reporting.--Section 1848(m)(5)(F) of
the Social Security Act (42 U.S.C. 1395w-4(m)(5)(F)) is
amended--
(A) by striking ``and subsequent years'' and
inserting ``through reporting periods occurring in
2014''; and
(B) by inserting ``and, for reporting periods
occurring in 2015 and subsequent years, the Secretary
may establish'' following ``shall establish''.
(3) Physician feedback program reports succeeded by reports
under mips.--Section 1848(n) of the Social Security Act (42
U.S.C. 1395w-4(n)) is amended by adding at the end the
following new paragraph:
``(11) Reports ending with 2016.--Reports under the Program
shall not be provided after December 31, 2016. See subsection
(q)(12) for reports under the eligible professionals Merit-
based Incentive Payment System.''.
(4) Coordination with satisfying meaningful ehr use
clinical quality measure reporting requirement.--Section
1848(o)(2)(A)(iii) of the Social Security Act (42 U.S.C. 1395w-
4(o)(2)(A)(iii)) is amended by inserting ``and subsection
(q)(5)(B)(ii)(II)'' after ``Subject to subparagraph (B)(ii)''.
(e) Promoting Alternative Payment Models.--
(1) Increasing transparency of physician focused payment
models.--Section 1868 of the Social Security Act (42 U.S.C.
1395ee) is amended by adding at the end the following new
subsection:
``(c) Physician Focused Payment Models.--
``(1) Technical advisory committee.--
``(A) Establishment.--There is established an ad
hoc committee to be known as the `Payment Model
Technical Advisory Committee' (referred to in this
subsection as the `Committee').
``(B) Membership.--
``(i) Number and appointment.--The
Committee shall be composed of 11 members
appointed by the Comptroller General of the
United States.
``(ii) Qualifications.--The membership of
the Committee shall include individuals with
national recognition for their expertise in
payment models and related delivery of care. No
more than 5 members of the Committee shall be
providers of services or suppliers, or
representatives of providers of services or
suppliers.
``(iii) Prohibition on federal
employment.--A member of the Committee shall
not be an employee of the Federal Government.
``(iv) Ethics disclosure.--The Comptroller
General shall establish a system for public
disclosure by members of the Committee of
financial and other potential conflicts of
interest relating to such members. Members of
the Committee shall be treated as employees of
Congress for purposes of applying title I of
the Ethics in Government Act of 1978 (Public
Law 95-521).
``(v) Date of initial appointments.--The
initial appointments of members of the
Committee shall be made by not later than 180
days after the date of enactment of this
subsection.
``(C) Term; vacancies.--
``(i) Term.--The terms of members of the
Committee shall be for 3 years except that the
Comptroller General shall designate staggered
terms for the members first appointed.
``(ii) Vacancies.--Any member appointed to
fill a vacancy occurring before the expiration
of the term for which the member's predecessor
was appointed shall be appointed only for the
remainder of that term. A member may serve
after the expiration of that member's term
until a successor has taken office. A vacancy
in the Committee shall be filled in the manner
in which the original appointment was made.
``(D) Duties.--The Committee shall meet, as needed,
to provide comments and recommendations to the
Secretary, as described in paragraph (2)(C), on
physician-focused payment models.
``(E) Compensation of members.--
``(i) In general.--Except as provided in
clause (ii), a member of the Committee shall
serve without compensation.
``(ii) Travel expenses.--A member of the
Committee shall be allowed travel expenses,
including per diem in lieu of subsistence, at
rates authorized for an employee of an agency
under subchapter I of chapter 57 of title 5,
United States Code, while away from the home or
regular place of business of the member in the
performance of the duties of the Committee.
``(F) Operational and technical support.--
``(i) In general.--The Assistant Secretary
for Planning and Evaluation shall provide
technical and operational support for the
Committee, which may be by use of a contractor.
The Office of the Actuary of the Centers for
Medicare & Medicaid Services shall provide to
the Committee actuarial assistance as needed.
``(ii) Funding.--The Secretary shall
provide for the transfer, from the Federal
Supplementary Medical Insurance Trust Fund
under section 1841, such amounts as are
necessary to carry out clause (i) (not to
exceed $5,000,000) for fiscal year 2014 and
each subsequent fiscal year. Any amounts
transferred under the preceding sentence for a
fiscal year shall remain available until
expended.
``(G) Application.--Section 14 of the Federal
Advisory Committee Act (5 U.S.C. App.) shall not apply
to the Committee.
``(2) Criteria and process for submission and review of
physician-focused payment models.--
``(A) Criteria for assessing physician-focused
payment models.--
``(i) Rulemaking.--Not later than November
1, 2015, the Secretary shall, through notice
and comment rulemaking, following a request for
information, establish criteria for physician-
focused payment models, including models for
specialist physicians, that could be used by
the Committee for making comments and
recommendations pursuant to paragraph (1)(D).
``(ii) MedPAC submission of comments.--
During the comment period for the proposed rule
described in clause (i), the Medicare Payment
Advisory Commission may submit comments to the
Secretary on the proposed criteria under such
clause.
``(iii) Updating.--The Secretary may update
the criteria established under this
subparagraph through rulemaking.
``(B) Stakeholder submission of physician focused
payment models.--On an ongoing basis, individuals and
stakeholder entities may submit to the Committee
proposals for physician-focused payment models that
such individuals and entities believe meet the criteria
described in subparagraph (A).
``(C) TAC review of models submitted.--The
Committee shall, on a periodic basis, review models
submitted under subparagraph (B), prepare comments and
recommendations regarding whether such models meet the
criteria described in subparagraph (A), and submit such
comments and recommendations to the Secretary.
``(D) Secretary review and response.--The Secretary
shall review the comments and recommendations submitted
by the Committee under subparagraph (C) and post a
detailed response to such comments and recommendations
on the Internet Website of the Centers for Medicare &
Medicaid Services.
``(3) Rule of construction.--Nothing in this subsection
shall be construed to impact the development or testing of
models under this title or titles XI, XIX, or XXI.''.
(2) Incentive payments for participation in eligible
alternative payment models.--Section 1833 of the Social
Security Act (42 U.S.C. 1395l) is amended by adding at the end
the following new subsection:
``(z) Incentive Payments for Participation in Eligible Alternative
Payment Models.--
``(1) Payment incentive.--
``(A) In general.--In the case of covered
professional services furnished by an eligible
professional during a year that is in the period
beginning with 2018 and ending with 2023 and for which
the professional is a qualifying APM participant, in
addition to the amount of payment that would otherwise
be made for such covered professional services under
this part for such year, there also shall be paid to
such professional an amount equal to 5 percent of the
payment amount for the covered professional services
under this part for the preceding year. For purposes of
the previous sentence, the payment amount for the
preceding year may be an estimation for the full
preceding year based on a period of such preceding year
that is less than the full year. The Secretary shall
establish policies to implement this subparagraph in
cases where payment for covered professional services
furnished by a qualifying APM participant in an
alternative payment model is made to an entity
participating in the alternative payment model rather
than directly to the qualifying APM participant.
``(B) Form of payment.--Payments under this
subsection shall be made in a lump sum, on an annual
basis, as soon as practicable.
``(C) Treatment of payment incentive.--Payments
under this subsection shall not be taken into account
for purposes of determining actual expenditures under
an alternative payment model and for purposes of
determining or rebasing any benchmarks used under the
alternative payment model.
``(D) Coordination.--The amount of the additional
payment for an item or service under this subsection or
subsection (m) shall be determined without regard to
any additional payment for the item or service under
subsection (m) and this subsection, respectively. The
amount of the additional payment for an item or service
under this subsection or subsection (x) shall be
determined without regard to any additional payment for
the item or service under subsection (x) and this
subsection, respectively. The amount of the additional
payment for an item or service under this subsection or
subsection (y) shall be determined without regard to
any additional payment for the item or service under
subsection (y) and this subsection, respectively.
``(2) Qualifying apm participant.--For purposes of this
subsection, the term `qualifying APM participant' means the
following:
``(A) 2018 and 2019.--With respect to 2018 and
2019, an eligible professional for whom the Secretary
determines that at least 25 percent of payments under
this part for covered professional services furnished
by such professional during the most recent period for
which data are available (which may be less than a
year) were attributable to such services furnished
under this part through an entity that participates in
an eligible alternative payment model with respect to
such services.
``(B) 2020 and 2021.--With respect to 2020 and
2021, an eligible professional described in either of
the following clauses:
``(i) Medicare revenue threshold option.--
An eligible professional for whom the Secretary
determines that at least 50 percent of payments
under this part for covered professional
services furnished by such professional during
the most recent period for which data are
available (which may be less than a year) were
attributable to such services furnished under
this part through an entity that participates
in an eligible alternative payment model with
respect to such services.
``(ii) Combination all-payer and medicare
revenue threshold option.--An eligible
professional--
``(I) for whom the Secretary
determines, with respect to items and
services furnished by such professional
during the most recent period for which
data are available (which may be less
than a year), that at least 50 percent
of the sum of--
``(aa) payments described
in clause (i); and
``(bb) all other payments,
regardless of payer (other than
payments made by the Secretary
of Defense or the Secretary of
Veterans Affairs under chapter
55 of title 10, United States
Code, or title 38, United
States Code, or any other
provision of law, and other
than payments made under title
XIX in a State in which no
medical home or alternative
payment model is available
under the State program under
that title),
meet the requirement described in
clause (iii)(I) with respect to
payments described in item (aa) and
meet the requirement described in
clause (iii)(II) with respect to
payments described in item (bb);
``(II) for whom the Secretary
determines at least 25 percent of
payments under this part for covered
professional services furnished by such
professional during the most recent
period for which data are available
(which may be less than a year) were
attributable to such services furnished
under this part through an entity that
participates in an eligible alternative
payment model with respect to such
services; and
``(III) who provides to the
Secretary such information as is
necessary for the Secretary to make a
determination under subclause (I), with
respect to such professional.
``(iii) Requirement.--For purposes of
clause (ii)(I)--
``(I) the requirement described in
this subclause, with respect to
payments described in item (aa) of such
clause, is that such payments are made
under an eligible alternative payment
model; and
``(II) the requirement described in
this subclause, with respect to
payments described in item (bb) of such
clause, is that such payments are made
under an arrangement in which--
``(aa) quality measures
comparable to measures under
the performance category
described in section
1848(q)(2)(B)(i) apply;
``(bb) certified EHR
technology is used; and
``(cc) the eligible
professional (AA) bears more
than nominal financial risk if
actual aggregate expenditures
exceeds expected aggregate
expenditures; or (BB) is a
medical home (with respect to
beneficiaries under title XIX)
that meets criteria comparable
to medical homes expanded under
section 1115A(c).
``(C) Beginning in 2022.--With respect to 2022 and
each subsequent year, an eligible professional
described in either of the following clauses:
``(i) Medicare revenue threshold option.--
An eligible professional for whom the Secretary
determines that at least 75 percent of payments
under this part for covered professional
services furnished by such professional during
the most recent period for which data are
available (which may be less than a year) were
attributable to such services furnished under
this part through an entity that participates
in an eligible alternative payment model with
respect to such services.
``(ii) Combination all-payer and medicare
revenue threshold option.--An eligible
professional--
``(I) for whom the Secretary
determines, with respect to items and
services furnished by such professional
during the most recent period for which
data are available (which may be less
than a year), that at least 75 percent
of the sum of--
``(aa) payments described
in clause (i); and
``(bb) all other payments,
regardless of payer (other than
payments made by the Secretary
of Defense or the Secretary of
Veterans Affairs under chapter
55 of title 10, United States
Code, or title 38, United
States Code, or any other
provision of law, and other
than payments made under title
XIX in a State in which no
medical home or alternative
payment model is available
under the State program under
that title),
meet the requirement described in
clause (iii)(I) with respect to
payments described in item (aa) and
meet the requirement described in
clause (iii)(II) with respect to
payments described in item (bb);
``(II) for whom the Secretary
determines at least 25 percent of
payments under this part for covered
professional services furnished by such
professional during the most recent
period for which data are available
(which may be less than a year) were
attributable to such services furnished
under this part through an entity that
participates in an eligible alternative
payment model with respect to such
services; and
``(III) who provides to the
Secretary such information as is
necessary for the Secretary to make a
determination under subclause (I), with
respect to such professional.
``(iii) Requirement.--For purposes of
clause (ii)(I)--
``(I) the requirement described in
this subclause, with respect to
payments described in item (aa) of such
clause, is that such payments are made
under an eligible alternative payment
model; and
``(II) the requirement described in
this subclause, with respect to
payments described in item (bb) of such
clause, is that such payments are made
under an arrangement in which--
``(aa) quality measures
comparable to measures under
the performance category
described in section
1848(q)(2)(B)(i) apply;
``(bb) certified EHR
technology is used; and
``(cc) the eligible
professional (AA) bears more
than nominal financial risk if
actual aggregate expenditures
exceeds expected aggregate
expenditures; or (BB) is a
medical home (with respect to
beneficiaries under title XIX)
that meets criteria comparable
to medical homes expanded under
section 1115A(c).
``(3) Additional definitions.--In this subsection:
``(A) Covered professional services.--The term
`covered professional services' has the meaning given
that term in section 1848(k)(3)(A).
``(B) Eligible professional.--The term `eligible
professional' has the meaning given that term in
section 1848(k)(3)(B).
``(C) Alternative payment model (apm).--The term
`alternative payment model' means any of the following:
``(i) A model under section 1115A (other
than a health care innovation award).
``(ii) The shared savings program under
section 1899.
``(iii) A demonstration under section
1866C.
``(iv) A demonstration required by Federal
law.
``(D) Eligible alternative payment model (apm).--
``(i) In general.--The term `eligible
alternative payment model' means, with respect
to a year, an alternative payment model--
``(I) that requires use of
certified EHR technology (as defined in
subsection (o)(4));
``(II) that provides for payment
for covered professional services based
on quality measures comparable to
measures under the performance category
described in section 1848(q)(2)(B)(i);
and
``(III) that satisfies the
requirement described in clause (ii).
``(ii) Additional requirement.--For
purposes of clause (i)(III), the requirement
described in this clause, with respect to a
year and an alternative payment model, is that
the alternative payment model--
``(I) is one in which one or more
entities bear financial risk for
monetary losses under such model that
are in excess of a nominal amount; or
``(II) is a medical home expanded
under section 1115A(c).
``(4) Limitation.--There shall be no administrative or
judicial review under section 1869, 1878, or otherwise, of the
following:
``(A) The determination that an eligible
professional is a qualifying APM participant under
paragraph (2) and the determination that an alternative
payment model is an eligible alternative payment model
under paragraph (3)(D).
``(B) The determination of the amount of the 5
percent payment incentive under paragraph (1)(A),
including any estimation as part of such
determination.''.
(3) Coordination conforming amendments.--Section 1833 of
the Social Security Act (42 U.S.C. 1395l) is further amended--
(A) in subsection (x)(3), by adding at the end the
following new sentence: ``The amount of the additional
payment for a service under this subsection and
subsection (z) shall be determined without regard to
any additional payment for the service under subsection
(z) and this subsection, respectively.''; and
(B) in subsection (y)(3), by adding at the end the
following new sentence: ``The amount of the additional
payment for a service under this subsection and
subsection (z) shall be determined without regard to
any additional payment for the service under subsection
(z) and this subsection, respectively.''.
(4) Encouraging development and testing of certain
models.--Section 1115A(b)(2) of the Social Security Act (42
U.S.C. 1315a(b)(2)) is amended--
(A) in subparagraph (B), by adding at the end the
following new clauses:
``(xxi) Focusing primarily on physicians'
services (as defined in section 1848(j)(3))
furnished by physicians who are not primary
care practitioners.
``(xxii) Focusing on practices of 15 or
fewer professionals.
``(xxiii) Focusing on risk-based models for
small physician practices which may involve
two-sided risk and prospective patient
assignment, and which examine risk-adjusted
decreases in mortality rates, hospital
readmissions rates, and other relevant and
appropriate clinical measures.
``(xxiv) Focusing primarily on title XIX,
working in conjunction with the Center for
Medicaid and CHIP Services.''; and
(B) in subparagraph (C)(viii), by striking ``other
public sector or private sector payers'' and inserting
``other public sector payers, private sector payers, or
Statewide payment models''.
(5) Construction regarding telehealth services.--Nothing in
the provisions of, or amendments made by, this Act shall be
construed as precluding an alternative payment model or a
qualifying APM participant (as those terms are defined in
section 1833(z) of the Social Security Act, as added by
paragraph (1)) from furnishing a telehealth service for which
payment is not made under section 1834(m) of the Social
Security Act (42 U.S.C. 1395m(m)).
(6) Integrating medicare advantage alternative payment
models.--Not later than July 1, 2015, the Secretary of Health
and Human Services shall submit to Congress a study that
examines the feasibility of integrating alternative payment
models in the Medicare Advantage payment system. The study
shall include the feasibility of including a value-based
modifier and whether such modifier should be budget neutral.
(7) Study and report on fraud related to alternative
payment models under the medicare program.--
(A) Study.--The Secretary of Health and Human
Services, in consultation with the Inspector General of
the Department of Health and Human Services, shall
conduct a study that--
(i) examines the applicability of the
Federal fraud prevention laws to items and
services furnished under title XVIII of the
Social Security Act for which payment is made
under an alternative payment model (as defined
in section 1833(z)(3)(C) of such Act (42 U.S.C.
1395l(z)(3)(C)));
(ii) identifies aspects of such alternative
payment models that are vulnerable to
fraudulent activity; and
(iii) examines the implications of waivers
to such laws granted in support of such
alternative payment models, including under any
potential expansion of such models.
(B) Report.--Not later than 2 years after the date
of the enactment of this Act, the Secretary shall
submit to Congress a report containing the results of
the study conducted under subparagraph (A). Such report
shall include recommendations for actions to be taken
to reduce the vulnerability of such alternative payment
models to fraudulent activity. Such report also shall
include, as appropriate, recommendations of the
Inspector General for changes in Federal fraud
prevention laws to reduce such vulnerability.
(f) Improving Payment Accuracy.--
(1) Studies and reports of effect of certain information on
quality and resource use.--
(A) Study using existing medicare data.--
(i) Study.--The Secretary of Health and
Human Services (in this subsection referred to
as the ``Secretary'') shall conduct a study
that examines the effect of individuals'
socioeconomic status on quality and resource
use outcome measures for individuals under the
Medicare program (such as to recognize that
less healthy individuals may require more
intensive interventions). The study shall use
information collected on such individuals in
carrying out such program, such as urban and
rural location, eligibility for Medicaid
(recognizing and accounting for varying
Medicaid eligibility across States), and
eligibility for benefits under the supplemental
security income (SSI) program. The Secretary
shall carry out this paragraph acting through
the Assistant Secretary for Planning and
Evaluation.
(ii) Report.--Not later than 2 years after
the date of the enactment of this Act, the
Secretary shall submit to Congress a report on
the study conducted under clause (i).
(B) Study using other data.--
(i) Study.--The Secretary shall conduct a
study that examines the impact of risk factors,
such as those described in section 1848(p)(3)
of the Social Security Act (42 U.S.C. 1395w-
4(p)(3)), race, health literacy, limited
English proficiency (LEP), and patient
activation, on quality and resource use outcome
measures under the Medicare program (such as to
recognize that less healthy individuals may
require more intensive interventions). In
conducting such study the Secretary may use
existing Federal data and collect such
additional data as may be necessary to complete
the study.
(ii) Report.--Not later than 5 years after
the date of the enactment of this Act, the
Secretary shall submit to Congress a report on
the study conducted under clause (i).
(C) Examination of data in conducting studies.--In
conducting the studies under subparagraphs (A) and (B),
the Secretary shall examine what non-Medicare data
sets, such as data from the American Community Survey
(ACS), can be useful in conducting the types of studies
under such paragraphs and how such data sets that are
identified as useful can be coordinated with Medicare
administrative data in order to improve the overall
data set available to do such studies and for the
administration of the Medicare program.
(D) Recommendations to account for information in
payment adjustment mechanisms.--If the studies
conducted under subparagraphs (A) and (B) find a
relationship between the factors examined in the
studies and quality and resource use outcome measures,
then the Secretary shall also provide recommendations
for how the Centers for Medicare & Medicaid Services
should--
(i) obtain access to the necessary data (if
such data is not already being collected) on
such factors, including recommendations on how
to address barriers to the Centers in accessing
such data; and
(ii) account for such factors in
determining payment adjustments based on
quality and resource use outcome measures under
the eligible professional Merit-based Incentive
Payment System under section 1848(q) of the
Social Security Act (42 U.S.C. 1395w-4(q)) and,
as the Secretary determines appropriate, other
similar provisions of title XVIII of such Act.
(E) Funding.--There are hereby appropriated from
the Federal Supplementary Medical Insurance Trust Fund
under section 1841 of the Social Security Act to the
Secretary to carry out this paragraph $6,000,000, to
remain available until expended.
(2) CMS activities.--
(A) Hierarchal condition category (hcc)
improvement.--Taking into account the relevant studies
conducted and recommendations made in reports under
paragraph (1), the Secretary, on an ongoing basis,
shall, as the Secretary determines appropriate,
estimate how an individual's health status and other
risk factors affect quality and resource use outcome
measures and, as feasible, shall incorporate
information from quality and resource use outcome
measurement (including care episode and patient
condition groups) into provisions of title XVIII of the
Social Security Act that are similar to the eligible
professional Merit-based Incentive Payment System under
section 1848(q) of such Act.
(B) Accounting for other factors in payment
adjustment mechanisms.--
(i) In general.--Taking into account the
studies conducted and recommendations made in
reports under paragraph (1) and other
information as appropriate, the Secretary
shall, as the Secretary determines appropriate,
account for identified factors with an effect
on quality and resource use outcome measures
when determining payment adjustment mechanisms
under provisions of title XVIII of the Social
Security Act that are similar to the eligible
professional Merit-based Incentive Payment
System under section 1848(q) of such Act.
(ii) Accessing data.--The Secretary shall
collect or otherwise obtain access to the data
necessary to carry out this paragraph through
existing and new data sources.
(iii) Periodic analyses.--The Secretary
shall carry out periodic analyses, at least
every 3 years, based on the factors referred to
in clause (i) so as to monitor changes in
possible relationships.
(C) Funding.--There are hereby appropriated from
the Federal Supplementary Medical Insurance Trust Fund
under section 1841 of the Social Security Act to the
Secretary to carry out this paragraph and the
application of this paragraph to the Merit-based
Incentive Payment System under section 1848(q) of such
Act $10,000,000, to remain available until expended.
(3) Strategic plan for accessing race and ethnicity data.--
Not later than 18 months after the date of the enactment of
this Act, the Secretary shall develop and report to Congress on
a strategic plan for collecting or otherwise accessing data on
race and ethnicity for purposes of carrying out the eligible
professional Merit-based Incentive Payment System under section
1848(q) of the Social Security Act and, as the Secretary
determines appropriate, other similar provisions of title XVIII
of such Act.
(g) Collaborating With the Physician, Practitioner, and Other
Stakeholder Communities To Improve Resource Use Measurement.--Section
1848 of the Social Security Act (42 U.S.C. 1395w-4), as amended by
subsection (c), is further amended by adding at the end the following
new subsection:
``(r) Collaborating With the Physician, Practitioner, and Other
Stakeholder Communities To Improve Resource Use Measurement.--
``(1) In general.--In order to involve the physician,
practitioner, and other stakeholder communities in enhancing
the infrastructure for resource use measurement, including for
purposes of the Merit-based Incentive Payment System under
subsection (q) and alternative payment models under section
1833(z), the Secretary shall undertake the steps described in
the succeeding provisions of this subsection.
``(2) Development of care episode and patient condition
groups and classification codes.--
``(A) In general.--In order to classify similar
patients into care episode groups and patient condition
groups, the Secretary shall undertake the steps
described in the succeeding provisions of this
paragraph.
``(B) Public availability of existing efforts to
design an episode grouper.--Not later than 120 days
after the date of the enactment of this subsection, the
Secretary shall post on the Internet website of the
Centers for Medicare & Medicaid Services a list of the
episode groups developed pursuant to subsection
(n)(9)(A) and related descriptive information.
``(C) Stakeholder input.--The Secretary shall
accept, through the date that is 60 days after the day
the Secretary posts the list pursuant to subparagraph
(B), suggestions from physician specialty societies,
applicable practitioner organizations, and other
stakeholders for episode groups in addition to those
posted pursuant to such subparagraph, and specific
clinical criteria and patient characteristics to
classify patients into--
``(i) care episode groups; and
``(ii) patient condition groups.
``(D) Development of proposed classification
codes.--
``(i) In general.--Taking into account the
information described in subparagraph (B) and
the information received under subparagraph
(C), the Secretary shall--
``(I) establish care episode groups
and patient condition groups, which
account for a target of an estimated
\2/3\ of expenditures under parts A and
B; and
``(II) assign codes to such groups.
``(ii) Care episode groups.--In
establishing the care episode groups under
clause (i), the Secretary shall take into
account--
``(I) the patient's clinical
problems at the time items and services
are furnished during an episode of
care, such as the clinical conditions
or diagnoses, whether or not inpatient
hospitalization is anticipated or
occurs, and the principal procedures or
services planned or furnished; and
``(II) other factors determined
appropriate by the Secretary.
``(iii) Patient condition groups.--In
establishing the patient condition groups under
clause (i), the Secretary shall take into
account--
``(I) the patient's clinical
history at the time of each medical
visit, such as the patient's
combination of chronic conditions,
current health status, and recent
significant history (such as
hospitalization and major surgery
during a previous period, such as 3
months); and
``(II) other factors determined
appropriate by the Secretary, such as
eligibility status under this title
(including eligibility under section
226(a), 226(b), or 226A, and dual
eligibility under this title and title
XIX).
``(E) Draft care episode and patient condition
groups and classification codes.--Not later than 180
days after the end of the comment period described in
subparagraph (C), the Secretary shall post on the
Internet website of the Centers for Medicare & Medicaid
Services a draft list of the care episode and patient
condition codes established under subparagraph (D) (and
the criteria and characteristics assigned to such
code).
``(F) Solicitation of input.--The Secretary shall
seek, through the date that is 60 days after the
Secretary posts the list pursuant to subparagraph (E),
comments from physician specialty societies, applicable
practitioner organizations, and other stakeholders,
including representatives of individuals entitled to
benefits under part A or enrolled under this part,
regarding the care episode and patient condition groups
(and codes) posted under subparagraph (E). In seeking
such comments, the Secretary shall use one or more
mechanisms (other than notice and comment rulemaking)
that may include use of open door forums, town hall
meetings, or other appropriate mechanisms.
``(G) Operational list of care episode and patient
condition groups and codes.--Not later than 180 days
after the end of the comment period described in
subparagraph (F), taking into account the comments
received under such subparagraph, the Secretary shall
post on the Internet website of the Centers for
Medicare & Medicaid Services an operational list of
care episode and patient condition codes (and the
criteria and characteristics assigned to such code).
``(H) Subsequent revisions.--Not later than
November 1 of each year (beginning with 2017), the
Secretary shall, through rulemaking, make revisions to
the operational lists of care episode and patient
condition codes as the Secretary determines may be
appropriate. Such revisions may be based on experience,
new information developed pursuant to subsection
(n)(9)(A), and input from the physician specialty
societies, applicable practitioner organizations, and
other stakeholders, including representatives of
individuals entitled to benefits under part A or
enrolled under this part.
``(3) Attribution of patients to physicians or
practitioners.--
``(A) In general.--In order to facilitate the
attribution of patients and episodes (in whole or in
part) to one or more physicians or applicable
practitioners furnishing items and services, the
Secretary shall undertake the steps described in the
succeeding provisions of this paragraph.
``(B) Development of patient relationship
categories and codes.--The Secretary shall develop
patient relationship categories and codes that define
and distinguish the relationship and responsibility of
a physician or applicable practitioner with a patient
at the time of furnishing an item or service. Such
patient relationship categories shall include different
relationships of the physician or applicable
practitioner to the patient (and the codes may reflect
combinations of such categories), such as a physician
or applicable practitioner who--
``(i) considers themself to have the
primary responsibility for the general and
ongoing care for the patient over extended
periods of time;
``(ii) considers themself to be the lead
physician or practitioner and who furnishes
items and services and coordinates care
furnished by other physicians or practitioners
for the patient during an acute episode;
``(iii) furnishes items and services to the
patient on a continuing basis during an acute
episode of care, but in a supportive rather
than a lead role;
``(iv) furnishes items and services to the
patient on an occasional basis, usually at the
request of another physician or practitioner;
or
``(v) furnishes items and services only as
ordered by another physician or practitioner.
``(C) Draft list of patient relationship categories
and codes.--Not later than 270 days after the date of
the enactment of this subsection, the Secretary shall
post on the Internet website of the Centers for
Medicare & Medicaid Services a draft list of the
patient relationship categories and codes developed
under subparagraph (B).
``(D) Stakeholder input.--The Secretary shall seek,
through the date that is 60 days after the Secretary
posts the list pursuant to subparagraph (C), comments
from physician specialty societies, applicable
practitioner organizations, and other stakeholders,
including representatives of individuals entitled to
benefits under part A or enrolled under this part,
regarding the patient relationship categories and codes
posted under subparagraph (C). In seeking such
comments, the Secretary shall use one or more
mechanisms (other than notice and comment rulemaking)
that may include open door forums, town hall meetings,
or other appropriate mechanisms.
