No official summary available for this bill.
[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 8404 Introduced in House (IH)]
<DOC>
118th CONGRESS
2d Session
H. R. 8404
To amend title XVIII of the Social Security Act to create a Radiation
Oncology Case Rate Value Based Payment Program exempt from budget
neutrality adjustment requirements, and to amend section 1128A of title
XI of the Social Security Act to create a new statutory exception for
the provision of free or discounted transportation for radiation
oncology patients to receive radiation therapy services.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
May 15, 2024
Mr. Fitzpatrick (for himself, Mr. Panetta, Mr. Joyce of Pennsylvania,
and Mr. Tonko) 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 create a Radiation
Oncology Case Rate Value Based Payment Program exempt from budget
neutrality adjustment requirements, and to amend section 1128A of title
XI of the Social Security Act to create a new statutory exception for
the provision of free or discounted transportation for radiation
oncology patients to receive radiation therapy services.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Radiation Oncology Case Rate Value
Based Program Act of 2024'' or the ``ROCR Value Based Program Act''.
SEC. 2. FINDINGS.
(a) Findings.--Congress finds the following:
(1) Radiation therapy is the careful use of various forms
of radiation, such as external beam radiation therapy, to treat
cancer and other diseases safely and effectively. Radiation
oncologists develop radiation treatment plans and coordinate
with highly specialized care teams to deliver radiation
therapy. Nearly 60 percent of cancer patients will receive
radiation therapy during their treatment.
(2) In 2021, the Centers for Medicare & Medicaid Services
reported approximately $4,200,000,000 in total spending for
radiation oncology services between the Medicare physician fee
schedule and hospital outpatient departments.
(3) The Centers for Medicare & Medicaid Services has
historically faced challenges in determining accurate pricing
for services that involve costly capital equipment, resulting
in fluctuating payment rates under the Medicare physician fee
schedules for services involving external beam radiation
therapy. Additionally, the Medicare physician fee schedule has
inadequately recognized the professional expertise physicians
and nonphysician professionals need to deliver radiation
therapy.
(4) The current payment systems incentivize greater volumes
of care while bundled payments incentivize patient centered,
efficient, and high value care.
(5) In 2017, the Centers for Medicare & Medicaid Services
recognized that the Medicare payment systems were not
adequately addressing radiation oncology services, and the
Center for Medicare & Medicaid Innovation released a
congressionally requested report on the pursuit of an
alternative payment model for radiation oncology (referred to
in this section as the ``Radiation Oncology Model'') that
addresses the issues in the Medicare physician fee schedule and
the Medicare hospital outpatient prospective payment system
payment methods.
(6) Concerns regarding the proposed Radiation Oncology
Model included the significant payment reductions proposed in
the model that would jeopardize access to high-quality
radiation therapy services and the onerous reporting
requirements for participating providers. The Radiation
Oncology Model saw indefinite implementation delays.
(7) It is necessary, therefore, to create a payment program
for radiation oncology services that appropriately recognizes
the value of quality radiation oncology services through its
financial incentives while containing costs and providing
patient-centered care.
SEC. 3. RADIATION ONCOLOGY CASE RATE VALUE BASED PAYMENT PROGRAM.
(a) In General.--Title XVIII of the Social Security Act (42 U.S.C.
1395 et seq.) is amended by adding at the end the following:
``SEC. 1899C. RADIATION ONCOLOGY CASE RATE VALUE BASED PAYMENT PROGRAM.
``(a) Establishment.--
``(1) In general.--Not later than 1 year after the date of
enactment of the ROCR Value Based Program Act, the Secretary
shall promulgate regulations, using the procedures described in
paragraph (5), establishing a Radiation Oncology Case Rate
Value Based Payment Program (referred to in this section as the
`ROCR Program') under which per episode payments are provided
to radiation therapy providers or radiation therapy suppliers
for covered treatment furnished to a covered individual during
an episode of care (as such terms are defined in subsection
(j)) in accordance with this section.
