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[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 10136 Introduced in House (IH)]
<DOC>
118th CONGRESS
2d Session
H. R. 10136
To amend title XVIII of the Social Security Act to align payment under
Medicare for specified surgical procedures with high-cost supplies
furnished in office-based facilities, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
November 15, 2024
Mr. Bilirakis (for himself, Mr. Davis of Illinois, and Mr. Murphy)
introduced the following bill; which was referred to the Committee on
Energy and Commerce, and in addition to the Committee on Ways and
Means, for a period to be subsequently determined by the Speaker, in
each case for consideration of such provisions as fall within the
jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to align payment under
Medicare for specified surgical procedures with high-cost supplies
furnished in office-based facilities, 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.
This Act may be cited as the ``Promoting Fairness for Medicare
Providers Act of 2024''.
SEC. 2. ALIGNING PAYMENT UNDER MEDICARE FOR SPECIFIED HIGH SUPPLY COST
SURGICAL PROCEDURES FURNISHED IN OFFICE-BASED FACILITIES.
(a) Coverage of Facility Services.--Section 1832(a)(2)(F) of the
Social Security Act (42 U.S.C. 1395k(a)(2)(F)) is amended--
(1) in the matter preceding clause (i), by striking
``specified by the Secretary'';
(2) in clause (i)--
(A) by inserting ``specified by the Secretary''
before ``pursuant''; and
(B) at the end, by striking ``or'';
(3) in clause (ii)--
(A) by inserting ``specified by the Secretary''
before ``pursuant''; and
(B) at the end, by striking the semicolon and
inserting ``, or''; and
(4) by adding at the end the following new clause:
``(iii) that are specified high supply cost
surgical procedures (as defined in section
1834(aa)(4) with respect to a year (beginning
with 2025) and furnished during such year in an
office-based facility (as defined in section
1834(aa)(5));''.
(b) Payment Rules.--
(1) Payment for facility services.--Section 1833(a)(1) of
the Social Security Act (42 U.S.C. 1395l(a)) is amended--
(A) by striking ``and (HH)'' and inserting
``(HH)''; and
(B) by inserting before the semicolon at the end
the following ``, and (II) with respect to facility
services furnished in connection with a specified high
supply cost surgical procedure (as defined in section
1834(aa)(4)) with respect to a year (beginning with
2025) furnished to an individual in an office-based
facility (as defined in section 1834(aa)(5)) during
such year, the amounts paid shall be, subject to
section 1834(aa)(3), 80 percent of the payment amount
determined under section 1834(aa) for such facility
services furnished in connection with such procedure at
such office-based facility''.
(2) Payment determination for specified high supply cost
surgical procedures furnished in office-based facilities.--
Section 1834 of the Social Security Act (42 U.S.C. 1395l(a)) is
amended by adding at the end the following new subsection:
``(aa) Payment for Specified High Supply Cost Surgical Procedures
Furnished in Office-Based Facilities.--
``(1) In general.--In the case of a specified high supply
cost surgical procedure furnished in an office-based facility
during 2025 or a subsequent year, subject to paragraphs (2) and
(3), payment for such procedure shall be determined under this
part in the same manner as payment would be determined under
this part if such procedure had been furnished in an ambulatory
surgical center and not considered office-based under section
1833(i)(1)(B), except that payment for facility services
furnished in connection with such procedure shall be equal to
90 percent of the amount that would be payable for facility
services furnished in connection with such procedure under
section 1833(i) for such year if such procedure had been
furnished in an ambulatory surgical center and treated as a
service commonly furnished in such a center.
``(2) Application in case of device-intensive procedures.--
In applying paragraph (1) in the case of a specified high
supply cost surgical procedure that is a device-intensive
procedure (as described in section 416.171(b)(2) of title 42,
Code of Federal Regulations (or any successor regulation)),
instead of the payment amount applied under such paragraph, the
payment amount for the facility services with respect to such
procedure shall be the amount that would be calculated under
section 416.172(h)(2)(ii) of title 42, Code of Federal
Regulations (or any successor regulation) with respect to a
procedure that has been assigned device-intensive status,
except that in applying such calculation the non-device portion
described in paragraph (B) of such section shall be equal to 90
percent of the amount that would otherwise be calculated for
such portion.