``(E) Operational list of patient relationship
categories and codes.--Not later than 180 days after
the end of the comment period described in subparagraph
(D), taking into account the comments received under
such subparagraph, the Secretary shall post on the
Internet website of the Centers for Medicare & Medicaid
Services an operational list of patient relationship
categories and codes.
``(F) Subsequent revisions.--Not later than
November 1 of each year (beginning with 2017), the
Secretary shall, through rulemaking, make revisions to
the operational list of patient relationship categories
and codes as the Secretary determines appropriate. Such
revisions may be based on experience, new information
developed pursuant to subsection (n)(9)(A), and input
from the physician specialty societies, applicable
practitioner organizations, and other stakeholders,
including representatives of individuals entitled to
benefits under part A or enrolled under this part.
``(4) Reporting of information for resource use
measurement.--Claims submitted for items and services furnished
by a physician or applicable practitioner on or after January
1, 2017, shall, as determined appropriate by the Secretary,
include--
``(A) applicable codes established under paragraphs
(2) and (3); and
``(B) the national provider identifier of the
ordering physician or applicable practitioner (if
different from the billing physician or applicable
practitioner).
``(5) Methodology for resource use analysis.--
``(A) In general.--In order to evaluate the
resources used to treat patients (with respect to care
episode and patient condition groups), the Secretary
shall--
``(i) use the patient relationship codes
reported on claims pursuant to paragraph (4) to
attribute patients (in whole or in part) to one
or more physicians and applicable
practitioners;
``(ii) use the care episode and patient
condition codes reported on claims pursuant to
paragraph (4) as a basis to compare similar
patients and care episodes and patient
condition groups; and
``(iii) conduct an analysis of resource use
(with respect to care episodes and patient
condition groups of such patients), as the
Secretary determines appropriate.
``(B) Analysis of patients of physicians and
practitioners.--In conducting the analysis described in
subparagraph (A)(iii) with respect to patients
attributed to physicians and applicable practitioners,
the Secretary shall, as feasible--
``(i) use the claims data experience of
such patients by patient condition codes during
a common period, such as 12 months; and
``(ii) use the claims data experience of
such patients by care episode codes--
``(I) in the case of episodes
without a hospitalization, during
periods of time (such as the number of
days) determined appropriate by the
Secretary; and
``(II) in the case of episodes with
a hospitalization, during periods of
time (such as the number of days)
before, during, and after the
hospitalization.
``(C) Measurement of resource use.--In measuring
such resource use, the Secretary--
``(i) shall use per patient total allowed
charges for all services under part A and this
part (and, if the Secretary determines
appropriate, part D) for the analysis of
patient resource use, by care episode codes and
by patient condition codes; and
``(ii) may, as determined appropriate, use
other measures of allowed charges (such as
subtotals for categories of items and services)
and measures of utilization of items and
services (such as frequency of specific items
and services and the ratio of specific items
and services among attributed patients or
episodes).
``(D) Stakeholder input.--The Secretary shall seek
comments from the physician specialty societies,
applicable practitioner organizations, and other
stakeholders, including representatives of individuals
entitled to benefits under part A or enrolled under
this part, regarding the resource use methodology
established pursuant to this paragraph. In seeking
comments the Secretary shall use one or more mechanisms
(other than notice and comment rulemaking) that may
include open door forums, town hall meetings, or other
appropriate mechanisms.
``(6) Implementation.--To the extent that the Secretary
contracts with an entity to carry out any part of the
provisions of this subsection, the Secretary may not contract
with an entity or an entity with a subcontract if the entity or
subcontracting entity currently makes recommendations to the
Secretary on relative values for services under the fee
schedule for physicians' services under this section.
``(7) Limitation.--There shall be no administrative or
judicial review under section 1869, section 1878, or otherwise
of--
``(A) care episode and patient condition groups and
codes established under paragraph (2);
``(B) patient relationship categories and codes
established under paragraph (3); and
``(C) measurement of, and analyses of resource use
with respect to, care episode and patient condition
codes and patient relationship codes pursuant to
paragraph (5).
``(8) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to this section.
``(9) Definitions.--In this section:
``(A) Physician.--The term `physician' has the
meaning given such term in section 1861(r)(1).
``(B) Applicable practitioner.--The term
`applicable practitioner' means--
``(i) a physician assistant, nurse
practitioner, and clinical nurse specialist (as
such terms are defined in section 1861(aa)(5)),
and a certified registered nurse anesthetist
(as defined in section 1861(bb)(2)); and
``(ii) beginning January 1, 2018, such
other eligible professionals (as defined in
subsection (k)(3)(B)) as specified by the
Secretary.
``(10) Clarification.--The provisions of sections
1890(b)(7) and 1890A shall not apply to this subsection.''.
SEC. 102. PRIORITIES AND FUNDING FOR MEASURE DEVELOPMENT.
Section 1848 of the Social Security Act (42 U.S.C. 1395w-4), as
amended by subsections (c) and (g) of section 101, is further amended
by inserting at the end the following new subsection:
``(s) Priorities and Funding for Measure Development.--
``(1) Plan identifying measure development priorities and
timelines.--
``(A) Draft measure development plan.--Not later
than January 1, 2015, the Secretary shall develop, and
post on the Internet website of the Centers for
Medicare & Medicaid Services, a draft plan for the
development of quality measures for application under
the applicable provisions (as defined in paragraph
(5)). Under such plan the Secretary shall--
``(i) address how measures used by private
payers and integrated delivery systems could be
incorporated under title XVIII;
``(ii) describe how coordination, to the
extent possible, will occur across
organizations developing such measures; and
``(iii) take into account how clinical best
practices and clinical practice guidelines
should be used in the development of quality
measures.
``(B) Quality domains.--For purposes of this
subsection, the term `quality domains' means at least
the following domains:
``(i) Clinical care.
``(ii) Safety.
``(iii) Care coordination.
``(iv) Patient and caregiver experience.
``(v) Population health and prevention.
``(C) Consideration.--In developing the draft plan
under this paragraph, the Secretary shall consider--
``(i) gap analyses conducted by the entity
with a contract under section 1890(a) or other
contractors or entities;
``(ii) whether measures are applicable
across health care settings;
``(iii) clinical practice improvement
activities submitted under subsection
(q)(2)(C)(iv) for identifying possible areas
for future measure development and identifying
existing gaps with respect to such measures;
and
``(iv) the quality domains applied under
this subsection.
``(D) Priorities.--In developing the draft plan
under this paragraph, the Secretary shall give priority
to the following types of measures:
``(i) Outcome measures, including patient
reported outcome and functional status
measures.
``(ii) Patient experience measures.
``(iii) Care coordination measures.
``(iv) Measures of appropriate use of
services, including measures of over use.
``(E) Stakeholder input.--The Secretary shall
accept through March 1, 2015, comments on the draft
plan posted under paragraph (1)(A) from the public,
including health care providers, payers, consumers, and
other stakeholders.
``(F) Final measure development plan.--Not later
than May 1, 2015, taking into account the comments
received under this subparagraph, the Secretary shall
finalize the plan and post on the Internet website of
the Centers for Medicare & Medicaid Services an
operational plan for the development of quality
measures for use under the applicable provisions. Such
plan shall be updated as appropriate.
``(2) Contracts and other arrangements for quality measure
development.--
``(A) In general.--The Secretary shall enter into
contracts or other arrangements with entities for the
purpose of developing, improving, updating, or
expanding in accordance with the plan under paragraph
(1) quality measures for application under the
applicable provisions. Such entities shall include
organizations with quality measure development
expertise.
``(B) Prioritization.--
``(i) In general.--In entering into
contracts or other arrangements under
subparagraph (A), the Secretary shall give
priority to the development of the types of
measures described in paragraph (1)(D).
``(ii) Consideration.--In selecting
measures for development under this subsection,
the Secretary shall consider--
``(I) whether such measures would
be electronically specified; and
``(II) clinical practice guidelines
to the extent that such guidelines
exist.
``(3) Annual report by the secretary.--
``(A) In general.--Not later than May 1, 2016, and
annually thereafter, the Secretary shall post on the
Internet website of the Centers for Medicare & Medicaid
Services a report on the progress made in developing
quality measures for application under the applicable
provisions.
``(B) Requirements.--Each report submitted pursuant
to subparagraph (A) shall include the following:
``(i) A description of the Secretary's
efforts to implement this paragraph.
``(ii) With respect to the measures
developed during the previous year--
``(I) a description of the total
number of quality measures developed
and the types of such measures, such as
an outcome or patient experience
measure;
``(II) the name of each measure
developed;
``(III) the name of the developer
and steward of each measure;
``(IV) with respect to each type of
measure, an estimate of the total
amount expended under this title to
develop all measures of such type; and
``(V) whether the measure would be
electronically specified.
``(iii) With respect to measures in
development at the time of the report--
``(I) the information described in
clause (ii), if available; and
``(II) a timeline for completion of
the development of such measures.
``(iv) A description of any updates to the
plan under paragraph (1) (including newly
identified gaps and the status of previously
identified gaps) and the inventory of measures
applicable under the applicable provisions.
``(v) Other information the Secretary
determines to be appropriate.
``(4) Stakeholder input.--With respect to paragraph (1),
the Secretary shall seek stakeholder input with respect to--
``(A) the identification of gaps where no quality
measures exist, particularly with respect to the types
of measures described in paragraph (1)(D);
``(B) prioritizing quality measure development to
address such gaps; and
``(C) other areas related to quality measure
development determined appropriate by the Secretary.
``(5) Definition of applicable provisions.--In this
subsection, the term `applicable provisions' means the
following provisions:
``(A) Subsection (q)(2)(B)(i).
``(B) Section 1833(z)(2)(C).
``(6) Funding.--For purposes of carrying out this
subsection, the Secretary shall provide for the transfer, from
the Federal Supplementary Medical Insurance Trust Fund under
section 1841, of $15,000,000 to the Centers for Medicare &
Medicaid Services Program Management Account for each of fiscal
years 2014 through 2018. Amounts transferred under this
paragraph shall remain available through the end of fiscal year
2021.''.
SEC. 103. ENCOURAGING CARE MANAGEMENT FOR INDIVIDUALS WITH CHRONIC CARE
NEEDS.
(a) In General.--Section 1848(b) of the Social Security Act (42
U.S.C. 1395w-4(b)) is amended by adding at the end the following new
paragraph:
``(8) Encouraging care management for individuals with
chronic care needs.--
``(A) In general.--In order to encourage the
management of care by an applicable provider (as
defined in subparagraph (B)) for individuals with
chronic care needs the Secretary shall--
``(i) establish one or more HCPCS codes for
chronic care management services for such
individuals; and
``(ii) subject to subparagraph (D), make
payment (as the Secretary determines to be
appropriate) under this section for such
management services furnished on or after
January 1, 2015, by an applicable provider.
``(B) Applicable provider defined.--For purposes of
this paragraph, the term `applicable provider' means a
physician (as defined in section 1861(r)(1)), physician
assistant or nurse practitioner (as defined in section
1861(aa)(5)(A)), or clinical nurse specialist (as
defined in section 1861(aa)(5)(B)) who furnishes
services as part of a patient-centered medical home or
a comparable specialty practice that--
``(i) is recognized as such a medical home
or comparable specialty practice by an
organization that is recognized by the
Secretary for purposes of such recognition as
such a medical home or practice; or
``(ii) meets such other comparable
qualifications as the Secretary determines to
be appropriate.
``(C) Budget neutrality.--The budget neutrality
provision under subsection (c)(2)(B)(ii)(II) shall
apply in establishing the payment under subparagraph
(A)(ii).
``(D) Policies relating to payment.--In carrying
out this paragraph, with respect to chronic care
management services, the Secretary shall--
``(i) make payment to only one applicable
provider for such services furnished to an
individual during a period;
``(ii) not make payment under subparagraph
(A) if such payment would be duplicative of
payment that is otherwise made under this title
for such services (such as in the case of
hospice care or home health services); and
``(iii) not require that an annual wellness
visit (as defined in section 1861(hhh)) or an
initial preventive physical examination (as
defined in section 1861(ww)) be furnished as a
condition of payment for such management
services.''.
(b) Education and Outreach.--
(1) Campaign.--
(A) In general.--The Secretary of Health and Human
Services (in this subsection referred to as the
``Secretary'') shall conduct an education and outreach
campaign to inform professionals who furnish items and
services under part B of title XVIII of the Social
Security Act and individuals enrolled under such part
of the benefits of chronic care management services
described in section 1848(b)(8) of the Social Security
Act, as added by subsection (a), and encourage such
individuals with chronic care needs to receive such
services.
(B) Requirements.--Such campaign shall--
(i) be directed by the Office of Rural
Health Policy of the Department of Health and
Human Services and the Office of Minority
Health of the Centers for Medicare & Medicaid
Services; and
(ii) focus on encouraging participation by
underserved rural populations and racial and
ethnic minority populations.
(2) Report.--
(A) In general.--Not later than December 31, 2017,
the Secretary shall submit to Congress a report on the
use of chronic care management services described in
such section 1848(b)(8) by individuals living in rural
areas and by racial and ethnic minority populations.
Such report shall--
(i) identify barriers to receiving chronic
care management services; and
(ii) make recommendations for increasing
the appropriate use of chronic care management
services.
SEC. 104. ENSURING ACCURATE VALUATION OF SERVICES UNDER THE PHYSICIAN
FEE SCHEDULE.
(a) Authority To Collect and Use Information on Physicians'
Services in the Determination of Relative Values.--
(1) In general.--Section 1848(c)(2) of the Social Security
Act (42 U.S.C. 1395w-4(c)(2)) is amended by adding at the end
the following new subparagraph:
``(M) Authority to collect and use information on
physicians' services in the determination of relative
values.--
``(i) Collection of information.--
Notwithstanding any other provision of law, the
Secretary may collect or obtain information on
the resources directly or indirectly related to
furnishing services for which payment is made
under the fee schedule established under
subsection (b). Such information may be
collected or obtained from any eligible
professional or any other source.
``(ii) Use of information.--Notwithstanding
any other provision of law, subject to clause
(v), the Secretary may (as the Secretary
determines appropriate) use information
collected or obtained pursuant to clause (i) in
the determination of relative values for
services under this section.
``(iii) Types of information.--The types of
information described in clauses (i) and (ii)
may, at the Secretary's discretion, include any
or all of the following:
``(I) Time involved in furnishing
services.
``(II) Amounts and types of
practice expense inputs involved with
furnishing services.
``(III) Prices (net of any
discounts) for practice expense inputs,
which may include paid invoice prices
or other documentation or records.
``(IV) Overhead and accounting
information for practices of physicians
and other suppliers.
``(V) Any other element that would
improve the valuation of services under
this section.
``(iv) Information collection mechanisms.--
Information may be collected or obtained
pursuant to this subparagraph from any or all
of the following:
``(I) Surveys of physicians, other
suppliers, providers of services,
manufacturers, and vendors.
``(II) Surgical logs, billing
systems, or other practice or facility
records.
``(III) Electronic health records.
``(IV) Any other mechanism
determined appropriate by the
Secretary.
``(v) Transparency of use of information.--
``(I) In general.--Subject to
subclauses (II) and (III), if the
Secretary uses information collected or
obtained under this subparagraph in the
determination of relative values under
this subsection, the Secretary shall
disclose the information source and
discuss the use of such information in
such determination of relative values
through notice and comment rulemaking.
``(II) Thresholds for use.--The
Secretary may establish thresholds in
order to use such information,
including the exclusion of information
collected or obtained from eligible
professionals who use very high
resources (as determined by the
Secretary) in furnishing a service.
``(III) Disclosure of
information.--The Secretary shall make
aggregate information available under
this subparagraph but shall not
disclose information in a form or
manner that identifies an eligible
professional or a group practice, or
information collected or obtained
pursuant to a nondisclosure agreement.
``(vi) Incentive to participate.--The
Secretary may provide for such payments under
this part to an eligible professional that
submits such solicited information under this
subparagraph as the Secretary determines
appropriate in order to compensate such
eligible professional for such submission. Such
payments shall be provided in a form and manner
specified by the Secretary.
``(vii) Administration.--Chapter 35 of
title 44, United States Code, shall not apply
to information collected or obtained under this
subparagraph.
``(viii) Definition of eligible
professional.--In this subparagraph, the term
`eligible professional' has the meaning given
such term in subsection (k)(3)(B).
``(ix) Funding.--For purposes of carrying
out this subparagraph, in addition to funds
otherwise appropriated, the Secretary shall
provide for the transfer, from the Federal
Supplementary Medical Insurance Trust Fund
under section 1841, of $2,000,000 to the
Centers for Medicare & Medicaid Services
Program Management Account for each fiscal year
beginning with fiscal year 2014. Amounts
transferred under the preceding sentence for a
fiscal year shall be available until
expended.''.
(2) Limitation on review.--Section 1848(i)(1) of the Social
Security Act (42 U.S.C. 1395w-4(i)(1)) is amended--
(A) in subparagraph (D), by striking ``and'' at the
end;
(B) in subparagraph (E), by striking the period at
the end and inserting ``, and''; and
(C) by adding at the end the following new
subparagraph:
``(F) the collection and use of information in the
determination of relative values under subsection
(c)(2)(M).''.
(b) Authority for Alternative Approaches To Establishing Practice
Expense Relative Values.--Section 1848(c)(2) of the Social Security Act
(42 U.S.C. 1395w-4(c)(2)), as amended by subsection (a), is amended by
adding at the end the following new subparagraph:
``(N) Authority for alternative approaches to
establishing practice expense relative values.--The
Secretary may establish or adjust practice expense
relative values under this subsection using cost,
charge, or other data from suppliers or providers of
services, including information collected or obtained
under subparagraph (M).''.
(c) Revised and Expanded Identification of Potentially Misvalued
Codes.--Section 1848(c)(2)(K)(ii) of the Social Security Act (42 U.S.C.
1395w-4(c)(2)(K)(ii)) is amended to read as follows:
``(ii) Identification of potentially
misvalued codes.--For purposes of identifying
potentially misvalued codes pursuant to clause
(i)(I), the Secretary shall examine codes (and
families of codes as appropriate) based on any
or all of the following criteria:
``(I) Codes that have experienced
the fastest growth.
``(II) Codes that have experienced
substantial changes in practice
expenses.
``(III) Codes that describe new
technologies or services within an
appropriate time period (such as 3
years) after the relative values are
initially established for such codes.
``(IV) Codes which are multiple
codes that are frequently billed in
conjunction with furnishing a single
service.
``(V) Codes with low relative
values, particularly those that are
often billed multiple times for a
single treatment.
``(VI) Codes that have not been
subject to review since implementation
of the fee schedule.
``(VII) Codes that account for the
majority of spending under the
physician fee schedule.
``(VIII) Codes for services that
have experienced a substantial change
in the hospital length of stay or
procedure time.
``(IX) Codes for which there may be
a change in the typical site of service
since the code was last valued.
``(X) Codes for which there is a
significant difference in payment for
the same service between different
sites of service.
``(XI) Codes for which there may be
anomalies in relative values within a
family of codes.
``(XII) Codes for services where
there may be efficiencies when a
service is furnished at the same time
as other services.
``(XIII) Codes with high intra-
service work per unit of time.
``(XIV) Codes with high practice
expense relative value units.
``(XV) Codes with high cost
supplies.
``(XVI) Codes as determined
appropriate by the Secretary.''.
(d) Target for Relative Value Adjustments for Misvalued Services.--
(1) In general.--Section 1848(c)(2) of the Social Security
Act (42 U.S.C. 1395w-4(c)(2)), as amended by subsections (a)
and (b), is amended by adding at the end the following new
subparagraph:
``(O) Target for relative value adjustments for
misvalued services.--With respect to fee schedules
established for each of 2015 through 2018, the
following shall apply:
``(i) Determination of net reduction in
expenditures.--For each year, the Secretary
shall determine the estimated net reduction in
expenditures under the fee schedule under this
section with respect to the year as a result of
adjustments to the relative values established
under this paragraph for misvalued codes.
``(ii) Budget neutral redistribution of
funds if target met and counting overages
towards the target for the succeeding year.--If
the estimated net reduction in expenditures
determined under clause (i) for the year is
equal to or greater than the target for the
year--
``(I) reduced expenditures
attributable to such adjustments shall
be redistributed for the year in a
budget neutral manner in accordance
with subparagraph (B)(ii)(II); and
``(II) the amount by which such
reduced expenditures exceeds the target
for the year shall be treated as a
reduction in expenditures described in
clause (i) for the succeeding year, for
purposes of determining whether the
target has or has not been met under
this subparagraph with respect to that
year.
``(iii) Exemption from budget neutrality if
target not met.--If the estimated net reduction
in expenditures determined under clause (i) for
the year is less than the target for the year,
reduced expenditures in an amount equal to the
target recapture amount shall not be taken into
account in applying subparagraph (B)(ii)(II)
with respect to fee schedules beginning with
2015.
``(iv) Target recapture amount.--For
purposes of clause (iii), the target recapture
amount is, with respect to a year, an amount
equal to the difference between--
``(I) the target for the year; and
``(II) the estimated net reduction
in expenditures determined under clause
(i) for the year.
``(v) Target.--For purposes of this
subparagraph, with respect to a year, the
target is calculated as 0.5 percent of the
estimated amount of expenditures under the fee
schedule under this section for the year.''.
(2) Conforming amendment.--Section 1848(c)(2)(B)(v) of the
Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)(v)) is amended
by adding at the end the following new subclause:
``(VIII) Reductions for misvalued
services if target not met.--Effective
for fee schedules beginning with 2015,
reduced expenditures attributable to
the application of the target recapture
amount described in subparagraph
(O)(iii).''.
(e) Phase-In of Significant Relative Value Unit (RVU) Reductions.--
(1) In general.--Section 1848(c) of the Social Security Act
(42 U.S.C. 1395w-4(c)) is amended by adding at the end the
following new paragraph:
``(7) Phase-in of significant relative value unit (rvu)
reductions.--Effective for fee schedules established beginning
with 2015, if the total relative value units for a service for
a year would otherwise be decreased by an estimated amount
equal to or greater than 20 percent as compared to the total
relative value units for the previous year, the applicable
adjustments in work, practice expense, and malpractice relative
value units shall be phased-in over a 2-year period.''.
(2) Conforming amendments.--Section 1848(c)(2) of the
Social Security Act (42 U.S.C. 1395w-4(c)(2)) is amended--
(A) in subparagraph (B)(ii)(I), by striking
``subclause (II)'' and inserting ``subclause (II) and
paragraph (7)''; and
(B) in subparagraph (K)(iii)(VI)--
(i) by striking ``provisions of
subparagraph (B)(ii)(II)'' and inserting
``provisions of subparagraph (B)(ii)(II) and
paragraph (7)''; and
(ii) by striking ``under subparagraph
(B)(ii)(II)'' and inserting ``under
subparagraph (B)(ii)(I)''.
(f) Authority To Smooth Relative Values Within Groups of
Services.--Section 1848(c)(2)(C) of the Social Security Act (42 U.S.C.
1395w-4(c)(2)(C)) is amended--
(1) in each of clauses (i) and (iii), by striking ``the
service'' and inserting ``the service or group of services''
each place it appears; and
(2) in the first sentence of clause (ii), by inserting ``or
group of services'' before the period.
(g) GAO Study and Report on Relative Value Scale Update
Committee.--
(1) Study.--The Comptroller General of the United States
(in this subsection referred to as the ``Comptroller General'')
shall conduct a study of the processes used by the Relative
Value Scale Update Committee (RUC) to provide recommendations
to the Secretary of Health and Human Services regarding
relative values for specific services under the Medicare
physician fee schedule under section 1848 of the Social
Security Act (42 U.S.C. 1395w-4).
(2) Report.--Not later than 1 year after the date of the
enactment of this Act, the Comptroller General shall submit to
Congress a report containing the results of the study conducted
under paragraph (1).
(h) Adjustment to Medicare Payment Localities.--
(1) In general.--Section 1848(e) of the Social Security Act
(42 U.S.C. 1395w-4(e)) is amended by adding at the end the
following new paragraph:
``(6) Use of msas as fee schedule areas in california.--
``(A) In general.--Subject to the succeeding
provisions of this paragraph and notwithstanding the
previous provisions of this subsection, for services
furnished on or after January 1, 2017, the fee schedule
areas used for payment under this section applicable to
California shall be the following:
``(i) Each Metropolitan Statistical Area
(each in this paragraph referred to as an
`MSA'), as defined by the Director of the
Office of Management and Budget as of December
31 of the previous year, shall be a fee
schedule area.
``(ii) All areas not included in an MSA
shall be treated as a single rest-of-State fee
schedule area.
``(B) Transition for msas previously in rest-of-
state payment locality or in locality 3.--
``(i) In general.--For services furnished
in California during a year beginning with 2017
and ending with 2021 in an MSA in a transition
area (as defined in subparagraph (D)), subject
to subparagraph (C), the geographic index
values to be applied under this subsection for
such year shall be equal to the sum of the
following:
``(I) Current law component.--The
old weighting factor (described in
clause (ii)) for such year multiplied
by the geographic index values under
this subsection for the fee schedule
area that included such MSA that would
have applied in such area (as estimated
by the Secretary) if this paragraph did
not apply.
``(II) MSA-based component.--The
MSA-based weighting factor (described
in clause (iii)) for such year
multiplied by the geographic index
values computed for the fee schedule
area under subparagraph (A) for the
year (determined without regard to this
subparagraph).
``(ii) Old weighting factor.--The old
weighting factor described in this clause--
``(I) for 2017, is \5/6\; and
``(II) for each succeeding year, is
the old weighting factor described in
this clause for the previous year minus
\1/6\.
``(iii) MSA-based weighting factor.--The
MSA-based weighting factor described in this
clause for a year is 1 minus the old weighting
factor under clause (ii) for that year.
``(C) Hold harmless.--For services furnished in a
transition area in California during a year beginning
with 2017, the geographic index values to be applied
under this subsection for such year shall not be less
than the corresponding geographic index values that
would have applied in such transition area (as
estimated by the Secretary) if this paragraph did not
apply.
``(D) Transition area defined.--In this paragraph,
the term `transition area' means each of the following
fee schedule areas for 2013:
``(i) The rest-of-State payment locality.
``(ii) Payment locality 3.
``(E) References to fee schedule areas.--Effective
for services furnished on or after January 1, 2017, for
California, any reference in this section to a fee
schedule area shall be deemed a reference to a fee
schedule area established in accordance with this
paragraph.''.
(2) Conforming amendment to definition of fee schedule
area.--Section 1848(j)(2) of the Social Security Act (42 U.S.C.
1395w-4(j)(2)) is amended by striking ``The term'' and
inserting ``Except as provided in subsection (e)(6)(D), the
term''.
(i) Disclosure of Data Used To Establish Multiple Procedure Payment
Reduction Policy.--The Secretary of Health and Human Services shall
make publicly available the information used to establish the multiple
procedure payment reduction policy to the professional component of
imaging services in the final rule published in the Federal Register,
v. 77, n. 222, November 16, 2012, pages 68891-69380 under the physician
fee schedule under section 1848 of the Social Security Act (42 U.S.C.
1395w-4).
SEC. 105. PROMOTING EVIDENCE-BASED CARE.
(a) In General.--Section 1834 of the Social Security Act (42 U.S.C.
1395m) is amended by adding at the end the following new subsection:
``(p) Recognizing Appropriate Use Criteria for Certain Imaging
Services.--
``(1) Program established.--
``(A) In general.--The Secretary shall establish a
program to promote the use of appropriate use criteria
(as defined in subparagraph (B)) for applicable imaging
services (as defined in subparagraph (C)) furnished in
an applicable setting (as defined in subparagraph (D))
by ordering professionals and furnishing professionals
(as defined in subparagraphs (E) and (F),
respectively).
``(B) Appropriate use criteria defined.--In this
subsection, the term `appropriate use criteria' means
criteria, only developed or endorsed by national
professional medical specialty societies or other
provider-led entities, to assist ordering professionals
and furnishing professionals in making the most
appropriate treatment decision for a specific clinical
condition. To the extent feasible, such criteria shall
be evidence-based.
``(C) Applicable imaging service defined.--In this
subsection, the term `applicable imaging service' means
an advanced diagnostic imaging service (as defined in
subsection (e)(1)(B)) for which the Secretary
determines--
``(i) one or more applicable appropriate
use criteria specified under paragraph (2)
apply;
``(ii) there are one or more qualified
clinical decision support mechanisms listed
under paragraph (3)(C); and
``(iii) one or more of such mechanisms is
available free of charge.
``(D) Applicable setting defined.--In this
subsection, the term `applicable setting' means a
physician's office, a hospital outpatient department
(including an emergency department), an ambulatory
surgical center, and any other provider-led outpatient
setting determined appropriate by the Secretary.
``(E) Ordering professional defined.--In this
subsection, the term `ordering professional' means a
physician (as defined in section 1861(r)) or a
practitioner described in section 1842(b)(18)(C) who
orders an applicable imaging service for an individual.
``(F) Furnishing professional defined.--In this
subsection, the term `furnishing professional' means a
physician (as defined in section 1861(r)) or a
practitioner described in section 1842(b)(18)(C) who
furnishes an applicable imaging service for an
individual.