``(2) Maintaining payment rates during period prior to
effective date of regulations.--The Secretary shall not reduce
the established payment rates for radiation therapy services
under the physician fee schedule under section 1848 or the
hospital outpatient prospective payment system under section
1833(t) during the time period beginning on the date of
enactment of the ROCR Value Based Program Act and ending on the
date that the regulations issued by the Secretary pursuant to
paragraph (1) become effective.
``(3) ROCR program goals.--The ROCR Program shall seek to--
``(A) create stable, unified payments for radiation
therapy services under this title;
``(B) reduce disparities in radiation therapy care
for Medicare beneficiaries by increasing access to
radiation therapy services close to the homes of
beneficiaries;
``(C) enhance quality of radiation therapy care
through practice accreditation and shorter courses of
treatment, when appropriate;
``(D) leverage and encourage the utilization of
state-of-the-art technology to improve care and
outcomes; and
``(E) protect Medicare resources by achieving
reasonable spending reductions in Medicare for
radiation therapy services.
``(4) Payments.--Under this section, with respect to
covered treatment furnished to covered individuals, payments
shall include--
``(A) per episode payments, as described in
subsection (b), to radiation therapy providers or
radiation therapy suppliers of radiation therapy
services which meet such requirements as the Secretary
shall establish by regulation; and
``(B) the health equity achievement in radiation
therapy add-on payment described in subsection (g).
``(5) Notice and comment rulemaking.--The Secretary shall
promulgate the regulations described in paragraph (1) in
accordance with section 553 of title 5, United States Code, and
issue an advanced notice of proposed rulemaking and notice of
proposed rulemaking with a comment period of not less than 60
days for each.
``(b) Per Episode Payments.--
``(1) In general.--
``(A) Payments.--The Secretary shall pay to a
radiation therapy provider or radiation therapy
supplier an amount equal to 80 percent of the per
episode payment amount determined under paragraph 3
(referred to in this section as `the per episode
payment amount') for each covered individual furnished
covered treatment for an included cancer type to cover
all professional and technical services furnished
during such treatment by the radiation therapy provider
or radiation therapy supplier during an episode of care
(as defined in subsection (j)).
``(B) Deductibles and coinsurance.--Subject to
subsection (e), the Secretary shall pay the per episode
payment amount (subject to any deductible and
coinsurance otherwise applicable under part B) to the
radiation therapy provider or radiation therapy
supplier for an episode of care, as described in
subsection (c).
``(2) Per episode payment requirements and timing.--
``(A) In general.--Subject to subparagraph (B), for
each episode of care furnished to a covered individual:
``(i) First-half of payment.--The Secretary
shall issue \1/2\ of the payment amount under
paragraph (1) prospectively not later than 30
days after the day of the first delivery of
covered treatment.
``(ii) Second-half of payment.--The
Secretary shall issue, with the exception of an
episode of care for treatment of bone or brain
metastases and subject to clause (iii), the
remaining half of the payment amount under
paragraph (1) on the date that is the earlier
of--
``(I) the day the course of covered
treatment is scheduled to end; or
``(II) the 90th day of the episode
of care.
``(iii) Second-half of payment for bone and
brain metastases.--The Secretary shall issue
the remaining half of the payment amount under
paragraph (1) for an episode of care for
treatment of bone or brain metastases on the
date that is the earlier of--
``(I) the day the course of covered
treatment is schedule to end; or
``(II) the 30th day of the episode
of care.
``(B) Patient death.--If a covered individual dies
during treatment, both episode of care payments under
subparagraphs (A) and (B) shall be paid to the
radiation therapy provider or radiation therapy
supplier not later than 30 days after the day of the
final delivery of radiation therapy treatment to the
covered individual.
``(C) Consistency of payment.--
``(i) In general.--The per episode payment
amount shall not change depending on the site
of service.
``(ii) Site of service defined.--For the
purposes of this subparagraph, the term `site
of service' means the hospital outpatient
department or physician office in which
radiation therapy treatment is furnished by the
radiation therapy provider or radiation therapy
supplier.