``(3) Limitation on copayment amount to inpatient hospital
deductible amount.--
``(A) In general.--In no case shall the amount of
coinsurance for facility services furnished in
connection with a specified high supply cost surgical
procedure in an office-based facility during a year
exceed the amount of the inpatient hospital deductible
established under section 1813(b) for that year.
``(B) Maintaining payment to provider.--In the case
that an individual enrolled under this part would,
without application of subparagraph (A), be subject to
an amount of coinsurance for facility services
furnished in connection with a specified high supply
cost surgical procedure in an office-based facility
during a year that exceeds the amount of the inpatient
hospital deductible established under section 1813(b)
for that year, the Secretary shall increase the amount
paid to the office-based facility as specified under
section 1833(a)(1)(II) for such facility services by
the amount by which--
``(i) the coinsurance payable by the
individual for such facility services without
application of this paragraph; exceeds
``(ii) the coinsurance payable by the
individual for such facility services with
application of this paragraph.
``(4) Specified high supply cost surgical procedure
defined.--
``(A) In general.--For purposes of this part,
subject to subparagraphs (B) and (C), the term
`specified high supply cost surgical procedure' means a
surgical procedure that as of 2023--
``(i) when performed in an ambulatory
surgical center, was payable under section
1833(i); and
``(ii) when performed in a physician's
office--
``(I) was payable under section
1848 at the practice expense relative
value unit-based amount for non-
facility sites of service; and
``(II) included a HCPCS code with a
supply item for which the price input
for such supply item, used for
determining the practice expense
relative value units for such code, was
greater than $500.
``(B) Review and revisions to specified services.--
``(i) In general.--For each year (beginning
with 2026), the Secretary shall review the
procedures included in the definition of
specified high supply cost surgical procedures
under this paragraph and, based on such review
and through rulemaking--
``(I) shall add a surgical
procedure (not described in
subparagraph (A)) for inclusion in such
definition if the procedure, with
respect to such year, satisfies the
criteria specified in clause (ii); and
``(II) may remove a surgical
procedure from inclusion in such
definition if the procedure, with
respect to such year, satisfies the
criteria specified in clause (iii).
``(ii) Criteria for required inclusion.--
For purposes of clause (i)(I), a surgical
procedure satisfies the criteria specified in
this clause, with respect to a year, if--
``(I) when performed in an
ambulatory surgical center, the
procedure is payable under section
1833(i); and
``(II) when performed in a
physician's office, the procedure--
``(aa) would be, without
application of this subsection
or section 1833(a)(i)(II),
payable under section 1848 at
the practice expense relative
value unit-based amount for
non-facility sites of services;
and
``(bb) includes a HCPCS
code with a supply item for
which the price input for such
supply item, used for
determining the practice
expense relative value units
for such code, is greater than
the threshold specified in
clause (iv) for such year.
``(iii) Criteria for permissive removal.--
For purposes of clause (i)(II), a surgical
procedure satisfies the criteria described in
this clause, with respect to a year, if, when
performed in a physician's office, the
procedure includes a HCPCS code with a supply
item for which the price input for such supply
item, used for determining the practice expense
relative value units for such code, does not
exceed the amount equal to 80 percent of the
threshold specified in clause (iv) for such
year.
``(iv) Dollar amount threshold specified.--
For purposes of clauses (ii) and (iii), the
threshold specified in this clause is--
``(I) with respect to 2026, the
dollar amount specified in subparagraph
(A)(ii), increased by the percentage
increase in the MEI (as defined in
section 1842(i)(3)) over the 3-year
period ending with 2026; or
``(II) with respect to a subsequent
year, the amount specified in this
clause for the preceding year increased
by the percentage increase in the MEI
(as defined in section 1842(i)(3)) for
such subsequent year.