``(2) Establishment of applicable appropriate use
criteria.--
``(A) In general.--Not later than November 15,
2015, the Secretary shall through rulemaking, and in
consultation with physicians, practitioners, and other
stakeholders, specify applicable appropriate use
criteria for applicable imaging services only from
among appropriate use criteria developed or endorsed by
national professional medical specialty societies or
other provider-led entities.
``(B) Considerations.--In specifying applicable
appropriate use criteria under subparagraph (A), the
Secretary shall take into account whether the
criteria--
``(i) have stakeholder consensus;
``(ii) are scientifically valid and
evidence based; and
``(iii) are based on studies that are
published and reviewable by stakeholders.
``(C) Revisions.--The Secretary shall review, on an
annual basis, the specified applicable appropriate use
criteria to determine if there is a need to update or
revise (as appropriate) such specification of
applicable appropriate use criteria and make such
updates or revisions through rulemaking.
``(D) Treatment of multiple applicable appropriate
use criteria.--In the case where the Secretary
determines that more than one appropriate use criteria
applies with respect to an applicable imaging service,
the Secretary shall permit one or more applicable
appropriate use criteria under this paragraph for the
service.
``(3) Mechanisms for consultation with applicable
appropriate use criteria.--
``(A) Identification of mechanisms to consult with
applicable appropriate use criteria.--
``(i) In general.--The Secretary shall
specify qualified clinical decision support
mechanisms that could be used by ordering
professionals to consult with applicable
appropriate use criteria for applicable imaging
services.
``(ii) Consultation.--The Secretary shall
consult with physicians, practitioners, health
care technology experts, and other stakeholders
in specifying mechanisms under this paragraph.
``(iii) Inclusion of certain mechanisms.--
Mechanisms specified under this paragraph may
include any or all of the following that meet
the requirements described in subparagraph
(B)(ii):
``(I) Use of clinical decision
support modules in certified EHR
technology (as defined in section
1848(o)(4)).
``(II) Use of private sector
clinical decision support mechanisms
that are independent from certified EHR
technology, which may include use of
clinical decision support mechanisms
available from medical specialty
organizations.
``(III) Use of a clinical decision
support mechanism established by the
Secretary.
``(B) Qualified clinical decision support
mechanisms.--
``(i) In general.--For purposes of this
subsection, a qualified clinical decision
support mechanism is a mechanism that the
Secretary determines meets the requirements
described in clause (ii).
``(ii) Requirements.--The requirements
described in this clause are the following:
``(I) The mechanism makes available
to the ordering professional applicable
appropriate use criteria specified
under paragraph (2) and the supporting
documentation for the applicable
imaging service ordered.
``(II) In the case where there are
more than one applicable appropriate
use criteria specified under such
paragraph for an applicable imaging
service, the mechanism indicates the
criteria that it uses for the service.
``(III) The mechanism determines
the extent to which an applicable
imaging service ordered is consistent
with the applicable appropriate use
criteria so specified.
``(IV) The mechanism generates and
provides to the ordering professional a
certification or documentation that
documents that the qualified clinical
decision support mechanism was
consulted by the ordering professional.
``(V) The mechanism is updated on a
timely basis to reflect revisions to
the specification of applicable
appropriate use criteria under such
paragraph.
``(VI) The mechanism meets privacy
and security standards under applicable
provisions of law.
``(VII) The mechanism performs such
other functions as specified by the
Secretary, which may include a
requirement to provide aggregate
feedback to the ordering professional.
``(C) List of mechanisms for consultation with
applicable appropriate use criteria.--
``(i) Initial list.--Not later than April
1, 2016, the Secretary shall publish a list of
mechanisms specified under this paragraph.
``(ii) Periodic updating of list.--The
Secretary shall identify on an annual basis the
list of qualified clinical decision support
mechanisms specified under this paragraph.
``(4) Consultation with applicable appropriate use
criteria.--
``(A) Consultation by ordering professional.--
Beginning with January 1, 2017, subject to subparagraph
(C), with respect to an applicable imaging service
ordered by an ordering professional that would be
furnished in an applicable setting and paid for under
an applicable payment system (as defined in
subparagraph (D)), an ordering professional shall--
``(i) consult with a qualified decision
support mechanism listed under paragraph
(3)(C); and
``(ii) provide to the furnishing
professional the information described in
clauses (i) through (iii) of subparagraph (B).
``(B) Reporting by furnishing professional.--
Beginning with January 1, 2017, subject to subparagraph
(C), with respect to an applicable imaging service
furnished in an applicable setting and paid for under
an applicable payment system (as defined in
subparagraph (D)), payment for such service may only be
made if the claim for the service includes the
following:
``(i) Information about which qualified
clinical decision support mechanism was
consulted by the ordering professional for the
service.
``(ii) Information regarding--
``(I) whether the service ordered
would adhere to the applicable
appropriate use criteria specified
under paragraph (2);
``(II) whether the service ordered
would not adhere to such criteria; or
``(III) whether such criteria was
not applicable to the service ordered.
``(iii) The national provider identifier of
the ordering professional (if different from
the furnishing professional).
``(C) Exceptions.--The provisions of subparagraphs
(A) and (B) and paragraph (6)(A) shall not apply to the
following:
``(i) Emergency services.--An applicable
imaging service ordered for an individual with
an emergency medical condition (as defined in
section 1867(e)(1)).
``(ii) Inpatient services.--An applicable
imaging service ordered for an inpatient and
for which payment is made under part A.
``(iii) Alternative payment models.--An
applicable imaging service ordered by an
ordering professional with respect to an
individual attributed to an alternative payment
model (as defined in section 1833(z)(3)(C)).
``(iv) Significant hardship.--An applicable
imaging service ordered by an ordering
professional who the Secretary may, on a case-
by-case basis, exempt from the application of
such provisions if the Secretary determines,
subject to annual renewal, that consultation
with applicable appropriate use criteria would
result in a significant hardship, such as in
the case of a professional who practices in a
rural area without sufficient Internet access.
``(D) Applicable payment system defined.--In this
subsection, the term `applicable payment system' means
the following:
``(i) The physician fee schedule
established under section 1848(b).
``(ii) The prospective payment system for
hospital outpatient department services under
section 1833(t).
``(iii) The ambulatory surgical center
payment systems under section 1833(i).
``(5) Identification of outlier ordering professionals.--
``(A) In general.--With respect to applicable
imaging services furnished beginning with 2017, the
Secretary shall determine, on an annual basis, no more
than five percent of the total number of ordering
professionals who are outlier ordering professionals.
``(B) Outlier ordering professionals.--The
determination of an outlier ordering professional
shall--
``(i) be based on low adherence to
applicable appropriate use criteria specified
under paragraph (2), which may be based on
comparison to other ordering professionals; and
``(ii) include data for ordering
professionals for whom prior authorization
under paragraph (6)(A) applies.
``(C) Use of two years of data.--The Secretary
shall use two years of data to identify outlier
ordering professionals under this paragraph.
``(D) Process.--The Secretary shall establish a
process for determining when an outlier ordering
professional is no longer an outlier ordering
professional.
``(E) Consultation with stakeholders.--The
Secretary shall consult with physicians, practitioners
and other stakeholders in developing methods to
identify outlier ordering professionals under this
paragraph.
``(6) Prior authorization for ordering professionals who
are outliers.--
``(A) In general.--Beginning January 1, 2020,
subject to paragraph (4)(C), with respect to services
furnished during a year, the Secretary shall, for a
period determined appropriate by the Secretary, apply
prior authorization for applicable imaging services
that are ordered by an outlier ordering professional
identified under paragraph (5).
``(B) Appropriate use criteria in prior
authorization.--In applying prior authorization under
subparagraph (A), the Secretary shall utilize only the
applicable appropriate use criteria specified under
this subsection.
``(C) Funding.--For purposes of carrying out this
paragraph, the Secretary shall provide for the
transfer, from the Federal Supplementary Medical
Insurance Trust Fund under section 1841, of $5,000,000
to the Centers for Medicare & Medicaid Services Program
Management Account for each of fiscal years 2019
through 2021. Amounts transferred under the preceding
sentence shall remain available until expended.
``(7) Construction.--Nothing in this subsection shall be
construed as granting the Secretary the authority to develop or
initiate the development of clinical practice guidelines or
appropriate use criteria.''.
(b) Conforming Amendment.--Section 1833(t)(16) of the Social
Security Act (42 U.S.C. 1395l(t)(16)) is amended by adding at the end
the following new subparagraph:
``(E) Application of appropriate use criteria for
certain imaging services.--For provisions relating to
the application of appropriate use criteria for certain
imaging services, see section 1834(p).''.
(c) Report on Experience of Imaging Appropriate Use Criteria
Program.--Not later than 18 months after the date of the enactment of
this Act, the Comptroller General of the United States shall submit to
Congress a report that includes a description of the extent to which
appropriate use criteria could be used for other services under part B
of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.),
such as radiation therapy and clinical diagnostic laboratory services.
SEC. 106. EMPOWERING BENEFICIARY CHOICES THROUGH ACCESS TO INFORMATION
ON PHYSICIANS' SERVICES.
(a) In General.--The Secretary shall make publicly available on
Physician Compare the information described in subsection (b) with
respect to eligible professionals.
(b) Information Described.--The following information, with respect
to an eligible professional, is described in this subsection:
(1) Information on the number of services furnished by the
eligible professional under part B of title XVIII of the Social
Security Act (42 U.S.C. 1395j et seq.), which may include
information on the most frequent services furnished or
groupings of services.
(2) Information on submitted charges and payments for
services under such part.
(3) A unique identifier for the eligible professional that
is available to the public, such as a national provider
identifier.
(c) Searchability.--The information made available under this
section shall be searchable by at least the following:
(1) The specialty or type of the eligible professional.
(2) Characteristics of the services furnished, such as
volume or groupings of services.
(3) The location of the eligible professional.
(d) Disclosure.--The information made available under this section
shall indicate, where appropriate, that publicized information may not
be representative of the eligible professional's entire patient
population, the variety of services furnished by the eligible
professional, or the health conditions of individuals treated.
(e) Implementation.--
(1) Initial implementation.--Physician Compare shall
include the information described in subsection (b)--
(A) with respect to physicians, by not later than
July 1, 2015; and
(B) with respect to other eligible professionals,
by not later than July 1, 2016.
(2) Annual updating.--The information made available under
this section shall be updated on Physician Compare not less
frequently than on an annual basis.
(f) Opportunity To Review and Submit Corrections.--The Secretary
shall provide for an opportunity for an eligible professional to
review, and submit corrections for, the information to be made public
with respect to the eligible professional under this section prior to
such information being made public.
(g) Definitions.--In this section:
(1) Eligible professional; physician; secretary.--The terms
``eligible professional'', ``physician'', and ``Secretary''
have the meaning given such terms in section 10331(i) of Public
Law 111-148.
(2) Physician compare.--The term ``Physician Compare''
means the Physician Compare Internet website of the Centers for
Medicare & Medicaid Services (or a successor website).
SEC. 107. EXPANDING AVAILABILITY OF MEDICARE DATA.
(a) Expanding Uses of Medicare Data by Qualified Entities.--
(1) Additional analyses.--
(A) In general.--Subject to subparagraph (B), to
the extent consistent with applicable information,
privacy, security, and disclosure laws (including
paragraph (3)), notwithstanding paragraph (4)(B) of
section 1874(e) of the Social Security Act (42 U.S.C.
1395kk(e)) and the second sentence of paragraph (4)(D)
of such section, beginning July 1, 2015, a qualified
entity may use the combined data described in paragraph
(4)(B)(iii) of such section received by such entity
under such section, and information derived from the
evaluation described in such paragraph (4)(D), to
conduct additional non-public analyses (as determined
appropriate by the Secretary) and provide or sell such
analyses to authorized users for non-public use
(including for the purposes of assisting providers of
services and suppliers to develop and participate in
quality and patient care improvement activities,
including developing new models of care).
(B) Limitations with respect to analyses.--
(i) Employers.--Any analyses provided or
sold under subparagraph (A) to an employer
described in paragraph (9)(A)(iii) may only be
used by such employer for purposes of providing
health insurance to employees and retirees of
the employer.
(ii) Health insurance issuers.--A qualified
entity may not provide or sell an analysis to a
health insurance issuer described in paragraph
(9)(A)(iv) unless the issuer is providing the
qualified entity with data under section
1874(e)(4)(B)(iii) of the Social Security Act
(42 U.S.C. 1395kk(e)(4)(B)(iii)).
(2) Access to certain data.--
(A) Access.--To the extent consistent with
applicable information, privacy, security, and
disclosure laws (including paragraph (3)),
notwithstanding paragraph (4)(B) of section 1874(e) of
the Social Security Act (42 U.S.C. 1395kk(e)) and the
second sentence of paragraph (4)(D) of such section,
beginning July 1, 2015, a qualified entity may--
(i) provide or sell the combined data
described in paragraph (4)(B)(iii) of such
section to authorized users described in
clauses (i), (ii), and (v) of paragraph (9)(A)
for non-public use, including for the purposes
described in subparagraph (B); or
(ii) subject to subparagraph (C), provide
Medicare claims data to authorized users
described in clauses (i), (ii), and (v), of
paragraph (9)(A) for non-public use, including
for the purposes described in subparagraph (B).
(B) Purposes described.--The purposes described in
this subparagraph are assisting providers of services
and suppliers in developing and participating in
quality and patient care improvement activities,
including developing new models of care.
(C) Medicare claims data must be provided at no
cost.--A qualified entity may not charge a fee for
providing the data under subparagraph (A)(ii).
(3) Protection of information.--
(A) In general.--Except as provided in subparagraph
(B), an analysis or data that is provided or sold under
paragraph (1) or (2) shall not contain information that
individually identifies a patient.
(B) Information on patients of the provider of
services or supplier.--To the extent consistent with
applicable information, privacy, security, and
disclosure laws, an analysis or data that is provided
or sold to a provider of services or supplier under
paragraph (1) or (2) may contain information that
individually identifies a patient of such provider or
supplier, including with respect to items and services
furnished to the patient by other providers of services
or suppliers.
(C) Prohibition on using analyses or data for
marketing purposes.--An authorized user shall not use
an analysis or data provided or sold under paragraph
(1) or (2) for marketing purposes.
(4) Data use agreement.--A qualified entity and an
authorized user described in clauses (i), (ii), and (v) of
paragraph (9)(A) shall enter into an agreement regarding the
use of any data that the qualified entity is providing or
selling to the authorized user under paragraph (2). Such
agreement shall describe the requirements for privacy and
security of the data and, as determined appropriate by the
Secretary, any prohibitions on using such data to link to other
individually identifiable sources of information. If the
authorized user is not a covered entity under the rules
promulgated pursuant to the Health Insurance Portability and
Accountability Act of 1996, the agreement shall identify the
relevant regulations, as determined by the Secretary, that the
user shall comply with as if it were acting in the capacity of
such a covered entity.
(5) No redisclosure of analyses or data.--
(A) In general.--Except as provided in subparagraph
(B), an authorized user that is provided or sold an
analysis or data under paragraph (1) or (2) shall not
redisclose or make public such analysis or data or any
analysis using such data.
(B) Permitted redisclosure.--A provider of services
or supplier that is provided or sold an analysis or
data under paragraph (1) or (2) may, as determined by
the Secretary, redisclose such analysis or data for the
purposes of performance improvement and care
coordination activities but shall not make public such
analysis or data or any analysis using such data.
(6) Opportunity for providers of services and suppliers to
review.--Prior to a qualified entity providing or selling an
analysis to an authorized user under paragraph (1), to the
extent that such analysis would individually identify a
provider of services or supplier who is not being provided or
sold such analysis, such qualified entity shall provide such
provider or supplier with the opportunity to appeal and correct
errors in the manner described in section 1874(e)(4)(C)(ii) of
the Social Security Act (42 U.S.C. 1395kk(e)(4)(C)(ii)).
(7) Assessment for a breach.--
(A) In general.--In the case of a breach of a data
use agreement under this section or section 1874(e) of
the Social Security Act (42 U.S.C. 1395kk(e)), the
Secretary shall impose an assessment on the qualified
entity both in the case of--
(i) an agreement between the Secretary and
a qualified entity; and
(ii) an agreement between a qualified
entity and an authorized user.
(B) Assessment.--The assessment under subparagraph
(A) shall be an amount up to $100 for each individual
entitled to, or enrolled for, benefits under part A of
title XVIII of the Social Security Act or enrolled for
benefits under part B of such title--
(i) in the case of an agreement described
in subparagraph (A)(i), for whom the Secretary
provided data on to the qualified entity under
paragraph (2); and
(ii) in the case of an agreement described
in subparagraph (A)(ii), for whom the qualified
entity provided data on to the authorized user
under paragraph (2).
(C) Deposit of amounts collected.--Any amounts
collected pursuant to this paragraph shall be deposited
in Federal Supplementary Medical Insurance Trust Fund
under section 1841 of the Social Security Act (42
U.S.C. 1395t).
(8) Annual reports.--Any qualified entity that provides or
sells an analysis or data under paragraph (1) or (2) shall
annually submit to the Secretary a report that includes--
(A) a summary of the analyses provided or sold,
including the number of such analyses, the number of
purchasers of such analyses, and the total amount of
fees received for such analyses;
(B) a description of the topics and purposes of
such analyses;
(C) information on the entities who received the
data under paragraph (2), the uses of the data, and the
total amount of fees received for providing, selling,
or sharing the data; and
(D) other information determined appropriate by the
Secretary.
(9) Definitions.--In this subsection and subsection (b):
(A) Authorized user.--The term ``authorized user''
means the following:
(i) A provider of services.
(ii) A supplier.
(iii) An employer (as defined in section
3(5) of the Employee Retirement Insurance
Security Act of 1974).
(iv) A health insurance issuer (as defined
in section 2791 of the Public Health Service
Act).
(v) A medical society or hospital
association.
(vi) Any entity not described in clauses
(i) through (v) that is approved by the
Secretary (other than an employer or health
insurance issuer not described in clauses (iii)
and (iv), respectively, as determined by the
Secretary).
(B) Provider of services.--The term ``provider of
services'' has the meaning given such term in section
1861(u) of the Social Security Act (42 U.S.C.
1395x(u)).
(C) Qualified entity.--The term ``qualified
entity'' has the meaning given such term in section
1874(e)(2) of the Social Security Act (42 U.S.C.
1395kk(e)).
(D) Secretary.--The term ``Secretary'' means the
Secretary of Health and Human Services.
(E) Supplier.--The term ``supplier'' has the
meaning given such term in section 1861(d) of the
Social Security Act (42 U.S.C. 1395x(d)).
(b) Access to Medicare Data by Qualified Clinical Data Registries
To Facilitate Quality Improvement.--
(1) Access.--
(A) In general.--To the extent consistent with
applicable information, privacy, security, and
disclosure laws, beginning July 1, 2015, the Secretary
shall, at the request of a qualified clinical data
registry under section 1848(m)(3)(E) of the Social
Security Act (42 U.S.C. 1395w-4(m)(3)(E)), provide the
data described in subparagraph (B) (in a form and
manner determined to be appropriate) to such qualified
clinical data registry for purposes of linking such
data with clinical outcomes data and performing risk-
adjusted, scientifically valid analyses and research to
support quality improvement or patient safety, provided
that any public reporting of such analyses or research
that identifies a provider of services or supplier
shall only be conducted with the opportunity of such
provider or supplier to appeal and correct errors in
the manner described in subsection (a)(6).
(B) Data described.--The data described in this
subparagraph is--
(i) claims data under the Medicare program
under title XVIII of the Social Security Act;
and
(ii) if the Secretary determines
appropriate, claims data under the Medicaid
program under title XIX of such Act and the
State Children's Health Insurance Program under
title XXI of such Act.
(2) Fee.--Data described in paragraph (1)(B) shall be
provided to a qualified clinical data registry under paragraph
(1) at a fee equal to the cost of providing such data. Any fee
collected pursuant to the preceding sentence shall be deposited
in the Centers for Medicare & Medicaid Services Program
Management Account.
(c) Expansion of Data Available to Qualified Entities.--Section
1874(e) of the Social Security Act (42 U.S.C. 1395kk(e)) is amended--
(1) in the subsection heading, by striking ``Medicare'';
and
(2) in paragraph (3)--
(A) by inserting after the first sentence the
following new sentence: ``Beginning July 1, 2015, if
the Secretary determines appropriate, the data
described in this paragraph may also include
standardized extracts (as determined by the Secretary)
of claims data under titles XIX and XXI for assistance
provided under such titles for one or more specified
geographic areas and time periods requested by a
qualified entity.''; and
(B) in the last sentence, by inserting ``or under
titles XIX or XXI'' before the period at the end.
(d) Revision of Placement of Fees.--Section 1874(e)(4)(A) of the
Social Security Act (42 U.S.C. 1395kk(e)(4)(A)) is amended, in the
second sentence--
(1) by inserting ``, for periods prior to July 1, 2015,''
after ``deposited''; and
(2) by inserting the following before the period at the
end: ``, and, beginning July 1, 2015, into the Centers for
Medicare & Medicaid Services Program Management Account''.
SEC. 108. REDUCING ADMINISTRATIVE BURDEN AND OTHER PROVISIONS.
(a) Medicare Physician and Practitioner Opt-Out to Private
Contract.--
(1) Indefinite, continuing automatic extension of opt out
election.--
(A) In general.--Section 1802(b)(3) of the Social
Security Act (42 U.S.C. 1395a(b)(3)) is amended--
(i) in subparagraph (B)(ii), by striking
``during the 2-year period beginning on the
date the affidavit is signed'' and inserting
``during the applicable 2-year period (as
defined in subparagraph (D))'';
(ii) in subparagraph (C), by striking
``during the 2-year period described in
subparagraph (B)(ii)'' and inserting ``during
the applicable 2-year period''; and
(iii) by adding at the end the following
new subparagraph:
``(D) Applicable 2-year periods for effectiveness
of affidavits.--In this subsection, the term
`applicable 2-year period' means, with respect to an
affidavit of a physician or practitioner under
subparagraph (B), the 2-year period beginning on the
date the affidavit is signed and includes each
subsequent 2-year period unless the physician or
practitioner involved provides notice to the Secretary
(in a form and manner specified by the Secretary), not
later than 30 days before the end of the previous 2-
year period, that the physician or practitioner does
not want to extend the application of the affidavit for
such subsequent 2-year period.''.
(B) Effective date.--The amendments made by
subparagraph (A) shall apply to affidavits entered into
on or after the date that is 60 days after the date of
the enactment of this Act.
(2) Public availability of information on opt-out
physicians and practitioners.--Section 1802(b) of the Social
Security Act (42 U.S.C. 1395a(b)) is amended--
(A) in paragraph (5), by adding at the end the
following new subparagraph:
``(D) Opt-out physician or practitioner.--The term `opt-out
physician or practitioner' means a physician or practitioner
who has in effect an affidavit under paragraph (3)(B).'';
(B) by redesignating paragraph (5) as paragraph
(6); and
(C) by inserting after paragraph (4) the following
new paragraph:
``(5) Posting of information on opt-out physicians and
practitioners.--
``(A) In general.--Beginning not later than
February 1, 2015, the Secretary shall make publicly
available through an appropriate publicly accessible
website of the Department of Health and Human Services
information on the number and characteristics of opt-
out physicians and practitioners and shall update such
information on such website not less often than
annually.
``(B) Information to be included.--The information
to be made available under subparagraph (A) shall
include at least the following with respect to opt-out
physicians and practitioners:
``(i) Their number.
``(ii) Their physician or professional
specialty or other designation.
``(iii) Their geographic distribution.
``(iv) The timing of their becoming opt-out
physicians and practitioners, relative to when
they first entered practice and with respect to
applicable 2-year periods.
``(v) The proportion of such physicians and
practitioners who billed for emergency or
urgent care services.''.
(b) Gainsharing Study and Report.--Not later than 6 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 legislative recommendations to amend existing fraud and
abuse laws, through exceptions, safe harbors, or other narrowly
targeted provisions, to permit gainsharing or similar arrangements
between physicians and hospitals 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 should accrue to the Medicare program under
title XVIII of the Social Security Act.
(c) Promoting Interoperability of Electronic Health Record
Systems.--
(1) Recommendations for achieving widespread ehr
interoperability.--
(A) Objective.--As a consequence of a significant
Federal investment in the implementation of health
information technology through the Medicare and
Medicaid EHR incentive programs, Congress declares it a
national objective to achieve widespread exchange of
health information through interoperable certified EHR
technology nationwide by December 31, 2017.
(B) Definitions.--In this paragraph:
(i) Widespread interoperability.--The term
``widespread interoperability'' means
interoperability between certified EHR
technology systems employed by meaningful EHR
users under the Medicare and Medicaid EHR
incentive programs and other clinicians and
health care providers on a nationwide basis.
(ii) Interoperability.--The term
``interoperability'' means the ability of two
or more health information systems or
components to exchange clinical and other
information and to use the information that has
been exchanged using common standards as to
provide access to longitudinal information for
health care providers in order to facilitate
coordinated care and improved patient outcomes.
(C) Establishment of metrics.--Not later than July
1, 2015, and in consultation with stakeholders, the
Secretary shall establish metrics to be used to
determine if and to the extent that the objective
described in subparagraph (A) has been achieved.
(D) Recommendations if objective not achieved.--If
the Secretary of Health and Human Services determines
that the objective described in subparagraph (A) has
not been achieved by December 31, 2017, then the
Secretary shall submit to Congress a report, by not
later than December 31, 2018, that identifies barriers
to such objective and recommends actions that the
Federal Government can take to achieve such objective.
Such recommended actions may include recommendations--
(i) to adjust payments for not being
meaningful EHR users under the Medicare EHR
incentive programs; and
(ii) for criteria for decertifying
certified EHR technology products.
(2) Preventing blocking the sharing of information.--
(A) For meaningful ehr professionals.--Section
1848(o)(2)(A)(ii) of the Social Security Act (42 U.S.C.
1395w-4(o)(2)(A)(ii)) is amended by inserting before
the period at the end the following: ``, and the
professional demonstrates (through a process specified
by the Secretary, such as the use of an attestation)
that the professional has not knowingly and willfully
taken any action to limit or restrict the compatibility
or interoperability of the certified EHR technology''.
(B) For meaningful ehr hospitals.--Section
1886(n)(3)(A)(ii) of the Social Security Act (42 U.S.C.
1395ww(n)(3)(A)(ii)) is amended by inserting before the
period at the end the following: ``, and the hospital
demonstrates (through a process specified by the
Secretary, such as the use of an attestation) that the
hospital has not knowingly and willfully taken any
action to limit or restrict the compatibility or
interoperability of the certified EHR technology''.
(C) Effective date.--The amendments made by this
subsection shall apply to meaningful EHR users as of
the date that is one year after the date of the
enactment of this Act.
(3) Study and report on the feasibility of establishing a
website to compare certified ehr technology products.--
(A) Study.--The Secretary shall conduct a study to
examine the feasibility of establishing mechanisms that
includes aggregated results of surveys of meaningful
EHR users on the functionality of certified EHR
technology products to enable such users to directly
compare the functionality and other features of such
products. Such information may be made available
through contracts with physician, hospital, or other
organizations that maintain such comparative
information.
(B) Report.--Not later than 1 year after the date
of the enactment of this Act, the Secretary shall
submit to Congress a report on the website. The report
shall include information on the benefits of, and
resources needed to develop and maintain, such a
website.
(4) Definitions.--In this subsection:
(A) The term ``certified EHR technology'' has the
meaning given such term in section 1848(o)(4) of the
Social Security Act (42 U.S.C. 1395w-4(o)(4)).
(B) The term ``meaningful EHR user'' has the
meaning given such term under the Medicare EHR
incentive programs.
(C) The term ``Medicare and Medicaid EHR incentive
programs'' means--
(i) in the case of the Medicare program
under title XVIII of the Social Security Act,
the incentive programs under section
1814(l)(3), section 1848(o), subsections (l)
and (m) of section 1853, and section 1886(n) of
the Social Security Act (42 U.S.C. 1395f(l)(3),
1395w-4(o), 1395w-23, 1395ww(n)); and
(ii) in the case of the Medicaid program
under title XIX of such Act, the incentive
program under subsections (a)(3)(F) and (t) of
section 1903 of such Act (42 U.S.C. 1396b).
(D) The term ``Secretary'' means the Secretary of
Health and Human Services.
(d) GAO Studies and Reports on the Use of Telehealth Under Federal
Programs and on Remote Patient Monitoring Services.--
(1) Study on telehealth services.--The Comptroller General
of the United States shall conduct a study on the following:
(A) How the definition of telehealth across various
Federal programs and Federal efforts can inform the use
of telehealth in the Medicare program under title XVIII
of the Social Security Act (42 U.S.C. 1395 et seq.).
(B) Issues that can facilitate or inhibit the use
of telehealth under the Medicare program under such
title, including oversight and professional licensure,
changing technology, privacy and security,
infrastructure requirements, and varying needs across
urban and rural areas.
(C) Potential implications of greater use of
telehealth with respect to payment and delivery system
transformations under the Medicare program under such
title XVIII and the Medicaid program under title XIX of
such Act (42 U.S.C. 1396 et seq.).
(D) How the Centers for Medicare & Medicaid
Services conducts oversight of payments made under the
Medicare program under such title XVIII to providers
for telehealth services.