``(3) Determination of per episode payment amount.--
``(A) In general.--The Secretary shall determine a
per episode payment amount for the professional
component and technical component of treatment for each
included cancer type.
``(B) Amount.--The Secretary shall determine the
per episode payment amount based on national base
rates, as described in subsection (d)(1) and as updated
in subsection (d)(2).
``(C) Adjustments.--The per episode payment amount
shall be subject to--
``(i) the adjustments as described in
subsection (d)(2) and (d)(3);
``(ii) a geographic adjustment, as
described in subsection (d)(3)(A);
``(iii) an inflation adjustment, pursuant
to which the Secretary shall adjust the per
episode payment amount by the percentage
increase in the Medicare Economic Index (as
described in section 1842 for the professional
component payments and the applicable
percentage increase in the Hospital Inpatient
Market Basket Update (as described in section
1886(b)(3)(B)(i)) for the technical component
payments during each 12-month period, and which
varies for the professional and technical
components of the service;
``(iv) a savings adjustment, as described
in subsection (d)(3)(B);
``(v) a health equity achievement in
radiation therapy adjustment applicable only to
the technical component payments, as described
in subsection (g); and
``(vi) a practice accreditation adjustment,
as described in subsection (h), that is only
applicable to technical component payments.
``(c) Treatment of Incomplete Episodes of Care; Concurrent
Treatment.--
``(1) Incomplete episode of care.--In the case of an
incomplete episode of care, payment shall be made to the
radiation therapy provider or radiation therapy supplier for
services furnished under the physician fee schedule under
section 1848 or the hospital outpatient prospective payment
system under section 1833(t), as applicable.
``(2) Multiple episodes of care for the same covered
individual.--A radiation therapy provider or radiation therapy
supplier may initiate a new episode of care for the same
beneficiary for the same course of therapy by providing another
radiation therapy treatment planning service and billing under
an applicable radiation therapy planning trigger code (as
defined in subsection (j).
``(3) Concurrent treatments.--In the case where a treatment
modality described in subsection (j)(3)(B)(i) is furnished to a
covered individual during an episode of care for an included
cancer type, payment may be made concurrently for the treatment
modality under the applicable payment system under this title
with per episode payment under this section for covered
treatment during the episode of care.
``(d) National Base Rate.--
``(1) Determination of national base rates.--For purposes
of the Secretary determining the per episode payment amount
under subsection (b)(3), the national base rates for the
professional component and technical component of radiation
therapy services for each included cancer type are based on the
M-Code national base rates identified in table 75 (including
HCPCS Codes for radiation therapy services and supplies) of the
Federal Register on November 16, 2021, 86 Fed. Reg. 63458,
63925.
``(2) Updates to the national base rates.--
``(A) Annual updates.--
``(i) In general.--Subject to clause (ii),
the Secretary shall annually update the initial
national base rates by--
``(I) in the case of the
professional component of the covered
treatment, the percentage increase in
the Medicare Economic Index; and
``(II) in the case of the technical
component of the covered treatment, the
applicable percentage increase
described in section 1886(b)(3)(B)(i).
``(ii) Payment floor.--For each annual
update, the Secretary shall not reduce the
national base rates below the established rates
from the prior year.
``(B) Periodic updates.--
``(i) In general.--The Secretary shall,
through notice and comment rulemaking, rebase
or revise the national base rates in 5-year
intervals, beginning on the day that is 5 years
after the date the regulations issued pursuant
to subsection (a)(1) become effective.
``(ii) Rebasing limit.--The Secretary shall
not reduce the national base rates through the
process of rebasing by more than 1 percent
every 5 years.
``(iii) Input from providers and
suppliers.--In rebasing or revising the
national base rates pursuant to clause (i), the
Secretary shall seek significant input from
radiation therapy providers, radiation therapy
suppliers, and other stakeholders.
``(C) Rebase and revise defined.--In this
subsection:
``(i) Rebase.--The term `rebase' means to
move the base year for the structure of costs
of the national base rates.