``(C) Special rule for use of more than one of the
same supply item in a procedure.--In the case of a
surgical procedure that requires the use of more than
one of the same supply item in such procedure--
``(i) in applying subparagraph (A)(ii)(II),
if as of 2023 the sum of the price inputs
described in such subparagraph of all of such
same supply items exceeds the dollar amount
specified in such subparagraph, then the
procedure shall be treated as satisfying the
requirement of such subparagraph; and
``(ii) in applying subparagraph (B), with
respect to 2026 or a subsequent year--
``(I) if the sum of the price
inputs described in clause (ii)(II)(bb)
of such subparagraph of all of such
same supply items exceeds the threshold
specified in clause (iv) of such
subparagraph for such year, then the
procedure shall be treated as
satisfying the criterion described in
such clause (ii)(II)(bb) with respect
to such year; and
``(II) if the sum of the price
inputs described in clause (iii) of
such subparagraph of all of such same
supply items does not exceed the amount
described in such clause for such year,
then the procedure shall be treated as
satisfying the criteria described in
such clause with respect to such year.
``(5) Office-based facility defined.--For purposes of this
part, the term `office-based facility' means a physician's
office that, with respect to facility services furnished in
connection with specified high supply cost surgical
procedures--
``(A) meets health, safety, and other standards
specified by the Secretary in regulations; and
``(B) has entered into an agreement with the
Secretary under which the physician's office--
``(i) accepts the payment amount determined
under this subsection as full payment for such
facility services;
``(ii) accepts an assignment described in
section 1842(b)(3)(B)(ii) with respect to
payment for all such facility services
furnished by the office to individuals enrolled
under this part; and
``(iii) participates under this part and is
paid as an office-based facility with respect
to all such procedures.''.
(3) Conforming amendments.--
(A) For services furnished in an ambulatory
surgical center.--Section 1833(i)(2) of the Social
Security Act (42 U.S.C. 1395l(i)(2)) is amended by
adding at the end the following new subparagraph:
``(F) For purposes of determining payment under
this subsection for a specified high supply cost
surgical procedure (as defined in section 1834(aa)(4)
with respect to a year (beginning with 2025)) furnished
in an ambulatory surgical center during such year, such
procedure shall be treated as a service commonly
furnished in an ambulatory surgical center.''.
(B) For services furnished in an off-campus
outpatient department of a provider.--Section
1833(t)(21)(C) of the Social Security Act (42 U.S.C.
1395l(t)(21)(C)) is amended by adding at the end the
following new sentence: ``In applying the previous
sentence in the case of a specified high supply cost
surgical procedure (as defined in section 1834(aa)(4)
with respect to a year) furnished by an off-campus
outpatient department of a provider, payment shall be
determined under section 1834(aa).''.
(C) For clarification on applicable payment for obf
facility services.--Section 1833(a)(4) of the Social
Security Act (42 U.S.C. 1395l(a)(4)) is amended by
inserting ``(other than in clause (iii) of such
section)'' after ``section 1832(a)(2)(F)''.
(c) Provider Agreement and Medicare Enrollment.--
(1) In general.--Section 1866(e) of the Social Security Act
(42 U.S.C. 1395cc(e)) is amended--
(A) in paragraph (2), by striking at the end
``and'';
(B) in paragraph (3), at the end, by striking the
period and adding ``; and''; and
(C) by adding at the end the following new
paragraph:
``(4) an office-based facility (as defined in paragraph (5)
of section 1834(aa)), but only with respect to the furnishing
during a year of specified high supply cost surgical procedures
(as defined in paragraph (4) of such section with respect to
such year).''.
(2) Consultation with state agencies regarding conditions
of participation.--Section 1863 of the Social Security Act (42
U.S.C. 1395z) is amended by striking ``or by ambulatory
surgical centers under section 1832(a)(2)(F)(i)'' and inserting
``by ambulatory surgical centers under section
1832(a)(2)(F)(i), or by office-based facilities (as defined in
section 1834(aa)(5)) with respect to furnishing specified high
supply cost surgical procedures (as defined in section
1834(aa)(4))''.
(3) Use of state agencies to determine compliance with
conditions of participation.--Section 1864(a) of the Social
Security Act (42 U.S.C. 1395aa(a)) is amended--
(A) in the first sentence, by inserting ``or
whether a physician's office is an office-based
facility (as defined in section 1834(aa)(5),'' after
``standards specified under section
1832(a)(2)(F)(i),''; and
(B) in the fifth sentence, by inserting ``office-
based facility (as defined in section 1834(aa)(5)) with
respect to furnishing ambulatory high supply cost
surgical procedures (as defined in section
1834(aa)(4)),'' after each occurrence of ``ambulatory
surgical center,''.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Subcommittee on Health.
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