(2) Study on remote patient monitoring services.--
(A) In general.--The Comptroller General of the
United States shall conduct a study--
(i) of the dissemination of remote patient
monitoring technology in the private health
insurance market;
(ii) of the financial incentives in the
private health insurance market relating to
adoption of such technology;
(iii) of the barriers to adoption of such
services under the Medicare program under title
XVIII of the Social Security Act;
(iv) that evaluates the patients,
conditions, and clinical circumstances that
could most benefit from remote patient
monitoring services; and
(v) that evaluates the challenges related
to establishing appropriate valuation for
remote patient monitoring services under the
Medicare physician fee schedule under section
1848 of the Social Security Act (42 U.S.C.
1395w-4) in order to accurately reflect the
resources involved in furnishing such services.
(B) Definitions.--For purposes of this paragraph:
(i) Remote patient monitoring services.--
The term ``remote patient monitoring services''
means services furnished through remote patient
monitoring technology.
(ii) Remote patient monitoring
technology.--The term ``remote patient
monitoring technology'' means a coordinated
system that uses one or more home-based or
mobile monitoring devices that automatically
transmit vital sign data or information on
activities of daily living and may include
responses to assessment questions collected on
the devices wirelessly or through a
telecommunications connection to a server that
complies with 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, as
part of an established plan of care for that
patient that includes the review and
interpretation of that data by a health care
professional.
(3) Reports.--Not later than 24 months after the date of
the enactment of this Act, the Comptroller General shall submit
to Congress--
(A) a report containing the results of the study
conducted under paragraph (1); and
(B) a report containing the results of the study
conducted under paragraph (2).
A report required under this paragraph shall be submitted
together with recommendations for such legislation and
administrative action as the Comptroller General determines
appropriate. The Comptroller General may submit one report
containing the results described in subparagraphs (A) and (B)
and the recommendations described in the previous sentence.
(e) Rule of Construction Regarding Healthcare Provider Standards of
Care.--
(1) Maintenance of state standards.--The development,
recognition, or implementation of any guideline or other
standard under any Federal health care provision shall not be
construed--
(A) to establish the standard of care or duty of
care owed by a health care provider to a patient in any
medical malpractice or medical product liability action
or claim; or
(B) to preempt any standard of care or duty of
care, owed by a health care provider to a patient, duly
established under State or common law.
(2) Definitions.--For purposes of this subsection:
(A) Federal health care provision.--The term
``Federal health care provision'' means any provision
of the Patient Protection and Affordable Care Act
(Public Law 111-148), title I or subtitle B of title II
of the Health Care and Education Reconciliation Act of
2010 (Public Law 111-152), or title XVIII or XIX of the
Social Security Act.
(B) Health care provider.--The term ``health care
provider'' means any individual or entity--
(i) licensed, registered, or certified
under Federal or State laws or regulations to
provide health care services; or
(ii) required to be so licensed,
registered, or certified but that is exempted
by other statute or regulation.
(C) Medical malpractice or medical product
liability action or claim.--The term ``medical
malpractice or medical product liability action or
claim'' means a medical malpractice action or claim (as
defined in section 431(7) of the Health Care Quality
Improvement Act of 1986 (42 U.S.C. 11151(7))) and
includes a liability action or claim relating to a
health care provider's prescription or provision of a
drug, device, or biological product (as such terms are
defined in section 201 of the Federal Food, Drug, and
Cosmetic Act or section 351 of the Public Health
Service Act).
(D) State.--The term ``State'' includes the
District of Columbia, Puerto Rico, and any other
commonwealth, possession, or territory of the United
States.
(3) Preservation of state law.--No provision of the Patient
Protection and Affordable Care Act (Public Law 111-148), title
I or subtitle B of title II of the Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152), or title XVIII
or XIX of the Social Security Act shall be construed to preempt
any State or common law governing medical professional or
medical product liability actions or claims.
TITLE II--EXTENSIONS
Subtitle A--Medicare Extensions
SEC. 201. WORK GEOGRAPHIC ADJUSTMENT.
Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)(E)) is amended by striking ``and before April 1, 2014,''.
SEC. 202. MEDICARE PAYMENT FOR THERAPY SERVICES.
(a) Repeal of Therapy Cap and 1-year Extension of Threshold for
Manual Medical Review.--Section 1833(g) of the Social Security Act (42
U.S.C. 1395l(g)) is amended--
(1) in paragraph (4)--
(A) by striking ``This subsection'' and inserting
``Except as provided in paragraph (5)(C)(iii), this
subsection''; and
(B) by inserting the following before the period at
the end: ``or with respect to services furnished on or
after the date of enactment of the Responsible Medicare
SGR Repeal and Beneficiary Access Improvement Act of
2014''; and
(2) in paragraph (5)(C), by adding at the end the following
new clause:
``(iii) Beginning on the date of enactment of the Responsible
Medicare SGR Repeal and Beneficiary Access Improvement Act of 2014 and
ending on the day before the date that is 12 months after such date of
enactment, the manual medical review process described in clause (i)
shall apply with respect to expenses incurred in a year for services
described in paragraphs (1) and (3) that exceed the threshold described
in clause (ii) for the year.''.
(b) Medical Review of Outpatient Therapy Services.--
(1) Medical review of outpatient therapy services.--Section
1833 of the Social Security Act (42 U.S.C. 1395l), as amended
by section 101(e)(2), is amended by adding at the end the
following new subsection:
``(aa) Medical Review of Outpatient Therapy Services.--
``(1) In general.--
``(A) Process for medical review.--The Secretary
shall implement a process for the medical review (as
described in paragraph (2)) of outpatient therapy
services (as defined in paragraph (10)) and, subject to
paragraph (12), apply such process to such services
furnished on or after the date that is 12 months after
the date of enactment of the Responsible Medicare SGR
Repeal and Beneficiary Access Improvement Act of 2014,
focusing on services identified under subparagraph (B).
``(B) Identification of services for review.--Under
the process, the Secretary shall identify services for
medical review, using such factors as the Secretary
determines appropriate, which may include the
following:
``(i) Services furnished by a therapy
provider (as defined in paragraph (10)) whose
pattern of billing is aberrant compared to
peers.
``(ii) Services furnished by a therapy
provider who, in a prior period, has a high
claims denial percentage or is less compliant
with other applicable requirements under this
title.
``(iii) Services furnished by a therapy
provider that is newly enrolled under this
title.
``(iv) Services furnished by a therapy
provider who has questionable billing
practices, such as billing medically unlikely
units of services in a day.
``(v) Services furnished to treat a type of
medical condition.
``(vi) Services identified by use of the
standardized data elements required to be
reported under section 1834(p).
``(vii) Services furnished by a single
therapy provider or a group that includes a
therapy provider identified by factors
described in this subparagraph.
``(viii) Other services as determined
appropriate by the Secretary.
``(2) Medical review.--
``(A) Prior authorization medical review.--
``(i) In general.--Subject to the
succeeding provisions of this subparagraph, the
Secretary shall use prior authorization medical
review for outpatient therapy services
furnished to an individual above one or more
thresholds established by the Secretary, such
as a dollar threshold or a threshold based on
other factors.
``(ii) Ending application of prior
authorization for a therapy provider.--The
Secretary shall end the application of prior
authorization medical review to outpatient
therapy services furnished by a therapy
provider if the Secretary determines that the
provider has a low denial rate under such prior
authorization. The Secretary may subsequently
reapply prior authorization medical review to
such therapy provider if the Secretary
determines it to be appropriate.
``(iii) Prior authorization of multiple
services.--The Secretary shall, where
practicable, provide for prior authorization
medical review for multiple services at a
single time, such as services in a therapy plan
of care described in section 1861(p)(2).
``(B) Other types of medical review.--The Secretary
may use pre-payment review or post-payment review for
services identified under paragraph (1)(B) that are not
subject to prior authorization medical review under
subparagraph (A).
``(C) Limitation for 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) Review contractors.--The Secretary shall conduct
prior authorization medical review of outpatient therapy
services under this subsection using medicare administrative
contractors (as described in section 1874A) or other review
contractors (other than contractors under section 1893(h) or
contractors paid on a contingent basis).
``(4) No payment without prior authorization.--With respect
to an outpatient therapy service 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 (6),
no payment shall 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.
``(5) Submission of information.--A therapy provider 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, but not later than 24 months
after the date of enactment of this subsection.
``(6) Timeliness.--If the Secretary does not make a prior
authorization determination under paragraph (4)(A) within 10
business days of the date of the Secretary's receipt of medical
documentation needed to make such determination, paragraph
(4)(B) shall not apply.
``(7) Construction.--With respect to an outpatient therapy
service 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.
``(8) Beneficiary protections.--With respect to services
furnished on or after January 1, 2015, where payment may not be
made as a result of application of medical review under this
subsection, 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).
``(9) 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.
``(C) Limitation.--There shall be no administrative
or judicial review under section 1869, section 1878, or
otherwise of the identification of services for medical
review or the process for medical review under this
subsection.
``(10) Definitions.--For purposes of this subsection:
``(A) Outpatient therapy services.--The term
`outpatient therapy services' means the following
services for which payment is made under section 1848,
1834(g), or 1834(k):
``(i) Physical therapy services of the type
described in section 1861(p).
``(ii) Speech-language pathology services
of the type described in such section though
the application of section 1861(ll)(2).
``(iii) Occupational therapy services of
the type described in section 1861(p) through
the operation of section 1861(g).
``(B) Therapy provider.--The term `therapy
provider' means a provider of services (as defined in
section 1861(u)) or a supplier (as defined in section
1861(d)) who submits a claim for outpatient therapy
services.
``(11) Funding.--For purposes of implementing this
subsection, the Secretary shall provide for the transfer, from
the Federal Supplementary Medical Insurance Trust Fund under
section 1841, of $35,000,000 to the Centers for Medicare &
Medicaid Services Program Management Account for each fiscal
year (beginning with fiscal year 2014). Amounts transferred
under this paragraph shall remain available until expended.
``(12) Scaling back.--
``(A) Periodic determinations.--Beginning with
2017, and every two years thereafter, the Secretary
shall--
``(i) make a determination of the improper
payment rate for outpatient therapy services
for a 12-month period; and
``(ii) make such determination publicly
available.
``(B) Scaling back.--If the improper payment rate
for outpatient therapy services determined for a 12-
month period under subparagraph (A) is 50 percent or
less of the Medicare fee-for-service improper payment
rate for such period, the Secretary shall--
``(i) reduce the amount and extent of
medical review conducted for a prospective year
under the process established in this
subsection; and
``(ii) return an appropriate portion of the
funding provided for such year under paragraph
(11).''.
(2) GAO study and report.--
(A) Study.--The Comptroller General of the United
States shall conduct a study on the effectiveness of
medical review of outpatient therapy services under
section 1833(aa) of the Social Security Act, as added
by paragraph (1). Such study shall include an analysis
of--
(i) aggregate data on--
(I) the number of individuals,
therapy providers, and claims subject
to such review; and
(II) the number of reviews
conducted under such section; and
(ii) the outcomes of such reviews.
(B) Report.--Not later than 3 years after the date
of enactment of this Act, the Comptroller General shall
submit to Congress a report containing the results of
the study under subparagraph (A), together with
recommendations for such legislation and administrative
action as the Comptroller General determines
appropriate.
(c) Collection of Standardized Data Elements for Outpatient Therapy
Services.--
(1) Collection of standardized data elements for outpatient
therapy services.--Section 1834 of the Social Security Act (42
U.S.C. 1395m) is amended by adding at the end the following new
subsection:
``(p) Collection of Standardized Data Elements for Outpatient
Therapy Services.--
``(1) Standardized data elements.--
``(A) In general.--Not later than 6 months after
the date of enactment of this subsection, the Secretary
shall post on the Internet website of the Centers for
Medicare & Medicaid Services a draft list of
standardized data elements for individuals receiving
outpatient therapy services.
``(B) Domains.--Such standardized data elements
shall include information with respect to the following
domains, as determined appropriate by the Secretary:
``(i) Demographic information.
``(ii) Diagnosis.
``(iii) Severity.
``(iv) Affected body structures and
functions.
``(v) Limitations with activities of daily
living and participation.
``(vi) Functional status.
``(vii) Other domains determined to be
appropriate by the Secretary.
``(C) Solicitation of input.--The Secretary shall
accept comments from stakeholders through the date that
is 60 days after the date the Secretary posts the draft
list of standardized data elements pursuant to
subparagraph (A). In seeking such comments, the
Secretary shall use one or more mechanisms to solicit
input from stakeholders that may include use of open
door forums, town hall meetings, requests for
information, or other mechanisms determined appropriate
by the Secretary.
``(D) Operational list of standardized data
elements.--Not later than 120 days after the end of the
comment period described in subparagraph (C), the
Secretary, taking into account such comments, shall
post on the Internet website of the Centers for
Medicare & Medicaid Services an operational list of
standardized data elements.
``(E) Subsequent revisions.--Subsequent revisions
to the operational list of standardized data elements
shall be made through rulemaking. Such revisions may be
based on experience and input from stakeholders.
``(2) System to report standardized data elements.--
``(A) In general.--Not later than 18 months after
the date the Secretary posts the operational list of
standardized data elements pursuant to paragraph
(1)(D), the Secretary shall develop and implement an
electronic system (which may be a web portal) for
therapy providers to report the standardized data
elements for individuals with respect to outpatient
therapy services.
``(B) Consultation.--The Secretary shall seek
comments from stakeholders regarding the best way to
report the standardized data elements.
``(3) Reporting.--
``(A) Frequency of reporting.--The Secretary shall
specify the frequency of reporting standardized data
elements. The Secretary shall seek comments from
stakeholders regarding the frequency of the reporting
of such data elements.
``(B) Reporting requirement.--Beginning on the date
the system to report standardized data elements under
this subsection is operational, no payment shall be
made under this part for outpatient therapy services
furnished to an individual unless a therapy provider
reports the standardized data elements for such
individual.
``(4) Report on new payment system for outpatient therapy
services.--
``(A) In general.--Not later than 24 months after
the date described in paragraph (3)(B), the Secretary
shall submit to Congress a report on the design of a
new payment system for outpatient therapy services. The
report shall include an analysis of the standardized
data elements collected and other appropriate data and
information.
``(B) Features.--Such report shall consider--
``(i) appropriate adjustments to payment
(such as case mix and outliers);
``(ii) payments on an episode of care
basis; and
``(iii) reduced payment for multiple
episodes.
``(C) Consultation.--The Secretary shall consult
with stakeholders regarding the design of such a new
payment system.
``(5) Implementation.--
``(A) Funding.--For purposes of implementing this
subsection, the Secretary shall provide for the
transfer, from the Federal Supplementary Medical
Insurance Trust Fund under section 1841, of $7,000,000
to the Centers for Medicare & Medicaid Services Program
Management Account for each of fiscal years 2014
through 2018. Amounts transferred under this
subparagraph shall remain available until expended.
``(B) Administration.--Chapter 35 of title 44,
United States Code, shall not apply to specification of
the standardized data elements and implementation of
the system to report such standardized data elements
under this subsection.
``(C) Limitation.--There shall be no administrative
or judicial review under section 1869, section 1878, or
otherwise of the specification of standardized data
elements required under this subsection or the system
to report such standardized data elements.
``(D) Definition of outpatient therapy services and
therapy provider.--In this subsection, the terms
`outpatient therapy services' and `therapy provider'
have the meaning given those term in section
1833(aa).''.
(2) Sunset of current claims-based collection of therapy
data.--Section 3005(g)(1) of the Middle Class Tax Extension and
Job Creation Act of 2012 (42 U.S.C. 1395l note) is amended, in
the first sentence, by inserting ``and ending on the date the
system to report standardized data elements under section
1834(p) of the Social Security Act (42 U.S.C. 1395m(p)) is
implemented,'' after ``January 1, 2013,''.
(d) Reporting of Certain Information.--Section 1842(t) of the
Social Security Act (42 U.S.C. 1395u(t)) is amended by adding at the
end the following new paragraph:
``(3) Each request for payment, or bill submitted, by a therapy
provider (as defined in section 1833(aa)(10)) for an outpatient therapy
service (as defined in such section) furnished by a therapy assistant
on or after January 1, 2015, shall include (in a form and manner
specified by the Secretary) an indication that the service was
furnished by a therapy assistant.''.
SEC. 203. MEDICARE AMBULANCE SERVICES.
(a) Extension of Certain Ambulance Add-on Payments.--
(1) Ground ambulance.--Section 1834(l)(13)(A) of the Social
Security Act (42 U.S.C. 1395m(l)(13)(A)) is amended by striking
``April 1, 2014'' and inserting ``January 1, 2019'' each place
it appears.
(2) Super rural ambulance.--Section 1834(l)(12)(A) of the
Social Security Act (42 U.S.C. 1395m(l)(12)(A)) is amended, in
the first sentence, by striking ``April 1, 2014'' and inserting
``January 1, 2019''.
(b) Requiring Ambulance Providers To Submit Cost and Other
Information.--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) Submission of cost and other information.--
``(A) Development of data collection system.--The
Secretary shall develop a data collection system (which
may include use of a cost survey and standardized
definitions) for providers and suppliers of ambulance
services to collect cost, revenue, utilization, and
other information determined appropriate by the
Secretary. Such system shall be designed to submit
information--
``(i) needed to evaluate the
appropriateness of payment rates under this
subsection;
``(ii) on the utilization of capital
equipment and ambulance capacity; and
``(iii) on different types of ambulance
services furnished in different geographic
locations, including rural areas and low
population density areas described in paragraph
(12).
``(B) Specification of data collection system.--
``(i) In general.--Not later than July 1,
2015, the Secretary shall--
``(I) specify the data collection
system under subparagraph (A) and the
time period during which such data is
required to be submitted; and
``(II) identify the providers and
suppliers of ambulance services who
would be required to submit the
information under such data collection
system.
``(ii) Respondents.--Subject to
subparagraph (D)(ii), the Secretary shall
determine an appropriate sample of providers
and suppliers of ambulance services to submit
information under the data collection system
for each period for which reporting of data is
required.
``(C) Penalty for failure to report cost and other
information.--Beginning on July 1, 2016, a 5 percent
reduction to payments under this part shall be made for
a 1-year prospective period specified by the Secretary
to a provider or supplier of ambulance services who--
``(i) is identified under subparagraph
(B)(i)(II) as being required to submit the
information under the data collection system;
and
``(ii) does not submit such information
during the period specified under subparagraph
(B)(i)(I).
``(D) Ongoing data collection.--
``(i) Revision of data collection system.--
The Secretary may, as determined appropriate,
periodically revise the data collection system.
``(ii) Subsequent data collection.--In
order to continue to evaluate the
appropriateness of payment rates under this
subsection, the Secretary shall, for years
after 2016 (but not less often than once every
3 years), require providers and suppliers of
ambulance services to submit information for a
period the Secretary determines appropriate.
The penalty described in subparagraph (C) shall
apply to such subsequent data collection
periods.
``(E) Consultation.--The Secretary shall consult
with stakeholders in carrying out the development of
the system and collection of information under this
paragraph, including the activities described in
subparagraphs (A) and (D). Such consultation shall
include the use of requests for information and other
mechanisms determined appropriate by the Secretary.
``(F) Administration.--Chapter 35 of title 44,
United States Code, shall not apply to the collection
of information required under this subsection.
``(G) Limitations on review.--There shall be no
administrative or judicial review under section 1869,
section 1878, or otherwise of the data collection
system or identification of respondents under this
paragraph.
``(H) Funding for implementation.--For purposes of
carrying out subparagraph (A), the Secretary shall
provide for the transfer, from the Federal
Supplementary Medical Insurance Trust Fund under
section 1841, of $1,000,000 to the Centers for Medicare
& Medicaid Services Program Management Account for
fiscal year 2014. Amounts transferred under this
subparagraph shall remain available until expended.''.
SEC. 204. REVISION OF THE MEDICARE-DEPENDENT HOSPITAL (MDH) PROGRAM.
(a) Permanent Extension of Payment Methodology.--
(1) In general.--Section 1886(d)(5)(G) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(G)) is amended--
(A) in clause (i), by striking ``and before April
1, 2014,''; and
(B) in clause (ii)(II), by striking ``and before
April 1, 2014,''.
(2) Conforming amendments.--
(A) Target amount.--Section 1886(b)(3)(D) of the
Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is
amended--
(i) in the matter preceding clause (i), by
striking ``and before April 1, 2014,''; and
(ii) in clause (iv), by striking ``through
fiscal year 2013 and the portion of fiscal year
2014 before April 1, 2014'' and inserting ``or
a subsequent fiscal year''.
(B) Hospital value-based purchasing program.--
Section 1886(o)(7)(D)(ii)(I) of the Social Security Act
(42 U.S.C. 1395ww(o)(7)(D)(ii)(I)) is amended by
striking ``(with respect to discharges occurring during
fiscal year 2012 and 2013)''.
(C) Hospital readmission reduction program.--
Section 1886(q)(2)(B)(i) of the Social Security Act (42
U.S.C. 1395ww(q)(2)(B)(i)) is amended by striking
``(with respect to discharges occurring during fiscal
years 2012 and 2013)''.
(D) Permitting hospitals to decline
reclassification.--Section 13501(e)(2) of the Omnibus
Budget Reconciliation Act of 1993 (42 U.S.C. 1395ww
note) is amended by striking ``fiscal year 1998, fiscal
year 1999, or fiscal year 2000 through the first 2
quarters of fiscal year 2014'' and inserting ``or
fiscal year 1998 or a subsequent fiscal year''.
(b) GAO Study and Report on Medicare-dependent Hospitals.--
(1) Study.--The Comptroller General of the United States
shall conduct a study on the following:
(A) The payor mix of medicare-dependent, small
rural hospitals (as defined in section
1886(d)(5)(G)(iv)), how such mix will trend in future
years, and whether or not the requirement under
subclause (IV) of such section should be revised.
(B) The characteristics of medicare-dependent,
small rural hospitals that meet the requirement of such
subclause (IV) through the application of paragraph
(a)(iii)(A) or (a)(iii)(B) of section 412.108 of the
Code of Federal Regulations, including Medicare
inpatient and outpatient utilization, payor mix, and
financial status, including Medicare and total margins,
and whether or not Medicare payments for such hospitals
should be revised.
(C) Such other items related to medicare-dependent,
small rural hospitals as the Comptroller General
determines appropriate.
(2) Report.--Not later than 12 months after the date of the
enactment of this Act, the Comptroller General of the United
States shall submit to Congress a report on the study conducted
under paragraph (1), together with recommendations for such
legislation and administrative action as the Comptroller
General determines appropriate.
(c) Implementation.--Notwithstanding any other provision of law,
for purposes of fiscal year 2014, the Secretary of Health and Human
Services may implement the provisions of, and the amendments made by,
this section through program instruction or otherwise.
SEC. 205. REVISION OF MEDICARE INPATIENT HOSPITAL PAYMENT ADJUSTMENT
FOR LOW-VOLUME HOSPITALS.
(a) In General.--Section 1886(d)(12) of the Social Security Act (42
U.S.C. 1395ww(d)(12)) is amended--
(1) in subparagraph (B)--
(A) in the subparagraph heading, by inserting ``for
fiscal years 2005 through 2010'' after ``increase'';
and
(B) in the matter preceding clause (i), by striking
``and for discharges occurring in the portion of fiscal
year 2014 beginning on April 1, 2014, fiscal year 2015,
and subsequent years'';
(2) in subparagraph (C)(i)--
(A) by striking ``fiscal years 2011, 2012, and
2013, and the portion of fiscal year 2014 before'' and
inserting ``fiscal year 2011 and subsequent fiscal
years,'' each place it appears; and
(B) by striking ``or portion of fiscal year'' after
``during the fiscal year''; and
(3) in subparagraph (D)--
(A) in the heading, by striking ``Temporary
applicable percentage increase'' and inserting
``Applicable percentage increase for fiscal year 2011
and subsequent fiscal years'';
(B) by striking ``fiscal years 2011, 2012, and
2013, and the portion of fiscal year 2014 before April
1, 2014'' and inserting ``fiscal year 2011 or a
subsequent fiscal year''; and
(C) by striking ``or the portion of fiscal year''
after ``in the fiscal year''.
(b) Implementation.--Notwithstanding any other provision of law,
for purposes of fiscal year 2014, the Secretary of Health and Human
Services may implement the provisions of, and the amendments made by,
this section through program instruction or otherwise.
SEC. 206. SPECIALIZED MEDICARE ADVANTAGE PLANS FOR SPECIAL NEEDS
INDIVIDUALS.
(a) Extension.--Section 1859(f)(1) of the Social Security Act (42
U.S.C. 1395w-28(f)(1)) is amended--
(1) by striking ``enrollment.--In the case'' and inserting
``enrollment.--
``(A) In general.--Subject to subparagraphs (B) and
(C), in the case'';
(2) in subparagraph (A), as added by paragraph (1), by
striking ``and for periods before January 1, 2016''; and
(3) by adding at the end the following new subparagraphs:
``(B) Application to dual snps.--Subparagraph (A)
shall only apply to a specialized MA plan for special
needs individuals described in subsection (b)(6)(B)(ii)
for periods before January 1, 2021.
``(C) Application to severe or disabling chronic
condition snps.--Subparagraph (A) shall only apply to a
specialized MA plan for special needs individuals
described in subsection (b)(6)(B)(iii) for periods
before January 1, 2018.''.
(b) Increased Integration of Dual SNPs.--
(1) In general.--Section 1859(f) of the Social Security Act
(42 U.S.C. 1395w-28(f)) is amended--
(A) in paragraph (3), by adding at the end the
following new subparagraph:
``(F) The plan meets the requirements applicable
under paragraph (8).''; and
(B) by adding at the end the following new
paragraph:
``(8) Increased integration of dual snps.--
``(A) Designated contact.--The Secretary, acting
through the Federal Coordinated Health Care Office
(Medicare-Medicaid Coordination Office) established
under section 2602 of the Patient Protection and
Affordable Care Act (in this paragraph referred to as
the `MMCO'), shall serve as a dedicated point of
contact for States to address misalignments that arise
with the integration of specialized MA plans for
special needs individuals described in subsection
(b)(6)(B)(ii) under this paragraph. Consistent with
such role, the MMCO shall--
``(i) establish a uniform process for
disseminating to State Medicaid agencies
information under this title impacting
contracts between such agencies and such plans
under this subsection; and
``(ii) establish basic resources for States
interested in exploring such plans as a
platform for integration.
``(B) Unified grievances and appeals process.--
``(i) In general.--Not later than April 1,
2015, the Secretary shall establish procedures
unifying the grievances and appeals procedures
under sections 1852(f), 1852(g), 1902(a)(3),
and 1902(a)(5) for items and services provided
by specialized MA plans for special needs
individuals described in subsection
(b)(6)(B)(ii) under this title and title XIX.
The Secretary shall solicit comment in
developing such procedures from States, plans,
beneficiary representatives, and other relevant
stakeholders.
``(ii) Procedures.--The procedures
established under clause (i) shall--
``(I) adopt the most protective
provisions for the enrollee under
current law, including continuation of
benefits under title XIX pending appeal
if an appeal is filed in a timely
manner;
``(II) take into account
differences in State plans under title
XIX;
``(III) be easily navigable by an
enrollee; and
``(IV) include the elements
described in clause (iii).
``(iii) Elements described.--The following
elements are described in this clause:
``(I) Single notification of all
applicable grievances and appeal rights
under this title and title XIX.
``(II) Notices written in plain
language and available in a language
and format that is accessible to the
enrollee.
``(III) Unified timeframes for
internal and external grievances and
appeals processes, such as an
individual's filing of a grievance or
appeal, a plan's acknowledgment and
resolution of a grievance or appeal,
and notification of decisions with
respect to a grievance or appeal.
``(IV) Guidelines to allow the plan
to process, track, and resolve
grievances and appeals, to ensure
beneficiaries are notified on a timely
basis of decisions that are made
throughout the grievance or appeals
process and are able to easily
determine the status of a grievance or
appeal.
``(C) Requirement for unified grievances and
appeals.--
``(i) In general.--For 2016 and subsequent
years, the contract of a specialized MA plan
for special needs individuals described in
subsection (b)(6)(B)(ii) with a State Medicaid
agency under this subsection shall require the
use of unified grievances and appeals
procedures as described in subparagraph (B).
``(ii) Consideration of application for
other snps.--The Secretary shall consider
applying the unified grievances and appeals
process described in subparagraph (B) to
specialized MA plans for special needs
individuals described in subsection
(b)(6)(B)(i) and subsection (b)(6)(B)(iii) that
have a substantial portion of enrollees who are
dually eligible for benefits under this title
and title XIX and are at risk for full benefits
under title XIX.
``(D) Requirement for full integration for certain
dual snps.--
``(i) Requirement.--Subject to the
succeeding provisions of this subparagraph, for
2018 and subsequent years, a specialized MA
plan for special needs individuals described in
subsection (b)(6)(B)(ii) shall--
``(I) integrate all benefits under
this title and title XIX; and
``(II) meet the requirements of a
fully integrated plan described in
section 1853(a)(1)(B)(iv)(II) (other
than the requirement that the plan have
similar average levels of frailty, as
determined by the Secretary, as the
PACE program), including with respect
to long-term care services or
behavioral health services to the
extent State law permits capitation of
those services under such plan.
``(ii) Initial sanctions for failure to
meet requirement for 2018 or 2019.--For each of
2018 and 2019, if the Secretary determines that
a plan has failed to meet the requirement
described in clause (i), the Secretary shall
impose one of the following on the plan:
``(I) A reduction in payment to the
plan under this part in an amount at
least equal to the portion of the
monthly rebate computed under section
1854(b)(1)(C)(i) for the plan and year
that would otherwise be kept by the
plan after application of the
beneficiary rebate rule under section
1854(b)(1)(C).