``(ii) Revise.--The term `revise' means
types of changes to national base rates other
than rebasing, such as using different data
sources, cost categories, or price proxies in
the national base rates input.
``(D) New technology or services.--
``(i) In general.--For purposes of this
subparagraph, the term `new technology or
services' means any technology or services
that, after the date of enactment of this
section, receives a Category 1 Current
Procedural Terminology code or is established
in the yearly update to the Medicare physician
fee schedule direct practice expense inputs or
any successor repository of the direct practice
expense input for the delivery of radiation
therapy services.
``(ii) Treatment under the national base
rates.--
``(I) Exclusion during initial
period.--The Secretary shall not
incorporate a radiation therapy service
that is a new technology or service
into the national base rates for an
included cancer type prior to the date
that is 10 years after such service is
first identified as a new technology or
service described in clause (i).
``(II) Incorporation after initial
period.--After the date specified in
subclause (I) with respect to a
radiation therapy service that is a new
technology or service, the Secretary
shall, through stakeholder meetings,
requests for information, and notice
and comment rulemaking, engage
providers, suppliers, radiation therapy
vendors, patient groups, and the public
on possible incorporation of the new
technology or service into the national
base rates for included cancer types
under paragraph (1).
``(iii) Before incorporation into the
national base rate.--Until incorporated into
the national base rates under clause (ii)(II),
any new technology or service shall be paid
under the applicable payment system under this
title.
``(iv) Assessment of certain criteria.--
Prior to incorporating a new technology or
service into the national base rates pursuant
to clause (ii)(II), the Secretary shall
consider market penetration and adoption, costs
relative to base rates, clinical benefits of
the new technology or service, and the clear
consensus of the stakeholder community.
``(3) Adjustments to national base rates.--
``(A) Geographic adjustment.--Prior to applying the
savings adjustment described in subparagraph (B), the
Secretary shall adjust the national base rates for
local cost and wage indices based on where the
radiation therapy services are furnished--
``(i) in the case of the professional
component payment rates, the geographic
adjustment processes described in the Medicare
Physician Fee Schedule Geographic Practice Cost
Index; and
``(ii) in the case of the technical
component payment rates, the geographic
adjustment processes in the hospital outpatient
prospective payment system under section
1833(t).
``(B) Savings adjustment.--
``(i) In general.--The Secretary shall
apply a savings adjustment under this
subparagraph after the geographic adjustments
have been applied under subparagraph (A).
``(ii) Savings adjustment defined.--The
term `savings adjustment' means the percentage
by which the professional component and
technical component payment rates are each
reduced to achieve Medicare savings.
``(e) Availability of Payment Plans for Payment of Coinsurance.--
Following the application of the adjustments described in subsection
(d), but before the application of any sequestration order issued under
the Balanced Budget and Emergency Deficit Control Act of 1985 (2 U.S.C.
900 et seq.), radiation therapy providers and radiation therapy
suppliers shall collect coinsurance for services furnished under the
ROCR Program subject to the following rules:
``(1) In general.--Radiation therapy providers and
radiation therapy suppliers may collect coinsurance applicable
under subsection (b)(1) for covered treatment furnished to a
covered individual under the ROCR Program in multiple
installments under a payment plan.
``(2) Limitation on use as a marketing tool.--Radiation
therapy providers and radiation therapy suppliers may not use
the availability of payment plans for such coinsurance as a
marketing tool to influence the choice of health care provider
by covered individuals.
``(3) Timing of provisions of information.--Radiation
therapy providers and radiation therapy suppliers offering a
payment plan for such coinsurance may inform the covered
individual of the availability of the payment plan prior to or
during the initial treatment planning session and as necessary
thereafter.
``(4) Beneficiary coinsurance payment.--The beneficiary
coinsurance payment shall equal 20 percent of the payment
amount to be paid to the radiation therapy provider or
radiation therapy supplier prior to the application of any
sequestration order issued under the Balanced Budget and
Emergency Deficit Control Act of 1985 (2 U.S.C. 900 et seq.)
for the billed ROCR Program episode of care, except as provided
in paragraph (5).