``(II) Closing enrollment in the
plan.
``(III) Sanctioning the plan in
accordance with section 1857(g).
``(IV) Other reasonable action
(other than the sanction described in
clause (iii)) the Secretary determines
appropriate.
``(iii) Sanctions for failure to meet
requirement for 2020 and subsequent years.--For
2020 and subsequent years, if the Secretary
determines that a plan has failed to meet the
requirement described in clause (i), the plan
shall be deemed to no longer meet the
definition of a specialized MA plan for special
needs individuals described in subsection
(b)(6)(B)(ii).
``(iv) Limitation.--This subparagraph shall
not apply to a specialized MA plan for special
needs individuals described in subsection
(b)(6)(B)(ii) that only enrolls individuals for
whom the only medical assistance to which the
individuals are entitled under the State plan
is medicare cost sharing described in section
1905(p)(3)(A)(ii).''.
(2) Conforming amendment to responsibilities of federal
coordinated health care office (mmco).--Section 2602(d) of the
Patient Protection and Affordable Care Act (42 U.S.C. 1315b(d))
is amended by adding at the end the following new paragraph:
``(6) To act as a designated contact for States under
subsection (f)(8)(A) of section 1859 of the Social Security Act
(42 U.S.C. 1395w-28) with respect to the integration of
specialized MA plans for special needs individuals described in
subsection (b)(6)(B)(ii) of such section.''.
(c) Improvements to Severe or Disabling Chronic Condition SNPs.--
Section 1859(f)(5) of the Social Security Act (42 U.S.C. 1395w-
28(f)(5)) is amended--
(1) by striking ``all snps.--The requirements'' and
inserting ``all snps.--
``(A) In general.--Subject to subparagraph (B), the
requirements'';
(2) by redesignating subparagraphs (A) and (B) as clauses
(i) and (ii), respectively, and indenting appropriately;
(3) in clause (ii), as redesignated by paragraph (2), by
redesignating clauses (i) through (iii) as subclauses (I)
through (III), respectively, and indenting appropriately; and
(4) by adding at the end the following new subparagraph:
``(B) Improvements to care management requirements
for severe or disabling chronic condition snps.--For
2016 and subsequent years, in the case of a specialized
MA plan for special needs individuals described in
subsection (b)(6)(B)(iii), the requirements described
in this paragraph include the following:
``(i) The interdisciplinary team under
subparagraph (A)(ii)(III) includes a team of
providers with demonstrated expertise,
including training in an applicable specialty,
in treating individuals similar to the targeted
population of the plan.
``(ii) Requirements developed by the
Secretary to provide face-to-face encounters
with individuals enrolled in the plan not less
frequently than on an annual basis.
``(iii) As part of the model of care under
clause (i) of subparagraph (A), the results of
the initial assessment and annual reassessment
under clause (ii)(I) of such subparagraph of
each individual enrolled in the plan are
addressed in the individual's individualized
care plan under clause (ii)(II) of such
subparagraph.
``(iv) As part of the annual evaluation and
approval of such model of care, the Secretary
shall take into account whether the plan
fulfilled the previous year's goals (as
required under the model of care).
``(v) The Secretary shall establish a
minimum benchmark for each element of the model
of care of a plan. The Secretary shall only
approve a plan's model of care under this
paragraph if each element of the model of care
meets the minimum benchmark applicable under
the preceding sentence.''.
(d) GAO Study on Quality Improvement.--
(1) Study.--The Comptroller General of the United States
shall conduct a study on how the Secretary of Health and Human
Services could change the quality measurement system under the
Medicare Advantage program under part C of title XVIII of the
Social Security Act (42 U.S.C. 1395w-21 et seq.) to allow an
accurate comparison of the quality of care provided by
specialized MA plans for special needs individuals (as defined
in section 1859(b)(6) of such Act (42 U.S.C. 1395w-28(b)(6)),
both for individual plans and such plans overall, compared to
the quality of care delivered by the original Medicare fee-for-
service program under parts A and B of such title and other
Medicare Advantage plans under such part C across similar
populations.
(2) Report.--Not later than July 1, 2016, the Comptroller
General shall submit to Congress a report containing the
results of the study under paragraph (1), together with
recommendations for such legislation and administrative action
as the Comptroller General determines appropriate.
(e) Changes to Quality Ratings and Measurement of SNPs and
Determination of Feasability of Quality Measurement at the Plan
Level.--Section 1853(o) of the Social Security Act (42 U.S.C. 1395w-
23(o)) is amended by adding at the end the following new paragraphs:
``(6) Changes to quality ratings of snps.--
``(A) Emphasis on improvement across snps.--Subject
to subparagraph (B), beginning in plan year 2016, in
the case of a specialized MA plan for special needs
individuals, the Secretary shall increase the emphasis
on the plan's improvement or decline in performance
when determining the star rating of the plan under this
subsection for the year as follows:
``(i)(I) For plan year 2016, at least 10
percent, but not more than 12 percent, of the
total star rating of the plan shall be based on
improvement or decline in performance.
``(II) For plan year 2017 and subsequent
plan years, at least 12 percent, but not more
than 15 percent, of the total star rating of
the plan shall be based on improvement or
decline in performance.
``(ii) Improvement or decline in
performance under this subparagraph shall be
measured based on net change in the individual
star rating measures of the plan, with
appropriate weight given to specific individual
star ratings measures, such as readmission
rates, as determined by the Secretary.
``(iii) The Secretary shall make an
appropriate adjustment to the improvement
rating of a plan under this subparagraph if the
plan has achieved a 4.5-star rating or the
highest rating possible overall or for an
individual measure in order to ensure that the
plan is not punished in cases where it is not
possible to improve.
``(B) No application to certain plans.--
Subparagraph (A) shall not apply, with respect to a
year, to a specialized MA plan for special needs
individuals that has a rating that is less than two-
and-one-half stars.
``(C) Quality measurement at the plan level.--
``(i) In general.--The Secretary may
require reporting for and apply under this
subsection quality measures at the plan level
for specialized MA plan for special needs
individuals instead of at the contract level.
``(ii) Consideration.--The Secretary shall
take into consideration the minimum number of
enrollees in a specialized MA plan for special
needs individuals in order to determine if a
statistically significant or valid measurement
of quality at the plan level is possible under
clause (i).
``(iii) Application.--If the Secretary
applies quality measurement at the plan level
under this subparagraph--
``(I) such quality measurement
shall include Medicare Health Outcomes
Survey (HOS), Healthcare Effectiveness
Data and Information Set (HEDIS), and
Consumer Assessment of Healthcare
Providers and Systems (CAHPS) measures;
and
``(II) payment and other
administrative actions linked to
quality measurement (including the 5-
star rating system under this
subsection) shall be applied at the
plan level in accordance with this
subparagraph.
``(7) Determination of feasibility of quality measurement
at the plan level.--
``(A) Determination of feasibility.--The Secretary
shall determine the feasibility of requiring reporting
for and applying under this subsection quality measures
at the plan level for all MA plans under this part.
``(B) Consideration of change.--After making a
determination under subparagraph (A), the Secretary
shall consider requiring such reporting and applying
such quality measures at the plan level as described in
such subparagraph.''.
SEC. 207. REASONABLE COST REIMBURSEMENT CONTRACTS.
(a) One-year Transition and Notice Regarding Transition.--Section
1876(h)(5)(C) of the Social Security Act (42 U.S.C. 1395mm(h)(5)(C)) is
amended--
(1) in clause (ii), in the matter preceding subclause (I),
by striking ``For any'' and inserting ``Subject to clause (iv),
for any''; and
(2) by adding at the end the following new clauses:
``(iv) In the case of an eligible organization that is offering a
reasonable cost reimbursement contract that may no longer be extended
or renewed because of the application of clause (ii), the following
shall apply:
``(I) Notwithstanding such clause, such contract may be
extended or renewed for the two years subsequent to the
previous year described in clause (ii). The second of the two
years described in the preceding sentence with respect to a
contract is referred to in this subsection as the `last
reasonable cost reimbursement contract year for the contract'.
``(II) The organization may not enroll any new enrollees
under such contract during the last reasonable cost
reimbursement contract year for the contract.
``(III) Not later than a date determined appropriate by the
Secretary prior to the beginning of the last reasonable cost
reimbursement contract year for the contract, the organization
shall provide notice to the Secretary as to whether or not the
organization will apply to have the contract converted over and
offered as a Medicare Advantage plan under part C for the year
following the last reasonable cost reimbursement contract year
for the contract.
``(IV) If the organization provides the notice described in
subclause (III) that the contract will be converted, the
organization shall, not later than a date determined
appropriate by the Secretary, provide the Secretary with such
information as the Secretary determines appropriate in order to
carry out sections 1851(c)(4) and 1854(a)(5), including
subparagraph (C) of such section.
``(v) If an eligible organization that is offering a reasonable
cost reimbursement contract that is extended or renewed pursuant to
clause (iv) provides the notice described in clause (iv)(III) that the
contract will be converted, the following provisions shall apply:
``(I) The deemed enrollment under section 1851(c)(4).
``(II) The special rule for quality increases under
1853(o)(3)(A)(iv).''.
(b) Deemed Enrollment From Reasonable Cost Reimbursement Contracts
Converted to Medicare Advantage Plans.--
(1) In general.--Section 1851(c) of the Social Security Act
(42 U.S.C. 1395w-21(c)) is amended--
(A) in paragraph (1), by striking ``Such
elections'' and inserting ``Subject to paragraph (4),
such elections''; and
(B) by adding at the end the following:
``(4) Deemed enrollment relating to converted reasonable
cost reimbursement contracts.--
``(A) In general.--On the first day of the annual,
coordinated election period under subsection (e)(3) for
plan years beginning on or after January 1, 2017, an MA
eligible individual described in clause (i) or (ii) of
subparagraph (B) is deemed to have elected to receive
benefits under this title through an applicable MA plan
(and shall be enrolled in such plan) beginning with
such plan year, if--
``(i) the individual is enrolled in a
reasonable cost reimbursement contract under
section 1876(h) in the previous plan year;
``(ii) such reasonable cost reimbursement
contract was extended or renewed for the last
reasonable cost reimbursement contract year of
the contract pursuant to section
1876(h)(5)(C)(iv);
``(iii) the eligible organization that is
offering such reasonable cost reimbursement
contract provided the notice described in
subclause (III) of such section that the
contract was to be converted;
``(iv) the applicable MA plan--
``(I) is the plan that was
converted from the reasonable cost
reimbursement contract described in
clause (iii);
``(II) is offered by the same
entity (or an organization affiliated
with such entity that has a common
ownership interest of control) that
entered into such contract; and
``(III) is offered in the service
area where the individual resides;
``(v) the applicable MA plan provides
benefits, premiums, and access to in-network
and out-of-network providers that are
comparable to the benefits, premiums, and
access to in-network and out-of-network
providers under such reasonable cost
reimbursement contract for the previous plan
year; and
``(vi) the applicable MA plan--
``(I) allows enrollees
transitioning from the converted
reasonable cost contract to such plan
to maintain current providers and
course of treatment at the time of
enrollment for at least 90 days after
enrollment; and
``(II) during such period, pays
non-contracting providers for items and
services furnished to the enrollee an
amount that is not less than the amount
of payment applicable for those items
and services under the original
medicare fee-for-service program under
parts A and B.
``(B) MA eligible individuals described.--
``(i) Without prescription drug coverage.--
An MA eligible individual described in this
clause, with respect to a plan year, is an MA
eligible individual who is enrolled in a
reasonable cost reimbursement contract under
section 1876(h) in the previous plan year and
who does not, for such previous plan year,
receive any prescription drug coverage under
part D, including coverage under section 1860D-
22.
``(ii) With prescription drug coverage.--An
MA eligible individual described in this
clause, with respect to a plan year, is an MA
eligible individual who is enrolled in a
reasonable cost reimbursement contract under
section 1876(h) in the previous plan year and
who, for such previous plan year, receives
prescription drug coverage under part D--
``(I) through such contract; or
``(II) through a prescription drug
plan, if the sponsor of such plan is
the same entity (or an organization
affiliated with such entity) that
entered into such contract.
``(C) Applicable ma plan defined.--In this
paragraph, the term `applicable MA plan' means, in the
case of an individual described in--
``(i) subparagraph (B)(i), an MA plan that
is not an MA-PD plan; and
``(ii) subparagraph (B)(ii), an MA-PD plan.
``(D) Identification and notification of deemed
individuals.--Not later than 30 days before the first
day of the annual, coordinated election period under
subsection (e)(3) for plan years beginning on or after
January 1, 2017, the Secretary shall identify and
notify the individuals who will be subject to deemed
elections under subparagraph (A) on the first day of
such period.''.
(2) Beneficiary option to discontinue or change ma plan or
ma-pd plan after deemed enrollment.--
(A) In general.--Section 1851(e)(2) of the Social
Security Act (42 U.S.C. 1395w-21(e)(4)) is amended by
adding at the end the following:
``(F) Special period for certain deemed
elections.--
``(i) In general.--At any time during the
period beginning after the last day of the
annual, coordinated election period under
paragraph (3) in which an individual is deemed
to have elected to enroll in an MA plan or MA-
PD plan under subsection (c)(4) and ending on
the last day of February of the first plan year
for which the individual is enrolled in such
plan, such individual may change the election
under subsection (a)(1) (including changing the
MA plan or MA-PD plan in which the individual
is enrolled).
``(ii) Limitation of one change.--An
individual may exercise the right under clause
(i) only once during the applicable period
described in such clause. The limitation under
this clause shall not apply to changes in
elections effected during an annual,
coordinated election period under paragraph (3)
or during a special enrollment period under
paragraph (4).''.
(B) Conforming amendments.--
(i) Plan requirement for open enrollment.--
Section 1851(e)(6)(A) of the Social Security
Act (42 U.S.C. 1395w-21(e)(6)(A)) is amended by
striking ``paragraph (1),'' and inserting
``paragraph (1), during the period described in
paragraph (2)(F),''.
(ii) Part d.--Section 1860D-1(b)(1)(B) of
such Act (42 U.S.C. 1395w-101(b)(1)(B)) is
amended--
(I) in clause (ii), by adding ``and
paragraph (4)'' after ``paragraph
(3)(A)''; and
(II) in clause (iii) by striking
``and (E)'' and inserting ``(E), and
(F)''.
(3) Treatment of esrd for deemed enrollment.--Section
1851(a)(3)(B) of the Social Security Act (42 U.S.C. 1395w-
21(a)(3)(B)) is amended by adding at the end the following
flush sentence:
``An individual who develops end-stage renal disease
while enrolled in a reasonable cost reimbursement
contract under section 1876(h) shall be treated as an
MA eligible individual for purposes of applying the
deemed enrollment under subsection (c)(4).''.
(c) Information Requirements.--Section 1851(d)(2)(B) of the Social
Security Act (42 U.S.C. 1395w-21(d)(2)(B)) is amended--
(1) by striking the subparagraph heading and inserting the
following: ``(i) notification to newly eligible medicare
advantage eligible individuals.--''; and
(2) by adding at the end the following:
``(ii) Notification related to certain deemed
elections.--The Secretary shall require the converting
cost plan to mail, not later than 15 days prior to the
first day of the annual, coordinated election period
under subsection (e)(3) of a year, to any individual
identified by the Secretary under subsection (c)(4)(D)
for such year--
``(I) a notification that such individual
will, on such day, be deemed to have made an
election to receive benefits under this title
through an MA plan or MA-PD plan (and shall be
enrolled in such plan) for the next plan year
under subsection (c)(4)(A), but that the
individual may make a different election during
the annual, coordinated election period for
such year;
``(II) the information described in
subparagraph (A);
``(III) a description of the differences
between such MA plan or MA-PD plan and the
reasonable cost reimbursement contract in which
the individual was most recently enrolled with
respect to benefits covered under such plans,
including cost-sharing, premiums, drug
coverage, and provider networks;
``(IV) information about the special period
for elections under subsection (e)(2)(F); and
``(V) other information the Secretary may
specify''.
(d) Treatment of Transition Plan for Quality Rating for Payment
Purposes.--Section 1853(o)(4) of the Social Security Act (42 U.S.C.
1395w-23(o)(4)) is amended by adding at the end the following new
subparagraph:
``(C) Special rule for first 3 plan years for plans
that were converted from a reasonable cost
reimbursement contract.--For purposes of applying
paragraph (1) and section 1854(b)(1)(C) for the first 3
plan years under this part in the case of an MA plan to
which deemed enrollment applies under section
1851(c)(4)--
``(i) such plan shall not be treated as a
new plan (as defined in paragraph
(3)(A)(iii)(II)); and
``(ii) in determining the star rating of
the plan under subparagraph (A), to the extent
that Medicare Advantage data for such plan is
not available for a measure used to determine
such star rating, the Secretary shall use data
from the period in which such plan was a
reasonable cost reimbursement contract.''.
SEC. 208. QUALITY MEASURE ENDORSEMENT AND SELECTION.
(a) Contract With an Entity Regarding Input on the Selection of
Measures.--
(1) In general.--Title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) is amended--
(A) by redesignating section 1890A as section
1890B; and
(B) by inserting after section 1890 the following
new section:
``contract with an entity regarding input on the selection of measures
``Sec. 1890A (a) Contract.--
``(1) In general.--For purposes of activities conducted
under this Act, the Secretary shall identify and have in effect
a contract with an entity that meets the requirements described
in subsection (c). Such contract shall provide that the entity
will perform the duties described in subsection (b).
``(2) Timing for first contract.--The first contract under
paragraph (1) shall begin on, or as soon as practicable after,
October 1, 2014.
``(3) Period of contract.--A contract under paragraph (1)
shall be for a period of 3 years (except as may be renewed
after a subsequent bidding process).
``(4) Competitive procedures.--Competitive procedures (as
defined in section 4(5) of the Office of Federal Procurement
Policy Act (41 U.S.C. 403(5))) shall be used to enter into a
contract under paragraph (1).
``(b) Duties.--The duties described in this subsection are the
following:
``(c) Requirements Described.--The requirements described in this
subsection are the following:
``(1) Private nonprofit, board membership, membership fees,
and not a measure developer.--The requirements described in
paragraphs (1), (2), (7), and (8) of section 1890(c).
``(2) Experience.--The entity has at least 4 years of
experience working with quality and efficiency measures.''.
(2) Duties of entity.--
(A) Transfer of priority setting process.--
Paragraph (1) of section 1890(b) of the Social Security
Act (42 U.S.C. 1395aaa(b)) is redesignated as paragraph
(1) of section 1890A(b) of such Act, as added by
paragraph (1).
(B) Transfer of multi-stakeholder process.--
Paragraphs (7) and (8) of such section 1890(b) are
redesignated as paragraphs (2) and (3), respectively,
of section 1890A(b) of such Act, as added by paragraph
(1) and amended by subparagraph (A).
(C) Additional duties.--Section 1890A(b) of such
Act, as added by paragraph (1) and amended by
subparagraphs (A) and (B), is amended by adding at the
end the following new paragraphs:
``(4) Facilitation to better coordinate and align public
and private sector use of quality measures.--
``(A) In general.--The entity shall facilitate
increased coordination and alignment between the public
and private sector with respect to quality and
efficiency measures.
``(B) Reports.--The entity shall prepare and make
available to the public annual reports on its findings
under this paragraph. Such public availability shall
include posting each report on the Internet website of
the entity.
``(5) Gap analysis.--The entity shall conduct an ongoing
analysis of--
``(A) gaps in endorsed quality and efficiency
measures, which shall include measures that are within
priority areas identified by the Secretary under the
national strategy established under section 399HH of
the Public Health Service Act; and
``(B) areas where quality measures are unavailable
or inadequate to identify or address such gaps.
``(6) Annual report to congress and the secretary;
secretarial publication and comment.--
``(A) Annual report.--By not later than June 1 of
each year, the entity shall submit to Congress and the
Secretary a report containing--
``(i) a description of--
``(I) the recommendations made
under paragraph (1);
``(II) the matters described in
clauses (i) and (ii) of paragraph
(2)(A);
``(III) the results of the analysis
under paragraph (5); and
``(IV) the performance by the
entity of the duties required under the
contract entered into with the
Secretary under subsection (a); and
``(ii) any other items determined
appropriate by the Secretary.
``(B) Secretarial review and publication of annual
report.--Not later than 6 months after receiving a
report under subparagraph (A), the Secretary shall--
``(i) review such report; and
``(ii) publish such report in the Federal
Register, together with any comments of the
Secretary on such report.''.
(D) Additional amendments.--Section 1890A(b) of
such Act, as so added and amended, is amended--
(i) in paragraph (2)--
(I) in subparagraph (A)(i)--
(aa) in subclause (I), by
inserting ``with a contract
under section 1890'' after
``entity''; and
(bb) in subclause (II), by
striking ``such entity'' and
inserting ``the entity with a
contract under section 1890'';
(II) in the heading of subparagraph
(B) by inserting ``and efficiency''
after ``Quality'';
(III) in subparagraph (B)(i)(III),
by striking ``this Act'' and inserting
``this title''; and
(IV) by adding at the end the
following new subparagraphs:
``(E) Input.--In providing the input described in
subparagraph (A), the multi-stakeholder groups--
``(i) shall include a detailed description
of the rationale for each recommendation made
by the multi-stakeholder group, including in
areas relating to--
``(I) the expected impact that
implementing the measure will have on
individuals;
``(II) the burden on providers of
services and suppliers;
``(III) the expected influence over
the behavior of providers of services
and suppliers;
``(IV) the applicability of a
measure for more than one setting or
program; and
``(V) other areas determined in
consultation with the Secretary; and
``(ii) may consider whether it is
appropriate to provide separate recommendations
with respect to measures for internal use,
public reporting, and payment provisions.
``(F) Equal representation.--In convening multi-
stakeholder groups pursuant to this paragraph, the
entity shall, to the extent feasible, make every effort
to ensure such groups are balanced across
stakeholders.''; and
(ii) in paragraph (3), by striking ``Not
later'' and all that follows through the period
at the end and inserting the following: ``Not
later than the applicable dates described in
section 1890B(a)(3) of each year (or, as
applicable, the timeframe described in section
1890B(a)(4)), the entity shall transmit to the
Secretary the input of the multi-stakeholder
groups under paragraph (2).''.
(b) Revisions to Contract With Consensus-based Entity.--
(1) Contract.--Section 1890(a) of the Social Security Act
(42 U.S.C. 1395aaa(a)) is amended--
(A) in paragraph (1), by striking ``, such as the
National Quality Forum,''; and
(B) in paragraph (3), by striking ``4 years'' and
inserting ``3 years''.
(2) Duties.--Section 1890(b) of the Social Security Act (42
U.S.C. 1395aaa(b)), as amended by subsection (a)(2), is
amended--
(A) by redesignating paragraphs (2) and (3) as
paragraphs (1) and (2), respectively;
(B) in paragraph (2), as redesignated by
subparagraph (A), by striking ``paragraph (2)'' and
inserting ``paragraph (1)'';
(C) by striking paragraphs (5) and (6); and
(D) by adding at the end the following new
paragraphs:
``(3) Facilitation to better coordinate and align public
and private sector use of quality measures.--
``(A) In general.--The entity shall facilitate
increased coordination and alignment between the public
and private sector with respect to quality and
efficiency measures.
``(B) Reports.--The entity shall prepare and make
available to the public annual reports on its findings
under this paragraph. Such public availability shall
include posting each report on the Internet website of
the entity.
``(4) Annual report to congress and the secretary;
secretarial publication and comment.--
``(A) Annual report.--By not later than March 1 of
each year, the entity shall submit to Congress and the
Secretary a report containing--
``(i) a description of--
``(I) the coordination of quality
initiatives under this title and titles
XIX and XXI with quality initiatives
implemented by other payers;
``(II) areas in which evidence is
insufficient to support endorsement of
quality measures in priority areas
identified by the Secretary under the
national strategy established under
section 399HH of the Public Health
Service Act and where targeted research
may address such gaps; and
``(III) the performance by the
entity of the duties required under the
contract entered into with the
Secretary under subsection (a); and
``(ii) any other items determined
appropriate by the Secretary.
``(B) Secretarial review and publication of annual
report.--Not later than 6 months after receiving a
report under subparagraph (A), the Secretary shall--
``(i) review such report; and
``(ii) publish such report in the Federal
Register, together with any comments of the
Secretary on such report.''.
(3) Requirements.--Section 1890(c) of the Social Security
Act (42 U.S.C. 1395aaa(c)) is amended by adding at the end the
following new paragraph:
``(8) Not a measure developer.--The entity is not a measure
developer.''.
(c) Revisions to Duties of the Secretary Regarding Use of
Measures.--
(1) In general.--Section 1890B(a) of the Social Security
Act (42 U.S.C. 1395aaa-1(a)), as redesignated by subsection
(a)(1)(A), is amended--
(A) by striking ``section 1890(b)(7)(B)'' each
place it appears and inserting ``section
1890A(b)(2)(B)'';
(B) in paragraph (1)--
(i) by striking ``section 1890(b)(7)'' and
inserting ``section 1890A(b)(2)''; and
(ii) by striking ``section 1890'' and
inserting ``section 1890A'';
(C) by striking paragraphs (2) and (3) and
inserting the following:
``(2) Public availability of measures considered for
selection.--Subject to paragraph (4), not later than October 1
or December 31 of each year (or as soon as practicable after
such dates for the first year of the contract), the Secretary
shall make available to the public a list of quality and
efficiency measures described in section 1890A(b)(2)(B) that
the Secretary is considering under this title. The Secretary
shall provide for an appropriate balance of the number of
measures to be made available by each such date in a year.
``(3) Transmission of multi-stakeholder input.--
``(A) In general.--Subject to paragraph (4), not
later than the applicable date described in
subparagraph (B) of each year, the entity with a
contract under section 1890A shall, pursuant to
subsection (b)(3) of such section, transmit to the
Secretary the input of multi-stakeholder groups
described in paragraph (1).
``(B) Applicable date described.--The applicable
date described in this subparagraph for a year is--
``(i) February 1 (or as soon as practicable
after such date for the first year of the
contract) with respect to quality and
efficiency measures made available under
paragraph (2) by October 1 of the preceding
year; and
``(ii) April 1 (or as soon as practicable
after such dates for the first year of the
contract) with respect to quality and
efficiency measures made available under
paragraph (2) by December 31 of the preceding
year.'';
(D) by redesignating--
(i) paragraph (6) as paragraph (8); and
(ii) paragraphs (4) and (5) as paragraphs
(5) and (6), respectively;
(E) by inserting after paragraph (3) the following
new paragraph:
``(4) Limited process for additional multi-stakeholder
input.--In addition to the Secretary making measures publically
available pursuant to the dates described in paragraph (2) and
multi-stakeholder groups transmitting the input pursuant to the
applicable dates described in paragraph (3)--
``(A) the Secretary may, at times that do not meet
the time requirements described in paragraph (2), make
available to the public a limited number of quality and
efficiency measures described in section 1890A(b)(2)
that the Secretary is considering under this title; and
``(B) if the Secretary uses the authority under
subparagraph (A), the entity with a contract under
section 1890A shall, pursuant to section 1890A(b)(3),
transmit to the Secretary on a timely basis the input
from a multi-stakeholder group described in paragraph
(1) with respect to such measures.'';
(F) in paragraph (6), as redesignated by
subparagraph (D)(ii), by inserting ``or that has not
been recommended by the multi-stakeholder group under
section 1890A(b)(2)'' before the period at the end; and
(G) by inserting after paragraph (6) the following
new paragraph:
``(7) Concordance rates.--For each year (beginning with
2015), the Secretary shall include a list of concordance rates
with respect to the input provided under section 1890A(b)(2)(A)
for those new measures adopted for each type of provider of
services and supplier in the annual final rule applicable to
such type of provider or supplier.''.
(2) Review.--Section 1890B(c) of the Social Security Act
(42 U.S.C. 1395aaa-1(c)), as redesignated by subsection
(a)(1)(A), is amended--
(A) in paragraph (1)(A), by striking ``section
1890(b)(7)(B)'' and inserting ``section
1890A(b)(2)(B)''; and
(B) in paragraph (2)--
(i) in subparagraph (A), by striking
``and'' at the end;
(ii) in subparagraph (B), by striking the
period at the end and inserting ``; and''; and
(iii) by adding at the end the following
new subparagraph:
``(C) take into consideration the benefits of the
alignment of measures between the public and private
sector.''.
(d) Funding for Quality Measure Endorsement, Input, and
Selection.--
(1) Fiscal year 2014.--In addition to amounts transferred
under section 3014(c) of the Patient Protection and Affordable
Care Act (Public Law 111-148), for purposes of carrying out
section 1890 and section 1890A (other than subsections (e) and
(f)), the Secretary shall provide for the transfer, from the
Federal Hospital Insurance Trust Fund under section 1817 and
the Federal Supplementary Medical Insurance Trust Fund under
section 1841, in such proportion as the Secretary determines
appropriate, to the Centers for Medicare & Medicaid Services
Program Management Account of $7,000,000 for fiscal year 2014.
Amounts transferred under the preceding sentence shall remain
available until expended.