``(5) Incomplete episode of care.--In the case of an
incomplete episode of care, the beneficiary coinsurance payment
shall equal 20 percent of the amount that would have been paid
in the absence of the ROCR Program for the radiation therapy
services furnished by the radiation therapy provider or
radiation therapy supplier that initiated the professional
component and, if applicable, the radiation therapy provider or
radiation therapy supplier that initiated the technical
component.
``(f) Mandatory Participation.--
``(1) In general.--Except as provided under paragraph (2)
or (3), a radiation therapy provider or radiation therapy
supplier that is participating in the program under this title
and furnishes a covered treatment to a covered individual shall
be required to participate in the ROCR Program.
``(2) Concurrent participation in the rocr program and
other models.--A radiation therapy provider or radiation
therapy supplier that is participating in a State-based Center
for Medicare & Medicaid Innovation model--
``(A) shall not be prohibited from also
participating in the ROCR Program; and
``(B) is not required to participate in the ROCR
Program.
``(3) Significant hardship exemption.--
``(A) In general.--The Secretary may, on a case-by-
case basis, exempt a radiation therapy provider or
radiation therapy supplier from the ROCR Program if the
Secretary determines that application of the program
would result in a significant hardship for such
radiation therapy provider or radiation therapy
supplier or for beneficiaries in the geographic area of
the radiation therapy provider or radiation therapy
supplier.
``(B) Procedure.--The Secretary shall promulgate
regulations, using the procedures described in
subsection (a)(5), regarding eligibility and the
procedure for applying for a significant hardship
exemption.
``(g) Health Equity Achievement in Radiation Therapy Add-On
Payment.--
``(1) In general.--Pursuant to paragraph (2) and subject to
paragraph (7), the Secretary shall adjust the per episode
payment amount in the amount of a health equity achievement in
radiation therapy add-on payment to advance health equity and
support covered individuals in accessing and completing their
radiation therapy treatments for covered treatments of included
cancer types through the provision of transportation services,
subject to the succeeding provisions of this subsection.
``(2) Eligibility.--
``(A) In general.--The health equity achievement in
radiation therapy add-on payment shall be made when the
ICD-10 diagnosis code Z59.82, transportation insecurity
is reported pursuant to subparagraph (B).
``(B) Determination of reporting code.--The
radiation therapy provider or radiation therapy
supplier shall follow the following procedures to
determine if the ICD-10 diagnosis code Z59.82,
transportation insecurity needs to be reported:
``(i) The radiation therapy provider or
radiation therapy supplier shall ask the
patient at the time of patient intake during
the initial patient consultation if, within the
previous 2 months, a lack of reliable
transportation has kept the patient from
attending medical appointments, meetings, or
work, or from completing activities of daily
living.
``(ii) If the patient answers yes to the
question in clause (i), ICD-10 diagnosis code
Z59.82 shall be reported.
``(3) Amount.--The health equity achievement in radiation
therapy add-on payment shall be in the amount of--
``(A) for services furnished during the year
following the date the regulations issued pursuant to
subsection (a)(1) become effective, $500 per patient
per episode of care; and
``(B) for services furnished in subsequent years,
the amount determined under this paragraph for the
preceding year, increased by $10.
``(4) Payment recipient.--The health equity achievement in
radiation therapy add-on payment shall be paid to the radiation
therapy provider or radiation therapy supplier that provides
the technical component of the radiation therapy services.
``(5) Not to be used in addition to or in lieu of other
services.--The health equity achievement in radiation therapy
add-on payment shall not be made in addition to or in lieu of
any other State or Federal program benefits that may be used
for transportation services.
``(6) Documentation.--
``(A) In general.--Radiation therapy providers and
radiation therapy suppliers who receive the health
equity achievement in radiation therapy add-on payment
shall maintain all documentation related to the
spending of such payment on transportation services per
covered individual for a period of 5 years after the
end of the episode of care of the applicable covered
individual.
``(B) Availability to the secretary.--The
documentation described in subparagraph (A) shall be
made available to the Secretary upon request.