(2) Fiscal years 2015 through 2017.--Section 1890B of the
Social Security Act (42 U.S.C. 1395aaa-1), as redesignated by
subsection (a)(1)(A), is amended by adding at the end the
following new subsection:
``(g) Funding.--
``(1) In general.--For purposes of carrying out this
section (other than subsections (e) and (f)) and sections 1890
and 1890A, the Secretary shall provide for the transfer, from
the Federal Hospital Insurance Trust Fund under section 1817
and the Federal Supplementary Medical Insurance Trust Fund
under section 1841, in such proportion as the Secretary
determines appropriate, to the Centers for Medicare & Medicaid
Services Program Management Account of $25,000,000 for each of
fiscal years 2015 through 2017.
``(2) Availability.--Amounts transferred under paragraph
(1) shall remain available until expended.''.
(3) Conforming amendment.--Subsection (d) of section 1890
of the Social Security Act (42 U.S.C. 1395aaa) is repealed.
(e) Conforming Amendments.--(1) Section 1848(m)(3)(E)(iii) of the
Social Security Act (42 U.S.C. 1395w-4(m)(3)(E)(iii)) is amended by
striking ``section 1890(b)(7) and 1890A(a)'' and inserting ``section
1890A(b)(2) and 1890B(a)''.
(2) Section 1866D(b)(2)(C) of the Social Security Act (42 U.S.C.
1395cc-4(b)(2)(C)) is amended by striking ``section 1890 and 1890A''
and inserting ``sections 1890, 1890A, and 1890B''.
(3) Section 1899A(n)(2)(A) of the Social Security Act (42 U.S.C.
1395cc-4(n)(2)(A)) is amended by striking ``section 1890(b)(7)(B)'' and
inserting ``section 1890A(b)(2)(B)''.
(f) Effective Date.--
(1) In general.--The amendments made by this section shall
take effect on October 1, 2014, and shall apply with respect to
contract periods under sections 1890 and 1890A of the Social
Security Act that begin on or after such date.
(2) New contracts.--The Secretary of Health and Human
Services shall enter into a new contract under both sections
1890 and 1890A of the Social Security Act, as amended by this
Act, for a contract period beginning on, or as soon as
practicable after, October 1, 2014.
SEC. 209. PERMANENT EXTENSION OF FUNDING OUTREACH AND ASSISTANCE FOR
LOW-INCOME PROGRAMS.
(a) Additional Funding for State Health Insurance Programs.--
Subsection (a)(1)(B)(iv) of section 119 of the Medicare Improvements
for Patients and Providers Act of 2008 (42 U.S.C. 1395b-3 note), as
amended by section 3306 of the Patient Protection and Affordable Care
Act (Public Law 111-148), section 610 of the American Taxpayer Relief
Act of 2012 (Public Law 112-240), and section 1110 of the Pathway for
SGR Reform Act of 2013 (Public Law 113-67), is amended to read as
follows:
``(iv) for fiscal year 2014 and for each
subsequent fiscal year, $7,500,000.''.
(b) Additional Funding for Area Agencies on Aging.--Subsection
(b)(1)(B)(iv) of such section 119, as so amended, is amended to read as
follows:
``(iv) for fiscal year 2014 and for each
subsequent fiscal year, $7,500,000.''.
(c) Additional Funding for Aging and Disability Resource Centers.--
Subsection (c)(1)(B)(iv) of such section 119, as so amended, is amended
to read as follows:
``(iv) for fiscal year 2014 and for each
subsequent fiscal year, $5,000,000.''.
(d) Additional Funding for Contract With the National Center for
Benefits and Outreach Enrollment.--Subsection (d)(2)(iv) of such
section 119, as so amended, is amended to read as follows:
``(iv) for fiscal year 2014 and for each
subsequent fiscal year, $5,000,000.''.
Subtitle B--Medicaid and Other Extensions
SEC. 211. QUALIFYING INDIVIDUAL PROGRAM.
(a) Extension.--Section 1902(a)(10)(E)(iv) of the Social Security
Act (42 U.S.C. 1396a(a)(10)(E)(iv)) is amended by striking ``March
2104'' and inserting ``December 2018''.
(b) Eliminating Limitations on Eligibility.--Section 1933 of the
Social Security Act (42 U.S.C. 1396u-3) is amended by striking
subsections (b) and (e).
(c) Eliminating Allocations.--Section 1933 of the Social Security
Act (42 U.S.C. 1396u-3) is amended by striking subsections (c) and (g).
(d) Conforming Amendments.--
(1) In general.--Section 1933 of the Social Security Act
(42 U.S.C. 1396u-3), as amended by subsections (b) and (c), is
further amended--
(A) by striking subsection (a) and inserting the
following new subsection:
``(a) Applicable FMAP.--With respect to assistance described in
section 1902(a)(10)(E)(iv) furnished in a State, the Federal medical
assistance percentage shall be equal to 100 percent.'';
(B) by striking subsection (d); and
(C) by redesignating subsection (f) as subsection
(b).
(2) Definition of fmap.--Section 1905(b) of the Social
Security Act (42 U.S.C. 1396d(b)) is amended by striking
``section 1933(d)'' and inserting ``section 1933(a)''.
(e) Effective Date.--The amendments made by this section shall take
effect on April 1, 2014, and shall apply with respect to calendar
quarters beginning on or after such date.
SEC. 212. TRANSITIONAL MEDICAL ASSISTANCE.
(a) Extension.--Sections 1902(e)(1)(B) and 1925(f) of the Social
Security Act (42 U.S.C. 1396a(e)(1)(B), 1396r-6(f)) are each amended by
striking ``March 31, 2014'' and inserting ``December 31, 2018''.
(b) Opt-out Option for States That Expand Adult Coverage and
Provide 12-month Continuous Eligibility Under Medicaid and CHIP.--
(1) In general.--Section 1925 of the Social Security Act
(42 U.S.C. 1396r-6), as amended by subsection (a), is further
amended--
(A) in subsection (a)--
(i) in paragraph (1)(A), by striking
``paragraph (5)'' and inserting ``paragraphs
(5) and (6)''; and
(ii) by adding at the end the following:
``(6) Opt-out option for states that expand adult coverage
and provide 12-month continuous eligibility under medicaid and
chip.--
``(A) In general.--In the case of a State described
in subparagraph (B), the State may elect through a
State plan amendment to have this section and sections
408(a)(11)(A), 1902(a)(52), 1902(e)(1), and 1931(c)(2)
not apply to the State.
``(B) State described.--A State is described in
this subparagraph if the State is one of the 50 States
or the District of Columbia and--
``(i) has elected to provide medical
assistance to individuals under subclause
(VIII) of section 1902(a)(10)(A)(i);
``(ii) has elected under section
1902(e)(12)(A) the option to provide continuous
eligibility for a 12-month period for
individuals under 19 years of age;
``(iii) has elected under section
1902(e)(12)(B) the option to provide continuous
eligibility for a 12-month period for all
categories of individuals described in that
section; and
``(iv) has elected to apply section
1902(e)(12)(A) to the State child health plan
under title XXI.''; and
(B) in subsection (b)(1), by striking ``subsection
(a)(5)'' and inserting ``paragraphs (5) and (6) of
subsection (a)''.
(2) Conforming amendment to 4-month requirement.--Section
1902(e)(1) of the Social Security Act (42 U.S.C. 1396a(e)(1)),
as amended by subsection (a), is further amended--
(A) in subparagraph (B), by striking ``Subparagraph
(A)'' and inserting ``Subject to subparagraph (C),
subparagraph (A)''; and
(B) by adding at the end the following:
``(C) If a State has made an election under section 1925(a)(6),
subparagraph (A) and section 1925 shall not apply to the State.''.
(c) Extension of 12-month Continuous Eligibility Option to Certain
Adult Enrollees Under Medicaid; Clarification of Application to CHIP.--
(1) In general.--Section 1902(e)(12) of the Social Security
Act (42 U.S.C. 1396a(e)(12)) is amended--
(A) by redesignating subparagraphs (A) and (B) as
clauses (i) and (ii), respectively;
(B) by inserting ``(A)'' after ``(12)''; and
(C) by adding at the end the following:
``(B) At the option of the State, the plan may provide that an
individual who is determined to be eligible for benefits under a State
plan approved under this title under any of the following eligibility
categories, or who is redetermined to be eligible for such benefits
under any of such categories, shall be considered to meet the
eligibility requirements met on the date of application and shall
remain eligible for those benefits until the end of the 12-month period
following the date of the determination or redetermination of
eligibility:
``(i) Section 1902(a)(10)(A)(i)(VIII).
``(ii) Section 1931.''.
(2) Application to chip.--Section 2107(e)(1) of the Social
Security Act (42 U.S.C. 1397gg(e)(1)) is amended--
(A) by redesignating subparagraphs (E) through (O)
as subparagraphs (F) through (P), respectively; and
(B) by inserting after subparagraph (D), the
following:
``(E) Section 1902(e)(12)(A) (relating to the State
option for 12-month continuous eligibility and
enrollment).''.
(d) Conforming and Technical Amendments Relating to Section 1931
Transitional Coverage Requirements.--
(1) In general.--Section 1931(c) of the Social Security Act
(42 U.S.C. 1396u-1(c)) is amended--
(A) in paragraph (1)--
(i) in the paragraph heading, by striking
``child'' and inserting ``spousal'';
(ii) by striking ``The provisions'' and
inserting ``Subject to paragraph (3), the
provisions''; and
(iii) by striking ``child or'';
(B) in paragraph (2), by striking ``For continued''
and inserting ``Subject to paragraph (3), for
continued''; and
(C) by adding at the end the following:
``(3) Opt-out option for states that expand adult coverage
and provide 12-month continuous eligibility under medicaid and
chip.--
``(A) In general.--In the case of a State described
in subparagraph (B), the State may elect through a
State plan amendment to have paragraphs (1) and (2) of
this subsection and sections 408(a)(11), 1902(a)(52),
1902(e)(1), and 1925 not apply to the State.
``(B) State described.--A State is described in
this subparagraph if the State is one of the 50 States
or the District of Columbia and--
``(i) has elected to provide medical
assistance to individuals under subclause
(VIII) of section 1902(a)(10)(A)(i);
``(ii) has elected under section
1902(e)(12)(A) the option to provide continuous
eligibility for a 12-month period for
individuals under 19 years of age;
``(iii) has elected under section
1902(e)(12)(B) the option to provide continuous
eligibility for a 12-month period for all
categories of individuals described in that
section; and
``(iv) has elected to apply section
1902(e)(12)(A) to the State child health plan
under title XXI.''.
(2) Conforming amendment to section 408.--Section
408(a)(11) of the Social Security Act (42 U.S.C. 608(a)(11) is
amended--
(A) in the paragraph heading, by striking ``child''
and inserting ``spousal''; and
(B) in subparagraph (B)--
(i) in the subparagraph heading, by
striking ``Child'' and inserting ``Spousal'';
and
(ii) by striking ``child or''.
(e) Conforming Amendment Relating to Maintenance of Effort for
Children.--Section 1902(gg)(4) of the Social Security Act (42 U.S.C.
1396a(gg)(4)) is amended by adding at the end the following:
``(C) States that expand adult coverage and elect
to opt-out of transitional coverage.--
``(i) In general.--For purposes of
determining compliance with the requirements of
paragraph (2), a State which exercises the
option under sections 1925(a)(6) and 1931(c)(3)
to provide no transitional medical assistance
or other extended eligibility (as applicable)
shall not, as a result of exercising such
option, be considered to have in effect
eligibility standards, methodologies, or
procedures described in clause (ii) that are
more restrictive than the standards,
methodologies, or procedures in effect under
the State plan or under a waiver of the plan on
the date of enactment of the Patient Protection
and Affordable Care Act.
``(ii) Standards, methodologies, or
procedures described.--The eligibility
standards, methodologies, or procedures
described in this clause are those standards,
methodologies, or procedures applicable to
determining the eligibility for medical
assistance of any child under 19 years of age
(or such higher age as the State may have
elected).''.
(f) Effective Date.--The amendments made by this section shall take
effect on April 1, 2014.
SEC. 213. EXPRESS LANE ELIGIBILITY.
Section 1902(e)(13)(I) of the Social Security Act (42 U.S.C.
1396a(e)(13)(I)) is amended by striking ``September 30, 2014'' and
inserting ``September 30, 2015''.
SEC. 214. PEDIATRIC QUALITY MEASURES.
(a) Continuation of Funding for Pediatric Quality Measures for
Improving the Quality of Children's Health Care.--Section 1139B(e) of
the Social Security Act (42 U.S.C. 1320b-9b(e)) is amended by adding at
the end the following: ``Of the funds appropriated under this
subsection, not less than $15,000,000 shall be used to carry out
section 1139A(b).''.
(b) Elimination of Restriction on Medicaid Quality Measurement
Program.--Section 1139B(b)(5)(A) of the Social Security Act (42 U.S.C.
1320b-9b(b)(5)(A)) is amended by striking ``The aggregate amount
awarded by the Secretary for grants and contracts for the development,
testing, and validation of emerging and innovative evidence-based
measures under such program shall equal the aggregate amount awarded by
the Secretary for grants under section 1139A(b)(4)(A)''.
SEC. 215. SPECIAL DIABETES PROGRAMS.
(a) Special Diabetes Programs for Type I Diabetes.--Section
330B(b)(2)(C) of the Public Health Service Act (42 U.S.C. 254c-
2(b)(2)(C)) is amended by striking ``2014'' and inserting ``2019''.
(b) Special Diabetes Programs for Indians.--Section 330C(c)(2)(C)
of the Public Health Service Act (42 U.S.C. 254c-3(c)(2)(C)) is amended
by striking ``2014'' and inserting ``2019''.
Subtitle C--Human Services Extensions
SEC. 221. ABSTINENCE EDUCATION GRANTS.
(a) In General.--Section 510 of the Social Security Act (42 U.S.C.
710) is amended--
(1) in subsection (a), in the matter preceding paragraph
(1), by striking ``2010 through 2014'' and inserting ``2015
through 2019''; and
(2) in subsection (d)--
(A) by striking ``2010 through 2014'' and inserting
``2015 through 2019''; and
(B) by striking the second sentence.
(b) Effective Date.--The amendments made by this section shall take
effect on October 1, 2014.
SEC. 222. PERSONAL RESPONSIBILITY EDUCATION PROGRAM.
(a) In General.--Section 513 of the Social Security Act (42 U.S.C.
713) is amended--
(1) in subsection (a)--
(A) in paragraph (1)(A), by striking ``2010 through
2014'' and inserting ``2015 through 2019'';
(B) in paragraph (4)--
(i) in subparagraph (A)--
(I) by striking ``2010 or 2011''
and inserting ``2015 or 2016'';
(II) by striking ``2010 through
2014'' and inserting ``2015 through
2019''; and
(III) by striking ``2012 through
2014'' and inserting ``2017 through
2019''; and
(ii) in subparagraph (B)(i)--
(I) by striking ``2012, 2013, and
2014'' and inserting ``2017, 2018, and
2019''; and
(II) by striking ``2010 or 2011''
and inserting ``2015 or 2016''; and
(C) in paragraph (5), by striking ``2009'' and
inserting ``2014'';
(2) in subsection (b)(2)(A), in the matter preceding clause
(i), by inserting ``and youth at risk of becoming victims of
sex trafficking (as defined in section 103(10) of the
Trafficking Victims Protection Act of 2000 (22 U.S.C.
7102(10))) or victims of a severe form of trafficking in
persons described in paragraph (9)(A) of that Act (22 U.S.C.
7102(9)(A)'' after ``adolescents'';
(3) in subsection(c)(1), by inserting ``youth at risk of
becoming victims of sex trafficking (as defined in section
103(10) of the Trafficking Victims Protection Act of 2000 (22
U.S.C. 7102(10))) or victims of a severe form of trafficking in
persons described in paragraph (9)(A) of that Act (22 U.S.C.
7102(9)(A),'' after ``youth in foster care,''; and
(4) in subsection (f), by striking ``2010 through 2014''
and inserting ``2015 through 2019''.
(b) Effective Date.--The amendments made by this section shall take
effect on October 1, 2014.
SEC. 223. FAMILY-TO-FAMILY HEALTH INFORMATION CENTERS.
(a) In General.--Section 501(c) of the Social Security Act (42
U.S.C. 701(c)) is amended--
(1) in paragraph (1)(A), by striking clause (iv) and
inserting the following:
``(iv) $6,000,000 for each of fiscal years
2014 through 2018.''; and
(2) by striking paragraph (5).
(b) Prevention of Duplicate Appropriations for Fiscal Year 2014.--
Expenditures made for fiscal year 2014 pursuant to section 501(c)(iv)
of the Social Security Act (42 U.S.C. 701(c)(iv)), as amended by
section 1203 of division B of the Bipartisan Budget Act of 2013 (Public
Law 113-67), shall be charged to the appropriation for that fiscal year
provided by the amendments made by this section.
SEC. 224. HEALTH WORKFORCE DEMONSTRATION PROJECT FOR LOW-INCOME
INDIVIDUALS.
Section 2008(c)(1) of the Social Security Act (42 U.S.C.
1397g(c)(1)) is amended by striking `` through 2014'' and inserting
``2012, and only to carry out subsection (a), $85,000,000 for each of
fiscal years 2013 through 2016''.
TITLE III--MEDICARE AND MEDICAID PROGRAM INTEGRITY
SEC. 301. 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 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 (3). The activities
described in the preceding sentence shall be conducted on a
regular basis.
``(2) Forms of outreach, education, training, and technical
assistance activities.--The outreach, education, training, and
technical assistance activities under a payment outreach and
education program shall be carried out through any of the
following:
``(A) Emails and other electronic communications.
``(B) Webinars.
``(C) Telephone calls.
``(D) In-person training.
``(E) Other forms of communications determined
appropriate by the Secretary.
``(3) Information to be provided through activities.--The
information to be provided to providers of services and
suppliers under a payment outreach and education program shall
include all of the following information:
``(A) A list of the provider's or supplier's 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 all 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.
``(4) Error rate reduction training.--
``(A) In general.--The activities under a payment
outreach and education program shall include error rate
reduction training.
``(B) Requirements.--
``(i) In general.--The training described
in subparagraph (A) shall--
``(I) be provided at least
annually; and
``(II) focus on reducing the
improper payments described in
paragraph (5).
``(C) Invitation.--A medicare administrative
contractor shall ensure that all providers of services
and suppliers located in the region covered by the
contract under this section are invited to attend the
training described in subparagraph (A) either in person
or online.
``(5) Priority.--A medicare administrative contractor shall
give priority to activities under the improper payment outreach
and education program that will reduce improper payments for
items and services that--
``(A) have the highest rate of improper payment;
``(B) 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; or
``(E) are due to other types of errors that the
Secretary determines could be prevented through
activities under the program.
``(6) 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
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 quarterly basis.
``(B) Information.--The information described in
subparagraph (A) shall include the following
information:
``(i) The providers of services and
suppliers that have the highest rate of
improper payments.
``(ii) The providers of services and
suppliers that have the greatest total dollar
amounts of improper payments.
``(iii) The items and services furnished in
the region that have the highest rates of
improper payments.
``(iv) The 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 improper payment outreach and
education program.
``(C) Format of information.--The information
furnished to medicare administrative contractors by the
Secretary under this paragraph shall be transmitted in
a manner that permits the contractor to easily identify
the areas of the Medicare program in which targeted
outreach, education, training, and technical assistance
would be most effective. In carrying out the preceding
sentence, the Secretary shall ensure that--
``(i) the information with respect to
improper payments made to a provider of
services or supplier clearly displays the name
and address of the provider or supplier, the
amount of the improper payment, and any other
information the Secretary determines
appropriate; and
``(ii) the information is in an electronic,
easily searchable database.
``(7) Communications.--All communications with providers of
services and suppliers under a payment outreach and education
program are subject to the standards and requirements of
subsection (g).
``(8) Funding.--After application of paragraph (1)(C) of
section 1893(h), the Secretary shall retain a portion of the
amounts recovered by recovery audit contractors under such
section which shall be available to the program management
account of the Centers for Medicare & Medicaid Services for
purposes of carrying out this subsection and to implement
corrective actions to help reduce the error rate of payments
under this title. The amount retained under the preceding
sentence shall not exceed an amount equal to 25 percent of the
amounts recovered under section 1893(h).''.
(2) Funding conforming amendment.--Section 1893(h)(2) of
the Social Security Act (42 U.S.C. 1395ddd(h)(2)) is amended by
inserting ``or section 1874(h)(8)'' after ``paragraph (1)(C)''.
(3) Effective date.--The amendments made by this subsection
take effect on January 1, 2015.
(b) Transparency.--Section 1893(h)(8) of the Social Security Act
(42 U.S.C. 1395ddd(h)(8)) is amended--
(1) by striking ``report.--The Secretary'' and inserting
``report.--
``(A) In general.--The Secretary''; and
(2) by adding at the end the following new subparagraph:
``(B) Inclusion of certain information.--
``(i) In general.--For reports submitted
under this paragraph for 2015 or a subsequent
year, each such report shall include the
information described in clause (ii) with
respect to each of the following categories of
audits carried out by recovery audit
contractors under this subsection:
``(I) Automated.
``(II) Complex.
``(III) Medical necessity review.
``(IV) Part A.
``(V) Part B.
``(VI) Durable medical equipment.
``(ii) Information described.--For purposes
of clause (i), the information described in
this clause, with respect to a category of
audit described in clause (i), is the result of
all appeals for each individual level of
appeals in such category.''.
(c) Recovery Audit Contractor Demonstration Project.--
(1) In general.--The Secretary shall conduct a
demonstration project under title XVIII of the Social Security
Act that--
(A) targets audits by recovery audit contractors
under section 1893(h) of the Social Security Act (42
U.S.C. 1395ddd(h)) with respect to high error providers
of services and suppliers identified under paragraph
(3); and
(B) rewards low error providers of services and
suppliers identified under such paragraph.
(2) Scope.--
(A) Duration.--The demonstration project shall be
implemented not later than January 1, 2015, and shall
be conducted for a period of three years.
(B) Demonstration area.--In determining the
geographic area of the demonstration project, the
Secretary shall consider the following:
(i) The total number of providers of
services and suppliers in the region.
(ii) The diversity of types of providers of
services and suppliers in the region.
(iii) The level and variation of improper
payment rates of and among individual providers
of services and suppliers in the region.
(iv) The inclusion of a mix of both urban
and rural areas.
(3) Identification of low error and high error providers of
services and suppliers.--
(A) In general.--In conducting the demonstration
project, the Secretary shall identify the following two
groups of providers in accordance with this paragraph:
(i) Low error providers of services and
suppliers.
(ii) High error providers of services and
suppliers.
(B) Analysis.--For purposes of identifying the
groups under subparagraph (A), the Secretary shall
analyze the following as they relate to the total
number and amount of claims submitted in the area and
by each provider:
(i) The improper payment rates of
individual providers of services and suppliers.
(ii) The amount of improper payments made
to individual providers of services and
suppliers.
(iii) The frequency of errors made by the
provider of services or supplier over time.
(iv) Other information determined
appropriate by the Secretary.
(C) Assignment based on composite score.--The
Secretary shall assign selected providers of services
and suppliers under the demonstration program based on
a composite score determined using the analysis under
subparagraph (B) as follows:
(i) Providers of services and suppliers
with high, expensive, and frequent errors shall
receive a high score and be identified as high
error providers of services and suppliers under
subparagraph (A).
(ii) Providers of services and suppliers
with few, inexpensive, and infrequent errors
shall receive a low score and be identified as
low error providers of services and suppliers
under such subparagraph.
(iii) Only a small proportion of the total
providers of services and suppliers and
individual types of providers of services and
suppliers in the geographic area of the
demonstration project shall be assigned to
either group identified under such
subparagraph.
(D) Timeframe of identification.--
(i) In general.--Any identification of a
provider of services or a supplier under
subparagraph (A) shall be for a period of 12
months.
(ii) Reevaluation.--The Secretary shall
reevaluate each such identification at the end
of such period.
(iii) Use of most current information.--In
carrying out the reevaluation under clause (ii)
with respect to a provider of services or
supplier, the Secretary shall--
(I) consider the most current
information available with respect to
the provider of services or supplier
under the analysis under subparagraph
(B); and
(II) take into account improvement
or regression of the provider of
services or supplier.
(4) Adjustment of record request maximum.--Under the
demonstration project, the Secretary shall establish procedures
to--
(A) increase the maximum record request made by
recovery audit contractors to providers of services and
suppliers identified as high error providers of
services and suppliers under paragraph (3); and
(B) decrease the maximum record request made by
recovery audit contractors to providers of services and
suppliers identified as low error providers of services
and supplier under such paragraph.
(5) Additional adjustments.--
(A) In general.--Under the demonstration project,
the Secretary may make additional adjustments to
requirements for recovery audit contractors under
section 1893(h) of the Social Security Act (42 U.S.C.
1395ddd(h)) and the conduct of audits with respect to
low error providers of services and suppliers
identified under paragraph (3) and high error providers
of services and suppliers identified under such
paragraph as the Secretary determines necessary in
order to incentivize reductions in improper payment
rates under title XVIII of such Act (42 U.S.C. 1395 et
seq.).
(B) Limitation.--The Secretary shall not exempt any
group of providers of services or suppliers in the
demonstration project from being subject to audit by a
recovery audit contractor under such section 1893(h).
(6) Evaluation and report.--
(A) Evaluation.--The Inspector General of the
Department of Health and Human Services shall conduct
an evaluation of the demonstration project under this
subsection. The evaluation shall include an analysis
of--
(i) the error rates of providers of
services and suppliers--
(I) identified under paragraph (3)
as low error providers of services and
suppliers;
(II) identified under such
paragraph as high error providers of
services and suppliers; and
(III) that are located in the
geographic area of the demonstration
project and are not identified as
either a low error or high error
provider of services or supplier under
such paragraph; and
(ii) any improvements in the error rates of
those high error providers of services and
suppliers identified under such paragraph.
(B) Report.--Not later than 12 months after
completion of the demonstration project, the Inspector
General shall submit to Congress a report containing
the results of the evaluation conducted under
subparagraph (A), together with recommendations on
whether the demonstration project should be continued
or expanded, including on a permanent or nationwide
basis.
(7) Funding.--
(A) Funding for implementation.--For purposes of
carrying out the demonstration project under this
subsection (other than the evaluation and report under
paragraph (6)), the Secretary shall provide for the
transfer, from the Federal Hospital Insurance Trust
Fund under section 1817 (42 U.S.C. 1395i) and the
Federal Supplementary Medical Insurance Trust Fund
under section 1841 (42 U.S.C. 1395t), in such
proportion as the Secretary determines appropriate, of
$10,000,000 to the Centers for Medicare & Medicaid
Services Program Management Account.
(B) Funding for inspector general evaluation and
report.--For purposes of carrying out the evaluation
and report under paragraph (6), the Secretary shall
provide for the transfer, from the Federal Hospital
Insurance Trust Fund under such section 1817 and the
Federal Supplementary Medical Insurance Trust Fund
under such section 1841, in such proportion as the
Secretary determines appropriate, of $245,000 to the
Inspector General of the Department of Health and Human
Services.
(C) Availability.--Amounts transferred under
subparagraph (A) or (B) shall remain available until
expended.
(8) Definitions.--In this section:
(A) Demonstration project.--The term
``demonstration project'' means the demonstration
project under this subsection.
(B) Provider of services.--The term ``provider of
services'' has the meaning given that term in section
1861(u).
(C) Recovery audit contractor.--The term ``recovery
audit contractor'' means an entity with a contract
under section 1893(h) of the Social Security Act (42
U.S.C. 1395ddd(h)).
(D) Secretary.--The term ``Secretary'' means the
Secretary of Health and Human Services.
(E) Supplier.--The term ``supplier'' has the
meaning given that term in section 1861(d).
SEC. 302. AUTHORITY FOR MEDICAID FRAUD CONTROL UNITS TO INVESTIGATE AND
PROSECUTE COMPLAINTS OF ABUSE AND NEGLECT OF MEDICAID
PATIENTS IN HOME AND COMMUNITY-BASED SETTINGS.
(a) In General.--Section 1903(q)(4)(A) of the Social Security Act
(42 U.S.C. 1396b(q)(4)(A)) is amended to read as follows:
``(4)(A) The entity's function includes a statewide program
for the--
``(i) investigation and prosecution, or referral
for prosecution or other action, of complaints of abuse
or neglect of patients in health care facilities which
receive payments under the State plan under this title
or under a waiver of such plan;
``(ii) at the option of the entity, investigation
and prosecution, or referral for prosecution or other
action, of complaints of abuse or neglect of
individuals in connection with any aspect of the
provision of medical assistance and the activities of
providers of such assistance in a home or community
based setting that is paid for under the State plan
under this title or under a waiver of such plan; and
``(iii) at the option of the entity, investigation
and prosecution, or referral for prosecution or other
action, of complaints of abuse or neglect of patients
residing in board and care facilities.''.
(b) Effective Date.--The amendment made by subsection (a) shall
take effect on January 1, 2015.
SEC. 303. IMPROVED USE OF FUNDS RECEIVED BY THE HHS INSPECTOR GENERAL
FROM OVERSIGHT AND INVESTIGATIVE ACTIVITIES.