``(7) No modification of coinsurance.--The Secretary may
not modify any coinsurance obligation when implementing the
health equity achievement in radiation therapy add-on payment.
``(h) Quality Incentives in the ROCR Value Based Payment Program.--
``(1) In general.--
``(A) Initial increase in payment.--With respect to
covered treatment for an included cancer type furnished
to a covered individual on or after the date the
regulations issued pursuant to subsection (a)(1) become
effective and before the date that is 3 years after
such date, in the case of a radiation therapy provider
or radiation therapy supplier that meets the
requirements described in paragraph (2), payments
otherwise made to such radiation therapy provider or
radiation therapy supplier under the ROCR Program for
the technical component of such services shall be
increased by 0.5 percent (or 0.25 percent in the case
of such a provider or supplier that is a small
radiation therapy supplier or small radiation therapy
provider.
``(B) Reduction in payment.--
``(i) In general.--Subject to clause (ii),
with respect to covered treatment for an
included cancer type furnished to a covered
individual on or after the date that is 3 years
after the regulations issued pursuant to
subsection (a)(1) become effective, in the case
of a radiation therapy provider or radiation
therapy supplier that does not meet the
requirements described in paragraph (2), the
per episode payment to such provider or
supplier under the ROCR Program shall be
reduced by 1.0 percent.
``(ii) Exclusion of small radiation therapy
providers and small radiation therapy
suppliers.--This subparagraph shall not apply
with respect to a small radiation therapy
provider or a small radiation therapy supplier.
``(C) Definition of small radiation therapy
provider and small radiation therapy supplier.--In this
subsection, the terms `small radiation therapy
provider' and `small radiation therapy supplier' mean,
with respect to a radiation therapy provider or
radiation therapy supplier, a provider or supplier that
meets the criteria specified by the Secretary, that may
include criteria relating to the number of linear
accelerators owned or used by the radiation therapy
provider or radiation therapy supplier, the volume of
patients treated by the radiation therapy provider or
radiation therapy supplier, or such other criteria as
the Secretary determines is appropriate, in
consultation with radiation therapy stakeholder
organizations.
``(2) Accreditation requirements.--
``(A) In general.--The requirements described in
this subparagraph with respect to a radiation therapy
provider or radiation therapy supplier (other than such
a provider or supplier that is a small radiation
therapy provider or small radiation therapy supplier)
are that the supplier or provider must--
``(i) maintain or be in the process of
obtaining accreditation by the American College
of Radiology, American College of Radiation
Oncology, or American Society for Radiation
Oncology;
``(ii) comply with certified electronic
health record technology requirements as
determined by the Secretary with exceptions
that are consistent with those of the Merit-
based Incentive Payment System established
under section 1848(q); and
``(iii) submit to the Secretary proof of
the accreditation described in clause (i) in
such form and manner as specified by the
Secretary.
``(B) Requirements for small radiation therapy
providers and small radiation therapy suppliers.--A
radiation therapy provider or radiation therapy
supplier that is a small radiation therapy provider or
small radiation therapy supplier may elect to satisfy
the accreditation requirement under this paragraph by--
``(i) meeting the requirements of
subparagraph (A);
``(ii) using an external audit that
encompasses similar criteria as a nationally
recognized radiation oncology accreditation
organization and submit the outcome of such
external audit to the Secretary; or
``(iii) complying with certified electronic
health record technology requirements as
determined by the Secretary with exceptions
that are consistent with those of the Merit-
Based Incentives Payment System established
under section 1848(q).
``(C) New providers.--A new radiation therapy
provider or new radiation supplier shall complete an
initiation of accreditation or external audit not later
than the date that is 1 year after such provider or
supplier begins furnishing covered treatment to covered
individuals.