(a) In General.--Section 1128C(b) of the Social Security Act (42
U.S.C. 1320a-7c(b)) is amended to read as follows:
``(b) Additional Use of Funds by Inspector General.--
``(1) Collections from medicare and medicaid recovery
actions.--Notwithstanding section 3302 of title 31, United
States Code, or any other provision of law affecting the
crediting of collections, the Inspector General of the
Department of Health and Human Services may receive and retain
for current use three percent of all amounts collected pursuant
to civil debt collection and administrative enforcement actions
related to false claims or frauds involving the Medicare
program under title XVIII or the Medicaid program under title
XIX.
``(2) Crediting.--Funds received by the Inspector General
under paragraph (1) shall be deposited as offsetting
collections to the credit of any appropriation available for
oversight and enforcement activities of the Inspector General
permitted under subsection (a), and shall remain available
until expended.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to funds received from settlements finalized, judgments entered,
or final agency decisions issued, on or after the date of the enactment
of this Act.
SEC. 304. PREVENTING AND REDUCING IMPROPER MEDICARE AND MEDICAID
EXPENDITURES.
(a) 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 2015 and
subsequent plan years, subject to subparagraph (B), the
Secretary shall prohibit PDP sponsors of prescription
drug plans from paying claims for prescription drugs
under this part that do not include a valid prescriber
National Provider Identifier.
``(B) Procedures.--The Secretary shall establish
procedures for determining the validity of prescriber
National Provider Identifiers under subparagraph (A).
``(C) Report.--Not later than January 1, 2017, 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).''.
(b) Reforming How CMS Tracks and Corrects the Vulnerabilities
Identified by Recovery Audit Contractors.--Section 1893(h) of the
Social Security Act (42 U.S.C. 1395ddd(h)) is amended--
(1) in paragraph (8), as amended by section 301, by adding
at the end the following new subparagraphs:
``(C) Inclusion of improper payment vulnerabilities
identified.--For reports submitted under this paragraph
for 2015 or a subsequent year, each such report shall
include--
``(i) a description of--
``(I) the types and financial cost
to the program under this title of
improper payment vulnerabilities
identified by recovery audit
contractors under this subsection; and
``(II) how the Secretary is
addressing such improper payment
vulnerabilities; and
``(ii) an assessment of the effectiveness
of changes made to payment policies and
procedures under this title in order to address
the vulnerabilities so identified.
``(D) Limitation.--The Secretary shall ensure that
each report submitted under subparagraph (A) does not
include information that the Secretary determines would
be sensitive or would otherwise negatively impact
program integrity.''; and
(2) by adding at the end the following new paragraph:
``(10) Addressing improper payment vulnerabilities.--The
Secretary shall address improper payment vulnerabilities
identified by recovery audit contractors under this subsection
in a timely manner, prioritized based on the risk to the
program under this title.''.
(c) Strengthening Medicaid Program Integrity Through Flexibility.--
Section 1936 of the Social Security Act (42 U.S.C. 1396u-6) is
amended--
(1) in subsection (a), by inserting ``, or otherwise,''
after ``entities''; and
(2) in subsection (e)--
(A) in paragraph (1), in the matter preceding
subparagraph (A), by inserting ``(including the costs
of equipment, salaries and benefits, and travel and
training)'' after ``Program under this section''; and
(B) in paragraph (3), by striking ``by 100'' and
inserting ``by 100, or such number as determined
necessary by the Secretary to carry out the Program
under this section,''.
(d) Access to the National Directory of New Hires.--Section 453(j)
of the Social Security Act (42 U.S.C. 653(j)) is amended by adding at
the end the following new paragraph:
``(12) Information comparisons and disclosures to assist in
administration of the medicare program and state health subsidy
programs.--
``(A) Disclosure to the administrator of the
centers for medicare & medicaid services.--The
Administrator of the Centers for Medicare & Medicaid
shall have access to the information in the National
Directory of New Hires for purposes of determining the
eligibility of an applicant for, or enrollee in, the
Medicare program under title XVIII or an applicable
State health subsidy program (as defined in section
1413(e) of the Patient Protection and Affordable Care
Act (42 U.S.C. 18083(e)).
``(B) Disclosure to the inspector general of the
department of health and human services.--
``(i) In general.--If the Inspector General
of the Department of Health and Human Services
transmits to the Secretary the names and social
security account numbers of individuals, the
Secretary shall disclose to the Inspector
General information on such individuals and
their employers maintained in the National
Directory of New Hires.
``(ii) Use of information.--The Inspector
General of the Department of Health and Human
Services may use information provided under
clause (i) only for purposes of --
``(I) enforcing mandatory and
permissive exclusions under title XI;
or
``(II) evaluating the integrity of
the Medicare program or an applicable
State health subsidy program (as
defined in section 1413(e) of the
Patient Protection and Affordable Care
Act).
The authority under this clause is in addition
to any authority conferred under the Inspector
General Act of 1978 (5 U.S.C. App).
``(C) Disclosure to state agencies.--
``(i) In general.--If, for purposes of
determining the eligibility of an applicant
for, or an enrollee in, an applicable State
health subsidy program (as defined in section
1413(e) of the Patient Protection and
Affordable Care Act (42 U.S.C. 18083(e)), a
State agency responsible for administering such
program transmits to the Secretary the names,
dates of birth, and social security account
numbers of individuals, the Secretary shall
disclose to such State agency information on
such individuals and their employers maintained
in the National Directory of New Hires, subject
to this subparagraph.
``(ii) Condition on disclosure by the
secretary.--The Secretary shall make a
disclosure under clause (i) only to the extent
that the Secretary determines that the
disclosure would not interfere with the
effective operation of the program under this
part.
``(iii) Use and disclosure of information
by state agencies.--
``(I) In general.--A State agency
may not use or disclose information
provided under clause (i) except for
purposes of determining the eligibility
of an applicant for, or an enrollee in,
a program referred to in clause (i).
``(II) Information security.--The
State agency shall have in effect data
security and control policies that the
Secretary finds adequate to ensure the
security of information obtained under
clause (i) and to ensure that access to
such information is restricted to
authorized persons for purposes of
authorized uses and disclosures.
``(III) Penalty for misuse of
information.--An officer or employee of
the State agency who fails to comply
with this clause shall be subject to
the sanctions under subsection (l)(2)
to the same extent as if such officer
or employee were an officer or employee
of the United States.
``(iv) Procedural requirements.--State
agencies requesting information under clause
(i) shall adhere to uniform procedures
established by the Secretary governing
information requests and data matching under
this paragraph.
``(v) Reimbursement of costs.--The State
agency shall reimburse the Secretary, in
accordance with subsection (k)(3), for the
costs incurred by the Secretary in furnishing
the information requested under this
subparagraph.''.
(e) Improving the Sharing of Data Between the Federal Government
and State Medicaid Programs.--
(1) In general.--The Secretary of Health and Human Services
(in this subsection referred to as the ``Secretary'') shall
establish a plan to encourage and facilitate the participation
of States in the Medicare-Medicaid Data Match Program (commonly
referred to as the ``Medi-Medi Program'') under section 1893(g)
of the Social Security Act (42 U.S.C. 1395ddd(g)).
(2) Program revisions to improve medi-medi data match
program participation by states.--Section 1893(g)(1)(A) of the
Social Security Act (42 U.S.C. 1395ddd(g)(1)(A)) is amended--
(A) in the matter preceding clause (i), by
inserting ``or otherwise'' after ``eligible entities'';
(B) in clause (i)--
(i) by inserting ``to review claims data''
after ``algorithms''; and
(ii) by striking ``service, time, or
patient'' and inserting ``provider, service,
time, or patient'';
(C) in clause (ii)--
(i) by inserting ``to investigate and
recover amounts with respect to suspect
claims'' after ``appropriate actions''; and
(ii) by striking ``; and'' and inserting a
semicolon;
(D) in clause (iii), by striking the period and
inserting ``; and''; and
(E) by adding at end the following new clause:
``(iv) furthering the Secretary's design,
development, installation, or enhancement of an
automated data system architecture--
``(I) to collect, integrate, and
assess data for purposes of program
integrity, program oversight, and
administration, including the Medi-Medi
Program; and
``(II) that improves the
coordination of requests for data from
States.''.
(3) Providing states with data on improper payments made
for items or services provided to dual eligible individuals.--
(A) In general.--The Secretary shall develop and
implement a plan that allows each State agency
responsible for administering a State plan for medical
assistance under title XIX of the Social Security Act
access to relevant data on improper or fraudulent
payments made under the Medicare program under title
XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.) for health care items or services provided to
dual eligible individuals.
(B) Dual eligible individual defined.--In this
paragraph, the term ``dual eligible individual'' means
an individual who is entitled to, or enrolled for,
benefits under part A of title XVIII of the Social
Security Act (42 U.S.C. 1395c et seq.), or enrolled for
benefits under part B of title XVIII of such Act (42
U.S.C. 1395j et seq.), and is eligible for medical
assistance under a State plan under title XIX of such
Act (42 U.S.C. 1396 et seq.) or under a waiver of such
plan.
TITLE IV--OTHER PROVISIONS
SEC. 401. COMMISSION ON IMPROVING PATIENT DIRECTED HEALTH CARE.
(a) Findings.--Congress finds the following:
(1) In order to elevate the role of patient choices in the
health care system, the American public must engage in an
informed, national, public debate on how the current health
care system empowers and informs health care decision-making,
and what can be done to improve the likelihood patients receive
the care they want and need.
(2) Research suggests that patients often do not receive
the care they want. As a result, the end of life is associated
with a substantial burden of suffering by the patient and
negative health and financial consequences that extend to
family members and society.
(3) Patients face a complex and fragmented health care
system that may decrease the likelihood that health care
choices are known and carried out. The health care system
should embed principles that take into account patient wishes.
(4) Decisions concerning health care, including end-of-life
issues, affect an increasing number of Americans.
(5) Medical advances are prolonging life expectancy in the
United States both in acute life-threatening situations and
protracted battles with illness. These advances raise new
challenges surrounding health care decision-making.
(6) The United States health care system should promote
consideration of a person's preference in health care decision-
making and end-of-life choices.
(b) Commission.--The Social Security Act is amended by inserting
after section 1150B (42 U.S.C. 1320b-24) the following new section:
``SEC. 1150C. COMMISSION ON IMPROVING PATIENT DIRECTED HEALTH CARE.
``(a) Purposes.--The purposes of this section are to--
``(1) provide a forum for a nationwide public debate on
improving patient self-determination in health care decision-
making;
``(2) identify strategies that ensure every American has
the health care they want; and
``(3) provide recommendations to Congress that result from
the debate.
``(b) Establishment.--The Secretary shall establish an entity to be
known as the Commission on Improving Patient Directed Health Care
(referred to in this section as the `Commission').
``(c) Membership.--
``(1) Number and appointment.--The Commission shall be
composed of 15 members. One member shall be the Secretary. The
Comptroller General of the United States shall appoint 14
members.
``(2) Qualifications.--The membership of the Commission
shall include--
``(A) health care consumers impacted by decision-
making in advance of a health care crisis, such as
individuals of advanced age, individuals with chronic,
terminal and mental illnesses, family care givers, and
individuals with disabilities;
``(B) providers in settings where crucial health
care decision-making occurs, such as those working in
intensive care settings, emergency room departments,
primary care settings, nursing homes, hospice, or
palliative care settings;
``(C) payors ensuring patients get the level of
care they want;
``(D) experts in advance care planning, hospice,
palliative care, information technology, bioethics,
aging policy, disability policy, pediatric ethics,
cultural sensitivity, psychology, and health care
financing;
``(E) individuals who represent culturally diverse
perspectives on patient self-determination and end-of-
life issues; and
``(F) members of the faith community.
``(d) Period of Appointment.--Members of the Commission shall be
appointed for the life of the Commission. Any vacancies shall not
affect the power and duties of the Commission but shall be filled in
the same manner as the original appointment.
``(e) Designation of the Chairperson.--Not later than 15 days after
the date on which all members of the Commission have been appointed,
the Comptroller General shall designate the chairperson of the
Commission.
``(f) Subcommittees.--The Commission may establish subcommittees if
doing so increases the efficiency of the Commission in completing
tasks.
``(g) Duties.--
``(1) Hearings.--Not later than 90 days after the date of
designation of the chairperson under subsection (e), the
Commission shall hold no fewer than 8 hearings to examine--
``(A) the current state of health care decision-
making and advance care planning laws in the United
States at the Federal level and across the States, as
well as options for improving advance care planning
tools, especially with regard to use, portability, and
storage;
``(B) consumer-focused approaches that educate the
American public about patient choices, care planning,
and other end-of-life issues;
``(C) the use of comprehensive, patient-centered
care plans by providers, the impact care plans have on
health care delivery and spending, and methods to
expand the use of high quality care planning tools in
both public and private health care systems;
``(D) the role of electronic medical records and
other technologies in improving patient-directed health
care;
``(E) innovative tools for improving patient
experience with advanced illness, such as palliative
care, hospice, and other models;
``(F) the role social determinants of health, such
as socio-economic status, play in patient self-
direction in health care;
``(G) the use of culturally-competent tools for
health care decision-making;
``(H) strategies for educating providers and
increasing provider engagement on care planning,
palliative care, hospice care, and other issues
surrounding honoring patient choices;
``(I) the sociological and psychological factors
that influence health care decision-making and end-of-
life choices; and
``(J) the role of spirituality and religion in
patient self-determination in health care.
``(2) Additional hearings.--The Commission may hold
additional hearings on subjects other than those listed in
paragraph (1) so long as such hearings are determined necessary
by the Commission in carrying out the purposes of this section.
Such additional hearings do not have to be completed within the
time period specified but shall not delay the other activities
of the Commission under this section.
``(3) Number and location of hearings and additional
hearings.--The Commission shall hold no fewer than 8 hearings
as indicated in paragraph (1) and in sufficient number in order
to receive information that reflects--
``(A) the geographic differences throughout the
United States;
``(B) diverse populations; and
``(C) a balance among urban and rural populations.
``(4) Interactive technology.--The Commission may encourage
public participation in hearings through interactive technology
and other means as determined appropriate by the Commission.
``(5) Report to the american people on patient directed
health care.--Not later than 90 days after the hearings
described in paragraphs (1) and (2) are completed, the
Commission shall prepare and make available to health care
consumers through the Internet and other appropriate public
channels, a report to be entitled, `Report to the American
People on Patient Directed Health Care'. Such a report shall be
understandable to the general public and include--
``(A) a summary of--
``(i) the hearings described in such
paragraphs;
``(ii) how the current health care system
empowers and informs decision-making in advance
of a health care crisis;
``(iii) factors that contribute to the
provision of health care that does not adhere
to patient wishes;
``(iv) the impact of care that does not
follow patient choices, particularly at the
end-of-life, on patients, families, providers,
spending, and the health care system;
``(v) the laws surrounding advance care
planning and health care decision-making
including issues of portability, use, and
storage;
``(vi) consumer-focused approaches to
education of the American public about patient
choices, care planning, and other end-of-life
issues;
``(vii) the role of care plans in health
care decision-making;
``(viii) the role of providers in ensuring
patients receive the care they want;
``(ix) the role of electronic medical
records and other technologies in improving
patient directed health care;
``(x) the impact of social determinants on
patient self-direction in health care services;
``(xi) the use of culturally competent
methods for health care decision-making;
``(xii) the sociological and psychological
factors that influence patient self-
determination; and
``(xiii) the role of spirituality and
religion in health care decision-making and
end-of-life care;
``(B) best practices from communities, providers,
and payors that document patient wishes and provide
health care that adheres to those wishes; and
``(C) information on educating providers about
health care decision-making and end-of-life issues.
``(6) Interim requirements.--Not later than 180 days after
the date of completion of the hearings, the Commission shall
prepare and make available to the public through the Internet
and other appropriate public channels, an interim set of
recommendations on patient self-determination in health care
and ways to improve and strengthen the health care system based
on the information and preferences expressed at the community
meetings. There shall be a 90-day public comment period on such
recommendations.
``(h) Recommendations.--Not later than 120 days after the
expiration of the public comment period described in subsection (g)(6),
the Commission shall submit to Congress and the President a final set
of recommendations. The recommendations must be comprehensive and
detailed. The recommendations must contain recommendations or proposals
for legislative or administrative action as the Commission deems
appropriate, including proposed legislative language to carry out the
recommendations or proposals.
``(i) Administration.--
``(1) Executive director.--There shall be an Executive
Director of the Commission who shall be appointed by the
chairperson of the Commission in consultation with the members
of the Commission.
``(2) Compensation.--While serving on the business of the
Commission (including travel time), a member of the Commission
shall be entitled to compensation at the per diem equivalent of
the rate provided for level IV of the Executive Schedule under
section 5315 of title 5, United States Code, and while so
serving away from home and the member's regular place of
business, a member may be allowed travel expenses, as
authorized by the chairperson of the Commission. For purposes
of pay and employment benefits, rights, and privileges, all
personnel of the Commission shall be treated as if they were
employees of the Senate.
``(3) Information from federal agencies.--The Commission
may secure directly from any Federal department or agency such
information as the Commission considers necessary to carry out
this section. Upon request of the Commission the head of such
department or agency shall furnish such information.
``(4) Postal services.--The Commission may use the United
States mails in the same manner and under the same conditions
as other departments and agencies of the Federal Government.
``(j) Detail.--Not more than 4 Federal Government employees
employed by the Department of Labor, 4 Federal Government employees
employed by the Social Security Administration, and 8 Federal
Government employees employed by the Department of Health and Human
Services may be detailed to the Commission under this section without
further reimbursement. Any detail of an employee shall be without
interruption or loss of civil service status or privilege.
``(k) Temporary and Intermittent Services.--The chairperson of the
Commission may procure temporary and intermittent services under
section 3109(b) of title 5, United States Code, at rates for
individuals which do not exceed the daily equivalent of the annual rate
of basic pay prescribed for level V of the Executive Schedule under
section 5316 of such title.
``(l) Annual Report.--Not later than 1 year after the date of
enactment of this Act, and annually thereafter during the existence of
the Commission, the Commission shall report to Congress and make public
a detailed description of the expenditures of the Commission used to
carry out its duties under this section.
``(m) Sunset of Commission.--The Commission shall terminate on the
date that is 3 years after the date on which all the members of the
Commission have been appointed under subsection (c)(1) and
appropriations are first made available to carry out this section.
``(n) Administration Review and Comments.--Not later than 45 days
after receiving the final recommendations of the Commission under
subsection (h), the President shall submit a report to Congress which
shall contain--
``(1) additional views and comments on such
recommendations; and
``(2) recommendations for such legislation and
administrative action as the President considers appropriate.
``(o) Authorization of Appropriations.--
``(1) In general.--There are authorized to be appropriated
to carry out this section, $3,000,000 for each of fiscal years
2014 and 2015.
``(2) Report to the american people on patient directed
health care.--There are authorized to be appropriated for the
preparation and dissemination of the Report to the American
People on Patient Directed Health Care described in subsection
(g)(5), $1,000,000 for the fiscal year in which the report is
required to be submitted.''.
SEC. 402. EXPANSION OF THE DEFINITION OF INPATIENT HOSPITAL SERVICES
FOR CERTAIN CANCER HOSPITALS.
Section 1861(b) of the Social Security Act (42 U.S.C. 1395x(b)) is
amended--
(1) in paragraph (3)--
(A) by inserting ``(a)'' after ``(3)'';
(B) by adding ``and'' after the semicolon at the
end; and
(C) by adding at the end the following new
subparagraph:
``(B) subject to the third sentence of this
subsection, with respect to a hospital that--
``(i) is described in section
1886(d)(1)(B)(v); and
``(ii) as of the date of the enactment of
the Responsible Medicare SGR Repeal and
Beneficiary Access Improvement Act of 2014, is
located in the same building, or on the same
campus, as another hospital (as described in
sections 412.22(e) and 412.22(f) of title 42,
Code of Federal Regulations, as in effect on
such date of enactment );
items and services described in paragraphs (1) and (2)
furnished on or after October 1, 2014, by such hospital
described in section 1886(d)(1)(B)(v) or by others
under arrangements with them made by the hospital;'';
and
(2) by adding at the end the following new flush sentence:
``Paragraph (3)(B) shall only apply to payments with respect to the
total number of the hospital's patient days at any satellite of the
hospital or such days at another hospital providing services under
arrangements to the hospital, determined as of the date of the
enactment of the Responsible Medicare SGR Repeal and Beneficiary Access
Improvement Act of 2014.''.
SEC. 403. QUALITY MEASURES FOR CERTAIN POST-ACUTE CARE PROVIDERS
RELATING TO NOTICE AND TRANSFER OF PATIENT HEALTH
INFORMATION AND PATIENT CARE PREFERENCES.
(a) Development.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') shall provide for the
development of one or more quality measures under title XVIII of the
Social Security Act (42 U.S.C. 1395 et seq.) to accurately communicate
the existence and provide for the transfer of patient health
information and patient care preferences when an individual transitions
from a hospital to return home or move to other post-acute care
settings.
(b) Use of Measure Developers.--The Secretary shall arrange for the
development of such measures by appropriate measure developers.
(c) Endorsement.--The Secretary shall arrange for such developed
measures to be submitted for endorsement to a consensus-based entity as
described in section 1890(a) of the Social Security Act (42 U.S.C.
1395aaa(a)).
(d) Use of Measures.--The Secretary shall, through notice and
comment rulemaking, use such measures under the quality reporting
programs with respect to--
(1) inpatient hospitals under section 1886(b)(3)(B)(viii)
of the Social Security Act (42 U.S.C. 1395ww(b)(3)(B)(viii));
(2) skilled nursing facilities under section 1888(e) of
such Act (42 U.S.C. 1395yy(e));
(3) home health services under section 1895(b)(3)(B)(v) of
such Act (42 U.S.C. 1395fff(b)(3)(B)(v)); and
(4) other providers of services (as defined in section
1861(u) of such Act) and suppliers (as defined in section
1861(d) of such Act) that the Secretary determines appropriate.
SEC. 404. CRITERIA FOR MEDICALLY NECESSARY, SHORT INPATIENT HOSPITAL
STAYS.
(a) In General.--The Secretary of Health and Human Services shall
consult with, and seek input from, interested stakeholders to determine
appropriate criteria for payment under the Medicare program under title
XVIII of the Social Security Act of an inpatient hospital admission
that--
(1) is medically necessary; and
(2) is an inpatient hospital stay that is less than two
midnights, as described in section 412.3 of title 42, Code of
Federal Regulation, as finalized in the final rule published by
the Centers for Medicare & Medicaid Services in the Federal
Register on August 19, 2013 (78 Federal Register 50496)
entitled ``Medicare Program; Hospital Inpatient Prospective
Payment Systems for Acute Care Hospitals and the Long-Term Care
Hospital Prospective Payment System and Fiscal Year 2014 Rates;
Quality Reporting Requirements for Specific Providers; Hospital
Conditions of Participation; Payment Policies Related to
Patient Status''.
(b) Interested Stakeholders.--In subsection (a), the term
``interested stakeholders'' means the following:
(1) Hospitals.
(2) Physicians
(3) Medicare administrative contractors under section 1874A
of the Social Security Act (42 U.S.C. 1395kk-1).
(4) Recovery audit contractors under section 1893(h) of
such Act (42 U.S.C. 1395ddd(h)).
(5) Other parties determined appropriate by the Secretary.
SEC. 405. TRANSPARENCY OF REASONS FOR EXCLUDING ADDITIONAL PROCEDURES
FROM THE MEDICARE AMBULATORY SURGICAL CENTER (ASC)
APPROVED LIST.
Section 1833(i)(1) of the Social Security Act (42 U.S.C.
1395l(i)(1)) is amended by adding at the end the following: ``In
updating such lists for application in years beginning after December
31, 2014, for each procedure that was not proposed but was requested to
be included on such lists during the public comment where the Secretary
does not finalize (in the final rule updating such lists) to so
include, the Secretary shall describe in such final rule the specific
safety criteria for not including such requested procedure on such
lists.''.
SEC. 406. SUPERVISION IN CRITICAL ACCESS HOSPITALS.
(a) General Supervision in Critical Access Hospitals.--Section
1834(g) of the Social Security Act (42 U.S.C. 1395m(g)) is amended by
adding at the end the following new paragraph:
``(6) Supervision.--In the case of services furnished on or
after the date of the enactment of this paragraph, the minimum
level of supervision with respect to outpatient therapeutic
critical access hospital services shall be general supervision
(as defined by the Secretary).''.
(b) Supervision of Cardiac and Pulmonary Rehabilitation Programs in
Critical Access Hospitals.--Section 1861(eee)(2)(B) of the Social
Security Act (42 U.S.C. 1395x(eee)(2)(B)) is amended by inserting ``,
or in the case of a critical access hospital, a physician, or
(beginning on the date of enactment of Responsible Medicare SGR Repeal
and Beneficiary Access Improvement Act of 2014) a nurse practitioner,
clinical nurse specialist, or physician assistant (as such terms are
defined in subsection (aa)(5)),'' after ``a physician''.
SEC. 407. REQUIRING STATE LICENSURE OF BIDDING ENTITIES UNDER THE
COMPETITIVE ACQUISITION PROGRAM FOR CERTAIN DURABLE
MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES
(DMEPOS).
Section 1847(a)(1) of the Social Security Act (42 U.S.C. 1395w-
3(a)(1)) is amended by adding at the end the following new
subparagraph:
``(G) Requiring state licensure of bidding
entities.--With respect to rounds of competitions
beginning on or after the date of enactment of this
subparagraph, the Secretary may only accept a bid from
an entity for an area if the entity meets applicable
State licensure requirements for such area for all
items in such bid for a product category.''.
SEC. 408. RECOGNITION OF ATTENDING PHYSICIAN ASSISTANTS AS ATTENDING
PHYSICIANS TO SERVE HOSPICE PATIENTS.
(a) Recognition of Attending Physician Assistants as Attending
Physicians To Serve Hospice Patients.--
(1) In general.--Section 1861(dd)(3)(B) of the Social
Security Act (42 U.S.C. 1395x(dd)(3)(B)) is amended--
(A) by striking ``or nurse'' and inserting ``, the
nurse''; and
(B) by inserting ``, or the physician assistant (as
defined in such subsection)'' after ``subsection
(aa)(5))''.
(2) Clarification of hospice role of physician
assistants.--Section 1814(a)(7)(A)(i)(I) of the Social Security
Act (42 U.S.C. 1395f(a)(7)(A)(i)(I)) is amended by inserting
``or a physician assistant'' after ``a nurse practitioner''.
(b) Effective Date.--The amendments made by this section shall
apply to items and services furnished on or after October 1, 2015.
SEC. 409. REMOTE PATIENT MONITORING PILOT PROJECTS.
(a) Pilot Projects.--
(1) In general.--Not later than 9 months after the date of
the enactment of this Act, the Secretary shall conduct pilot
projects under title XVIII of the Social Security Act for the
purpose of providing incentives to home health agencies to
furnish remote patient monitoring services that reduce
expenditures under such title.
(2) Site requirements.--
(A) Urban and rural.--The Secretary shall conduct
the pilot projects under this section in both urban and
rural areas.
(B) Site in a small state.--The Secretary shall
conduct at least 1 of the pilot projects in a State
with a population of less than 1,000,000.
(b) Medicare Beneficiaries Within the Scope of Projects.--
(1) In general.--The Secretary shall specify the criteria
for identifying those Medicare beneficiaries who shall be
considered within the scope of the pilot projects under this
section for purposes of the application of subsection (c) and
for the assessment of the effectiveness of the home health
agency in achieving the objectives of this section.
(2) Criteria.--The criteria specified under paragraph (1)--
(A) shall include conditions and clinical
circumstances, including congestive heart failure,
diabetes, and chronic pulmonary obstructive disease,
and other conditions determined appropriate by the
Secretary; and
(B) may provide for the inclusion in the projects
of Medicare beneficiaries who begin receiving home
health services under title XVIII of the Social
Security Act after the date of the implementation of
the projects.
(c) Incentives.--
(1) Performance targets.--The Secretary shall establish for
each home health agency participating in a pilot project under
this section a performance target using one of the following
methodologies, as determined appropriate by the Secretary:
(A) Adjusted historical performance target.--The
Secretary shall establish for the agency--
(i) a base expenditure amount equal to the
average total payments made under parts A, B,
and D of title XVIII of the Social Security Act
for Medicare beneficiaries determined to be
within the scope of the pilot project in a base
period determined by the Secretary; and
(ii) an annual per capita expenditure
target for such beneficiaries, reflecting the
base expenditure amount adjusted for risk,
changes in costs, and growth rates.
(B) Comparative performance target.--The Secretary
shall establish for the agency a comparative
performance target equal to the average total payments
made under such parts A, B, and D during the pilot
project for comparable individuals in the same
geographic area that are not determined to be within
the scope of the pilot project.
(2) Payment.--Subject to paragraph (3), the Secretary shall
pay to each home health agency participating in a pilot project
a payment for each year under the pilot project equal to a 75
percent share of the total Medicare cost savings realized for
such year relative to the performance target under paragraph
(1).
(3) Limitation on expenditures.--The Secretary shall limit
payments under this section in order to ensure that the
aggregate expenditures under title XVIII of the Social Security
Act (including payments under this subsection) do not exceed
the amount that the Secretary estimates would have been
expended if the pilot projects under this section had not been
implemented, including any reasonable costs incurred by the
Secretary in the administration of the pilot projects.
(4) No duplication in participation in shared savings
programs.--A home health agency that participates in any of the
following shall not be eligible to participate in the pilot
projects under this section:
(A) A model tested or expanded under section 1115A
of the Social Security Act (42 U.S.C. 1315a) that
involves shared savings under title XVIII of such Act
or any other program or demonstration project that
involves such shared savings.
(B) The independence at home medical practice
demonstration program under section 1866E of such Act
(42 U.S.C. 1395cc-5).
(d) Waiver Authority.--The Secretary may waive such provisions of
titles XI and XVIII of the Social Security Act as the Secretary
determines to be appropriate for the conduct of the pilot projects
under this section.
(e) Report to Congress.--Not later than 3 years after the date that
the first pilot project under this section is implemented, the
Secretary shall submit to Congress a report on the projects. Such
report shall contain--
(1) a detailed description of the projects, including any
changes in clinical outcomes for Medicare beneficiaries under
the projects, Medicare beneficiary satisfaction under the
projects, utilization of items and services under parts A, B,
and D of title XVIII of the Social Security Act by Medicare
beneficiaries under the projects, and Medicare per-beneficiary
and Medicare aggregate spending under the projects;
(2) a detailed description of issues related to the
expansion of the projects under subsection (f);
(3) recommendations for such legislation and administrative
actions as the Secretary considers appropriate; and
(4) other items considered appropriate by the Secretary.
(f) Expansion.--If the Secretary determines that any of the pilot
projects under this section enhance health outcomes for Medicare
beneficiaries and reduce expenditures under title XVIII of the Social
Security Act, the Secretary shall initiate comparable projects in
additional areas.
(g) Payments Have No Effect on Other Medicare Payments to Home
Health Agencies.--A payment under this section shall have no effect on
the amount of payments that a home health agency would otherwise
receive under title XVIII of the Social Security Act for the provision
of home health services.
(h) Study and Report on the Appropriate Valuation for Remote
Patient Monitoring Services Under the Medicare Physician Fee
Schedule.--
(1) Study.--The Secretary shall conduct a study on the
appropriate valuation for remote patient monitoring services
under the Medicare physician fee schedule under section 1848 of
the Social Security Act (42 U.S.C. 1395w-4) in order to
accurately reflect the resources involved in furnishing such
services.
(2) Report.--Not later than 6 months after the date of the
enactment of this Act, the Secretary shall submit to Congress a
report on the study conducted under paragraph (1), together
with such recommendations as the Secretary determines
appropriate.
(i) Definitions.--In this section:
(1) Home health agency.--The term ``home health agency''
has the meaning given that term in section 1861(o) of the
Social Security Act (42 U.S.C. 1395x(o)).
(2) Remote patient monitoring services.--
(A) In general.--The term ``remote patient
monitoring services'' means services furnished in the
home using remote patient monitoring technology which--
(i) shall include patient monitoring or
patient assessment; and
(ii) may include in-home technology-based
professional consultations, patient training
services, clinical observation, treatment, and
any additional services that utilize
technologies specified by the Secretary.
(B) Limitation.--The term ``remote patient
monitoring services'' shall not include a
telecommunication that consists solely of a telephone
audio conversation, facsimile, or electronic text mail
between a health care professional and a patient.
(3) Remote patient monitoring technology.--The term
``remote patient monitoring technology'' means a coordinated
system that uses one or more home-based or mobile monitoring
devices that automatically transmit vital sign data or
information on activities of daily living and may include
responses to assessment questions collected on the devices
wirelessly or through a telecommunications connection to a
server that complies with 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, as part of an
established plan of care for that patient that includes the
review and interpretation of that data by a health care
professional.
(4) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
SEC. 410. COMMUNITY-BASED INSTITUTIONAL SPECIAL NEEDS PLAN
DEMONSTRATION PROGRAM.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary'') shall establish a
Community-Based Institutional Special Needs Plan (CBI-SNP)
demonstration program to prevent and delay institutionalization under
Medicaid among targeted low-income Medicare beneficiaries.
(b) Establishment.--The Secretary shall enter into agreements with
not more than 5 specialized MA plans for special needs individuals, as
defined in section 1859(b)(6)(B)(i) of the Social Security Act (42
U.S.C. 1395w-28(b)(6)(B)(i)), to conduct the CBI-SNP demonstration
program. Under the CBI-SNP demonstration program, a targeted low-income
Medicare beneficiary shall receive, as supplemental benefits under
section 1852(a)(3) of such Act (42 U.S.C. 1395w-22(a)(3)), long-term
care services or supports that--
(1) the Secretary determines appropriate for the purposes
of the CBI-SNP demonstration program; and
(2) for which payment may be made under the State plan
under title XIX of such Act (42 U.S.C. 1396 et seq.) of the
State in which the targeted low-income Medicare beneficiary is
located.
(c) Eligible Plans.--To be eligible to participate in the CBI-SNP
demonstration program, a specialized MA plan for special needs
individuals must--
(1) serve special needs individuals (as defined in section
1859(b)(6)(B)(i) of the Social Security Act (42 U.S.C. 1395w-
28(b)(6)(B)(i));
(2) have experience in offering special needs plans for
nursing home-eligible, non-institutionalized Medicare
beneficiaries who live in the community;
(3) be located in a State that the Secretary has determined
will participate in the CBI-SNP demonstration program by
agreeing to make available data necessary for purposes of
conducting the independent evaluation required under subsection
(f); and
(4) meet such other criteria as the Secretary may require.
(d) Targeted Low-income Medicare Beneficiary Defined.--In this
section, the term ``targeted low-income Medicare beneficiary'' means a
Medicare beneficiary who--
(1) is enrolled in a specialized MA plan for special needs
individuals that has been selected to participate in the CBI-
SNP demonstration program;
(2) is a subsidy eligible individual (as defined in section
1860D-14(a)(3)(A) of the Social Security Act (42 U.S.C. 1395w-
114(a)(3)(A)); and
(3) is unable to perform 2 or more activities of daily
living (as defined in section 7702B(c)(2)(B) of the Internal
Revenue Code of 1986).
(e) Implementation Deadline; Duration.--The CBI-SNP demonstration
program shall be implemented not later than January 1, 2016, and shall
be conducted for a period of 3 years.
(f) Independent Evaluation and Reports.--
(1) Independent evaluation.--Not later than 2 years after
the completion of the CBI-SNP demonstration program, the
Secretary shall provide for the evaluation of the CBI-SNP
demonstration program by an independent third party. The
evaluation shall determine whether the CBI-SNP demonstration
program has improved patient care and quality of life for the
targeted low-income Medicare beneficiaries participating in the
CBI-SNP demonstration program. Specifically, the evaluation
shall determine if the CBI-SNP demonstration program has--
(A) reduced hospitalizations or re-
hospitalizations;
(B) reduced Medicaid nursing home facility stays;
and
(C) reduced spenddown of income and assets for
purposes of becoming eligible for Medicaid.
(2) Reports.--Not later than 3 years after the completion
of the CBI-SNP demonstration program, the Secretary shall
submit to Congress a report containing the results of the
evaluation conducted under paragraph (1), together with such
recommendations for legislative or administrative action as the
Secretary determines appropriate.
(g) Funding.--
(1) Funding for implementation.--For purposes of carrying
out the demonstration program under this section (other than
the evaluation and report under subsection (f)), 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 Medical
Insurance Trust Fund under section 1841 of such Act (42 U.S.C.
1395t), in such proportion as the Secretary determines
appropriate, of $3,000,000 to the Centers for Medicare &
Medicaid Services Program Management Account.
(2) Funding for evaluation and report.--For purposes of
carrying out the evaluation and report under subsection (f),
the Secretary shall provide for the transfer from the Federal
Hospital Insurance Trust Fund under such section 1817 and the
Federal Supplementary Medical Insurance Trust Fund under such
section 1841, in such proportion as the Secretary determines
appropriate, of $500,000.
(3) Availability.--Amounts transferred under paragraph (1)
or (2) shall remain available until expended.
(h) Budget Neutrality.--In conducting the CBI-SNP demonstration
program, the Secretary shall ensure that the aggregate payments made by
the Secretary do not exceed the amount which the Secretary estimates
would have been expended under titles XVIII and XIX of the Social
Security Act (42 U.S.C. 1395 et seq., 1396 et seq.) if the CBI-SNP
demonstration program had not been implemented.
(i) Paperwork Reduction Act.--Chapter 35 of title 44, United States
Code, shall not apply to the testing and evaluation of the CBI-SNP
demonstration program under this section.
SEC. 411. APPLYING CMMI WAIVER AUTHORITY TO PACE IN ORDER TO FOSTER
INNOVATIONS.
(a) CMMI Waiver Authority.--Subsection (d)(1) of section 1115A of
the Social Security Act (42 U.S.C. 1315a) is amended--
(1) by inserting ``(other than subsections (b)(1)(A) and
(c)(5) of section 1894)'' after ``XVIII''; and
(2) by striking ``and 1903(m)(2)(A)(iii)'' and inserting
``1903(m)(2)(A)(iii), and 1934 (other than subsections
(b)(1)(A) and (c)(5) of such section)''.
(b) Sense of the Senate.--It is the sense of the Senate that the
Secretary of Health and Human Services should use the waiver authority
provided under the amendments made by this section to provide, in a
budget neutral manner, programs of all-inclusive care for the elderly
(PACE programs) with increased operational flexibility to support the
ability of such programs to improve and innovate and to reduce
technical and administrative barriers that have hindered enrollment in
such programs.
SEC. 412. IMPROVE AND MODERNIZE MEDICAID DATA SYSTEMS AND REPORTING.
(a) In General.--The Secretary of Health and Human Services shall
implement a strategic plan to increase the usefulness of data about
State Medicaid programs reported by States to the Centers for Medicare
& Medicaid Services. The strategic plan shall address redundancies and
gaps in Medicaid data systems and reporting through improvements to,
and modernization of, computer and data systems. Areas for improvement
under the plan shall include (but not be limited to) the following:
(1) The reporting of encounter data by managed care plans.
(2) The timeliness and quality of reported data, including
enrollment data.
(3) The consistency of data reported from multiple sources.
(4) Information about State program policies.
(b) Implementation Status Report.--Not later than 1 year after the
date of enactment of this Act, the Secretary of Health and Human
Services shall submit a report to Congress on the status of the
implementation of the strategic plan required under subsection (a).
(c) Authorization of Appropriations.--There is authorized to be
appropriated to the Secretary of Health and Human Services for the
period of fiscal years 2015 through 2019, such sums as may be necessary
to carry out this section.
SEC. 413. FAIRNESS IN MEDICAID SUPPLEMENTAL NEEDS TRUSTS.
(a) In General.--Section 1917(d)(4)(A) of the Social Security Act
(42 U.S.C. 1396p(d)(4)(A)) is amended by inserting ``the individual,''
after ``for the benefit of such individual by''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to trusts established on or after the date of the enactment of
this Act.
SEC. 414. HELPING ENSURE LIFE- AND LIMB-SAVING ACCESS TO PODIATRIC
PHYSICIANS.
(a) Including Podiatrists as Physicians Under the Medicaid
Program.--
(1) In general.--Section 1905(a)(5)(A) of the Social
Security Act (42 U.S.C. 1396d(a)(5)(A)) is amended by striking
``section 1861(r)(1)'' and inserting ``paragraphs (1) and (3)
of section 1861(r)''.
(2) Effective date.--
(A) In general.--Except as provided in subparagraph
(B), the amendment made by paragraph (1) shall apply to
services furnished on or after the date of enactment of
this Act.
(B) Extension of effective date for state law
amendment.--In the case of a State plan under title XIX
of the Social Security Act (42 U.S.C. 1396 et seq.)
which the Secretary of Health and Human Services
determines requires State legislation in order for the
plan to meet the additional requirement imposed by the
amendment made by paragraph (1), the State plan shall
not be regarded as failing to comply with the
requirements of such title solely on the basis of its
failure to meet these additional requirements before
the first day of the first calendar quarter beginning
after the close of the first regular session of the
State legislature that begins after the date of
enactment of this Act. For purposes of the previous
sentence, in the case of a State that has a 2-year
legislative session, each year of the session is
considered to be a separate regular session of the
State legislature.
(b) Modifications to Requirements for Diabetic Shoes to Be Included
Under Medical and Other Health Services Under Medicare.--
(1) In general.--Section 1861(s)(12) of the Social Security
Act (42 U.S.C. 1395x(s)(12)) is amended to read as follows:
``(12) subject to section 4072(e) of the Omnibus Budget
Reconciliation Act of 1987, extra-depth shoes with inserts or
custom molded shoes (in this paragraph referred to as
`therapeutic shoes') with inserts for an individual with
diabetes, if--
``(A) the physician who is managing the
individual's diabetic condition--
``(i) documents that the individual has
diabetes;
``(ii) certifies that the individual is
under a comprehensive plan of care related to
the individual's diabetic condition; and
``(iii) documents agreement with the
prescribing podiatrist or other qualified
physician (as established by the Secretary)
that it is medically necessary for the
individual to have such extra-depth shoes with
inserts or custom molded shoes with inserts;
``(B) the therapeutic shoes are prescribed by a
podiatrist or other qualified physician (as established
by the Secretary) who--
``(i) examines the individual and
determines the medical necessity for the
individual to receive the therapeutic shoes;
and
``(ii) communicates in writing the medical
necessity to the physician described in
subparagraph (A) for the individual to have
therapeutic shoes along with findings that the
individual has peripheral neuropathy with
evidence of callus formation, a history of pre-
ulcerative calluses, a history of previous
ulceration, foot deformity, previous
amputation, or poor circulation; and
``(C) the therapeutic shoes are fitted and
furnished by a podiatrist or other qualified supplier
(as established by the Secretary), such as a pedorthist
or orthotist, who is not the physician described in
subparagraph (A) (unless the Secretary finds that the
physician is the only such qualified individual in the
area);''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply with respect to items and services furnished on or
after January 1, 2015.
SEC. 415. DEMONSTRATION PROGRAMS TO IMPROVE COMMUNITY MENTAL HEALTH
SERVICES.
(a) Criteria for Certified Community Behavioral Health Clinics to
Participate in Demonstration Programs.--
(1) Publication.--Not later than September 1, 2015, the
Secretary shall publish criteria for a clinic to be certified
by a State as a certified community behavioral health clinic
for purposes of participating in a demonstration program
conducted under subsection (d).
(2) Requirements.--The criteria published under this
subsection shall include criteria with respect to the
following:
(A) Staffing.--Staffing requirements, including
criteria that staff have diverse disciplinary
backgrounds, have necessary State-required license and
accreditation, and are culturally and linguistically
trained to serve the needs of the clinic's patient
population.
(B) Availability and accessibility of services.--
Availability and accessibility of services, including
crisis management services that are available and
accessible 24 hours a day, the use of a sliding scale
for payment, and no rejection for services or limiting
of services on the basis of a patient's ability to pay
or a place of residence.
(C) Care coordination.--Care coordination,
including requirements to coordinate care across
settings and providers to ensure seamless transitions
for patients across the full spectrum of health
services including acute, chronic, and behavioral
health needs. Care coordination requirements shall
include partnerships or formal contracts with the
following:
(i) Federally-qualified health centers (and
as applicable, rural health clinics) to provide
Federally-qualified health center services (and
as applicable, rural health clinic services) to
the extent such services are not provided
directly through the certified community
behavioral health clinic.
(ii) Inpatient psychiatric facilities and
substance use detoxification, post-
detoxification step-down services, and
residential programs.
(iii) Other community or regional services,
supports, and providers, including schools,
child welfare agencies, juvenile and criminal
justice agencies and facilities, Indian Health
Service youth regional treatment centers, State
licensed and nationally accredited child
placing agencies for therapeutic foster care
service, and other social and human services.
(iv) Department of Veterans Affairs medical
centers, independent outpatient clinics, drop-
in centers, and other facilities of the
Department as defined in section 1801 of title
38, United States Code.
(v) Inpatient acute care hospitals and
hospital outpatient clinics.
(D) Scope of services.--Provision (in a manner
reflecting person-centered care) of the following
services which, if not available directly through the
certified community behavioral health clinic, are
provided or referred through formal relationships with
other providers:
(i) Crisis mental health services,
including 24-hour mobile crisis teams,
emergency crisis intervention services, and
crisis stabilization.
(ii) Screening, assessment, and diagnosis,
including risk assessment.
(iii) Patient-centered treatment planning
or similar processes, including risk assessment
and crisis planning.
(iv) Outpatient mental health and substance
use services.
(v) Outpatient clinic primary care
screening and monitoring of key health
indicators and health risk.
(vi) Targeted case management.
(vii) Psychiatric rehabilitation services.
(viii) Peer support and counselor services
and family supports.
(ix) Intensive, community-based mental
health care for members of the armed forces and
veterans, particularly those members and
veterans located in rural areas, provided the
care is consistent with minimum clinical mental
health guidelines promulgated by the Veterans
Health Administration including clinical
guidelines contained in the Uniform Mental
Health Services Handbook of such
Administration.
(E) Quality and other reporting.--Reporting of
encounter data, clinical outcomes data, quality data,
and such other data as the Secretary requires.
(F) Organizational authority.--Criteria that a
clinic be a non-profit or part of a local government
behavioral health authority or operated under the
authority of the Indian Health Service, an Indian tribe
or tribal organization pursuant to a contract, grant,
cooperative agreement, or compact with the Indian
Health Service pursuant to the Indian Self-
Determination Act (25 U.S.C. 450 et seq.), or an urban
Indian organization pursuant to a grant or contract
with the Indian Health Service under title V of the
Indian Health Care Improvement Act (25 U.S.C. 1601 et
seq.).
(b) Guidance on Development of Prospective Payment System for
Testing Under Demonstration Programs.--
(1) In general.--Not later than September 1, 2015, the
Secretary, through the Administrator of the Centers for
Medicare & Medicaid Services, shall issue guidance for the
establishment of a prospective payment system that shall only
apply to medical assistance for mental health services
furnished by a certified community behavioral health clinic
participating in a demonstration program under subsection (d).
(2) Requirements.--The guidance issued by the Secretary
under paragraph (1) shall provide that--
(A) no payment shall be made for inpatient care,
residential treatment, room and board expenses, or any
other non-ambulatory services, as determined by the
Secretary; and
(B) no payment shall be made to satellite
facilities of certified community behavioral health
clinics if such facilities are established after the
date of enactment of this Act.
(c) Planning Grants.--
(1) In general.--Not later than January 1, 2016, the
Secretary shall award planning grants to States for the purpose
of developing proposals to participate in time-limited
demonstration programs described in subsection (d).
(2) Use of funds.--A State awarded a planning grant under
this subsection shall--
(A) solicit input with respect to the development
of such a demonstration program from patients,
providers, and other stakeholders;
(B) certify clinics as certified community
behavioral health clinics for purposes of participating
in a demonstration program conducted under subsection
(d); and
(C) establish a prospective payment system for
mental health services furnished by a certified
community behavioral health clinic participating in a
demonstration program under subsection (d) in
accordance with the guidance issued under subsection
(b).
(d) Demonstration Programs.--
(1) In general.--Not later than September 1, 2017, the
Secretary shall select States to participate in demonstration
programs that are developed through planning grants awarded
under subsection (c), meet the requirements of this subsection,
and represent a diverse selection of geographic areas,
including rural and underserved areas.
(2) Application requirements.--
(A) In general.--The Secretary shall solicit
applications to participate in demonstration programs
under this subsection solely from States awarded
planning grants under subsection (c).
(B) Required information.--An application for a
demonstration program under this subsection shall
include the following:
(i) The target Medicaid population to be
served under the demonstration program.
(ii) A list of participating certified
community behavioral health clinics.
(iii) Verification that the State has
certified a participating clinic as a certified
community behavioral health clinic in
accordance with the requirements of subsection
(b).
(iv) A description of the scope of the
mental health services available under the
State Medicaid program that will be paid for
under the prospective payment system tested in
the demonstration program.
(v) Verification that the State has agreed
to pay for such services at the rate
established under the prospective payment
system.
(vi) Such other information as the
Secretary may require relating to the
demonstration program including with respect to
determining the soundness of the proposed
prospective payment system.
(3) Number and length of demonstration programs.--Not more
than 8 States shall be selected for 4-year demonstration
programs under this subsection.
(4) Requirements for selecting demonstration programs.--
(A) In general.--The Secretary shall give
preference to selecting demonstration programs where
participating certified community behavioral health
clinics--
(i) provide the most complete scope of
services described in subsection (a)(2)(D) to
individuals eligible for medical assistance
under the State Medicaid program;
(ii) will improve availability of, access
to, and participation in, services described in
subsection (a)(2)(D) to individuals eligible
for medical assistance under the State Medicaid
program;
(iii) will improve availability of, access
to, and participation in assisted outpatient
mental health treatment in the State; or
(iv) demonstrate the potential to expand
available mental health services in a
demonstration area and increase the quality of
such services without increasing net Federal
spending.
(5) Payment for medical assistance for mental health
services provided by certified community behavioral health
clinics.--
(A) In general.--The Secretary shall pay a State
participating in a demonstration program under this
subsection the Federal matching percentage specified in
subparagraph (B) for amounts expended by the State to
provide medical assistance for mental health services
described in the demonstration program application in
accordance with paragraph (2)(B)(iv) that are provided
by certified community behavioral health clinics to
individuals who are enrolled in the State Medicaid
program. Payments to States made under this paragraph
shall be considered to have been under, and are subject
to the requirements of, section 1903 of the Social
Security Act (42 U.S.C. 1396b).
(B) Federal matching percentage.--The Federal
matching percentage specified in this subparagraph is
with respect to medical assistance described in
subparagraph (A) that is furnished--
(i) to a newly eligible individual
described in paragraph (2) of section 1905(y)
of the Social Security Act (42 U.S.C.
1396d(y)), the matching rate applicable under
paragraph (1) of that section; and
(ii) to an individual who is not a newly
eligible individual (as so described) but who
is eligible for medical assistance under the
State Medicaid program, the enhanced FMAP
applicable to the State.
(C) Limitations.--
(i) In general.--Payments shall be made
under this paragraph to a State only for mental
health services--
(I) that are described in the
demonstration program application in
accordance with paragraph (2)(B)(iv);
(II) for which payment is available
under the State Medicaid program; and
(III) that are provided to an
individual who is eligible for medical
assistance under the State Medicaid
program.
(ii) Prohibited payments.--No payment shall
be made under this paragraph--
(I) for inpatient care, residential
treatment, room and board expenses, or
any other non-ambulatory services, as
determined by the Secretary; or
(II) with respect to payments made
to satellite facilities of certified
community behavioral health clinics if
such facilities are established after
the date of enactment of this Act.
(6) Waiver of statewideness requirement.--The Secretary
shall waive section 1902(a)(1) of the Social Security Act (42
U.S.C. 1396a(a)(1)) (relating to statewideness) as may be
necessary to conduct demonstration programs in accordance with
the requirements of this subsection.
(7) Annual reports.--
(A) In general.--Not later than 1 year after the
date on which the first State is selected for a
demonstration program under this subsection, and
annually thereafter, the Secretary shall submit to
Congress an annual report on the use of funds provided
under all demonstration programs conducted under this
subsection. Each such report shall include--
(i) an assessment of access to community-
based mental health services under the Medicaid
program in the area or areas of a State
targeted by a demonstration program compared to
other areas of the State;
(ii) an assessment of the quality and scope
of services provided by certified community
behavioral health clinics compared to
community-based mental health services provided
in States not participating in a demonstration
program under this subsection and in areas of a
demonstration State that are not participating
in the demonstration program; and
(iii) an assessment of the impact of the
demonstration programs on the Federal and State
costs of a full range of mental health services
(including inpatient, emergency and ambulatory
services).
(B) Recommendations.--Not later than December 31,
2021, the Secretary shall submit to Congress
recommendations concerning whether the demonstration
programs under this section should be continued,
expanded, modified, or terminated.
(e) Definitions.--In this section:
(1) Federally-qualified health center services; federally-
qualified health center; rural health clinic services; rural
health clinic.--The terms ``Federally-qualified health center
services'', ``Federally-qualified health center'', ``rural
health clinic services'', and ``rural health clinic'' have the
meanings given those terms in section 1905(l) of the Social
Security Act (42 U.S.C. 1396d(l)).
(2) Enhanced fmap.--The term ``enhanced FMAP'' has the
meaning given that term in section 2105(b) of the Social
Security Act (42 U.S.C. 1397dd(b) but without regard to the
second and third sentences of that section.
(3) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(4) State.--The term ``State'' has the meaning given such
term for purposes of title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
(f) Funding.--
(1) In general.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to the
Secretary--
(A) for purposes of carrying out subsections (a),
(b), and (d)(7), $2,000,000 for fiscal year 2014; and
(B) for purposes of awarding planning grants under
subsection (c), $25,000,000 for fiscal year 2016.
(2) Availability.--Funds appropriated under paragraph (1)
shall remain available until expended.
SEC. 416. ANNUAL MEDICAID DSH REPORT.
Section 1923 of the Social Security Act (42 U.S.C. 1396r-4) is
amended by adding at the end the following:
``(k) Annual Report to Congress.--
``(1) In general.--Beginning January 1, 2015, and annually
thereafter, the Secretary shall submit a report to Congress on
the program established under this section for making payment
adjustments to disproportionate share hospitals for the purpose
of providing Congress with information relevant to determining
an appropriate level of overall funding for such payment
adjustments during and after the period in which aggregate
reductions in the DSH allotments to States are required under
paragraphs (7) and (8) of subsection (f).
``(2) Required report information.--Except as otherwise
provided, each report submitted under this subsection shall
include the following:
``(A) Information and data relating to changes in
the number of uninsured individuals for the most recent
year for which such data are available as compared to
2013 and as compared to the Congressional Budget Office
estimates of uninsured individuals made at the time of
the enactment of the Patient Protection and Affordable
Care Act (Public Law 111-148) and the Health Care and
Education Reconciliation Act of 2010 (Public Law 111-
152).
``(B) Information and data relating to the extent
to which hospitals continue to incur uncompensated care
costs from providing unreimbursed or under-reimbursed
services to individuals who either are eligible for
medical assistance under the State plan under this
title or under a waiver of such plan or who have no
health insurance (or other source of third party
coverage) for such services.
``(C) Information and data relating to the extent
to which hospitals continue to provide charity care and
unreimbursed or under-reimbursed services, or otherwise
incur bad debt, under the program established under
this title, the State Children's Health Insurance
Program established under title XXI, and State or local
indigent care programs, as reported on cost reports
submitted under title XVIII or such other data as the
Secretary determines appropriate.
``(D) In the first report submitted under this
section, a methodology for estimating the amount of
unpaid patient deductibles, copayments and coinsurance
incurred by hospitals for patients enrolled in
qualified health plans through an American Health
Benefits Exchange, using existing data and minimizing
the administrative burden on hospitals to the extent
possible, and in subsequent reports, data regarding
such uncompensated care costs collected pursuant to
such methodology.
``(E) For each State, information and data relating
to the difference between the DSH allotment for the
State for the fiscal year that began on October 1 of
the year preceding the year in which the report is
submitted and the aggregate amount of uncompensated
care costs for all disproportionate share hospitals in
the State.
``(F) Information and data relating to the extent
to which there are certain vital hospital systems that
are disproportionately experiencing high levels of
uncompensated care and that have multiple other
missions, such as a commitment to graduate medical
education, the provision of tertiary and trauma care
services, providing public health and essential
community services, and providing comprehensive,
coordinated care.
``(G) Such other information and data relevant to
the determination of the level of funding for, and
amount of, State DSH allotments as the Secretary
determines appropriate
``(3) Authorization of appropriations.--There is authorized
to be appropriated to the Secretary for the period of fiscal
years 2015 through 2109, such sums as may be necessary to carry
out this subsection.''.
SEC. 417. IMPLEMENTATION.
To the extent the Secretary of Health and Human Services issues a
regulation to carry out the provisions of this Act, the Secretary
shall, unless otherwise specified in this Act--
(1) issue a notice of proposed rulemaking that includes the
proposed regulation;
(2) provide a period of not less than 60 calendar days for
comments on the proposed regulation;
(3) not more than 24 months following the date of
publication of the proposed rule, publish the final regulation
or take alternative action (such as withdrawing the rule or
proposing a revised rule with a new comment period) on the
proposed regulation; and
(4) not less than 30 days before the effective date of the
final regulation, publish the final regulation or take
alternative action (such as withdrawing the rule or proposing a
revised rule with a new comment period) on the proposed
regulation.
TITLE V--RESTORING INDIVIDUAL LIBERTY
SEC. 501. RESTORING INDIVIDUAL LIBERTY.
Sections 1501 and 1502 and subsections (a), (b), (c), and (d) of
section 10106 of the Patient Protection and Affordable Care Act (and
the amendments made by such sections and subsections) are repealed and
the Internal Revenue Code of 1986 shall be applied and administered as
if such provisions and amendments had never been enacted.
Calendar No. 330
113th CONGRESS
2d Session
S. 2122
_______________________________________________________________________
A BILL
To amend titles XVIII and XIX of the Social Security Act to repeal the
Medicare sustainable growth rate and to improve Medicare and Medicaid
payments, and for other purposes.
_______________________________________________________________________
March 13, 2014
Read the second time and placed on the calendar
Introduced in Senate
Introduced in the Senate. Read the first time. Placed on Senate Legislative Calendar under Read the First Time.
Read the second time. Placed on Senate Legislative Calendar under General Orders. Calendar No. 330.
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