``(i) Reporting Requirements.--
``(1) Report on the rocr program.--Not earlier than 7 years
after the date of the enactment of this section, the
Comptroller General of the United States (referred to in this
subsection as the `Comptroller General') shall, after seeking
out the perspectives of radiation oncology stakeholders, submit
to the appropriate committees of jurisdiction of the Senate and
the House of Representatives a report that--
``(A) evaluates--
``(i) the implementation of the ROCR
Program, and the impact such Program has had on
Federal healthcare spending;
``(ii) the impact the ROCR Program has had
on the ability of covered individuals to access
covered treatment;
``(iii) whether any cancer types or
radiation therapy services, such as
brachytherapy, proton therapy, or therapeutic
radiopharmaceuticals, should be added or
removed from the ROCR Program; and
``(iv) the potential application of the
ROCR Program to benefits provided under part C
of this title; and
``(B) includes any recommendations for
administrative and legislative changes.
``(2) Report on access to radiation therapy in rural and
underserved areas.--Not later than 3 years after the date of
the enactment of this section, the Comptroller General shall
submit a report to the appropriate committees of jurisdiction
of the Senate and the House of Representatives that identifies
the following:
``(A) Radiation therapy deserts.
``(B) Methods to increase access to new radiation
therapy technologies in rural and underserved areas,
including technologies required for clinical treatment
planning, simulation, dosimetry, medical radiation
physics, radiation treatment devices, radiation
treatment delivery, radiation treatment management, and
such other items as the Comptroller General may
determine are medically necessary.
``(C) A program to provide assistance in the form
of grants or loans to radiation therapy providers or
radiation therapy suppliers for the purpose of ensuring
access to the most current radiation therapy
technology.
``(3) Determination and definition of radiation therapy
deserts.--
``(A) Definition.--For purposes of this subsection,
the term `radiation therapy desert' means a region
determined by the Comptroller General under
subparagraph (B) with a mismatch between radiation
therapy resources and oncologic need.
``(B) Determination.--In determining whether a
region qualifies as a radiation therapy desert, the
Comptroller General shall take into account the ratio
or density of radiation therapy providers and radiation
therapy suppliers practicing in a geographic area as
compared to the population size in that geographic
area.
``(j) Definitions.--In this section:
``(1) Applicable radiation therapy planning trigger code.--
The term `applicable radiation therapy planning trigger code'
means services identified, as of the date that the regulations
issued pursuant to subsection (a)(1) become effective, by the
following HCPCS codes (and as subsequently modified by the
Secretary):
``(A) 77261, therapeutic radiology treatment
planning, simple.
``(B) 77262, therapeutic radiology treatment
planning, intermediate.
``(C) 77263, therapeutic radiology treatment
planning, complex.
``(2) Covered individual.--The term `covered individual'
means an individual who--
``(A) is enrolled for benefits under part B;
``(B) is not enrolled in a Medicare Advantage plan
under part C or a PACE program under section 1894; and
``(C) is diagnosed with an included cancer type.
``(3) Covered treatment.--
``(A) In general.--The term `covered treatment'
means, subject to subparagraph (B), radiation therapy
services furnished to a covered individual.
``(B) Exclusions.--Such term does not include--
``(i) during the period beginning on the
date on which the regulation issued pursuant to
subsection (a)(1) become effective and ending
on the date that is 10 years after such date,
brachytherapy, proton beam radiation therapy
services, intraoperative radiotherapy,
superficial radiation therapy, hyperthermia,
and therapeutic radiopharmaceuticals;
``(ii) inpatient radiation therapy services
furnished in a subsection (d) hospital or
ambulatory surgical center;
``(iii) radiation therapy services
furnished in cancer hospitals that are exempt
from the hospital outpatient prospective
payment system under section 1833(t);
``(iv) physician services that are
furnished or supervised by the physician
furnishing radiation therapy or by another
physician, such as cancer surgeries,
chemotherapy, and other services; or
``(v) physician services that are furnished
using technology represented by Healthcare
Common Procedure Coding System codes that are
not included in the M-code national base rates
identified in table 75 (including in HCPCS
Codes for radiation therapy services and
supplies) of the Federal Register on November
16, 2021, 86 Fed. Reg. 63485, 63925.
``(4) Episode of care.--The term `episode of care' means,
with respect to a covered individual, the period--
``(A) beginning on the day radiation therapy
planning for an included cancer type, billed under an
applicable radiation therapy planning trigger code, is
furnished to a covered individual if radiation therapy
treatment is initiated not later than 30 days after the
day such radiation therapy planning service is
furnished; and
``(B) ends--
``(i) for treatment of all included cancer
types except bone and brain metastases
treatment, the day that is 90 days after the
day the episode of care begins under clause
(i); and
``(ii) for bone and brain metastases
treatment, the day that is 30 days after the
day the episode of care begins under clause
(i).
``(5) Included cancer types.--The term `included cancer
type' means any of the following types of cancer:
``(A) Anal.
``(B) Bladder.
``(C) Bone Metastases.
``(D) Brain Metastases.
``(E) Breast.
``(F) Cervical.
``(G) Central Nervous System Tumors.
``(H) Colorectal.
``(I) Head and Neck.
``(J) Lung.
``(K) Lymphoma.
``(L) Pancreatic.
``(M) Prostate.
``(N) Upper Gastrointestinal.
``(O) Uterine.
``(6) Healthcare common procedure coding system.--The term
`Healthcare Common Procedure Coding System' means the
standardized coding system used by Medicare and other health
insurance programs to ensure that claims are processed in an
orderly and consistent manner.
``(7) Incomplete episode of care.--The term `incomplete
episode of care' means, with respect to a covered individual,
an episode of care that is not completed because--
``(A) the individual being treated ceases to be a
covered individual, including in the case where the
individual loses benefits under this title, at any time
after the initial treatment planning service is
furnished and before the episode of care for the
covered treatment is complete; or
``(B) a covered individual switches radiation
therapy provider or radiation therapy supplier before
all included radiation therapy services in the episode
of care for the covered treatment have been furnished.
``(8) Professional component.--The term `professional
component' means the included radiation therapy services that
may only be furnished by a physician.
``(9) Radiation therapy.--The term `radiation therapy'
means the careful use of various forms of radiation, such as
external beam radiation therapy, to treat cancer and other
diseases safely and effectively.
``(10) Radiation therapy provider.--The term `radiation
therapy provider' means a hospital outpatient department
enrolled under this title that furnishes radiation therapy
services.
``(11) Radiation therapy services.--The term `radiation
therapy services' means the treatment planning, technical
preparation, special services (such as simulation), treatment
delivery, and treatment management services associated with
cancer treatment that uses high doses of radiation to kill
cancer cells and shrink tumors.
``(12) Radiation therapy supplier.--The term `radiation
therapy supplier' means a physician group practice or
freestanding radiation therapy center enrolled under this title
that furnishes radiation therapy services.
``(13) Technical component.--The term `technical component'
means the included radiation therapy services that are not
furnished by a physician, including the provision of equipment,
supplies, personnel, and administrative costs related to
radiation therapy services.
``(14) Transportation services.--The term `transportation
services' means the provision of free or discounted
transportation made available to covered individuals furnished
covered treatment which are not air, luxury, or ambulance-level
transportation, but may include car services, ride shares, or
public transportation.''.
(b) Exclusion of Participating Radiation Therapy Providers,
Radiation Therapy Suppliers, and Physicians From the Merit-Based
Incentive Payment System.--Section 1848(q)(1)(C)(ii) of the Social
Security Act (42 U.S.C. 1395w-4(q)(1)(c)(II)) is amended--
(1) in subclause (II), by striking ``or'' at the end;
(2) in subclause (III), by striking the period at the end
and inserting ``; or''; and
(3) by adding at the end the following new subclause:
``(IV) is a radiation therapy
provider or radiation therapy supplier
(as those terms are defined in
subsection (j) of section1899C) that is
participating in the Radiation Oncology
Case Rate Value Based Payment Program
established under that section.''.
SEC. 4. REVISION TO CIVIL MONETARY PENALTIES REGARDING RADIATION
ONCOLOGY CASE RATE PATIENT TRANSPORTATION SERVICES.
Section 1128A of the Social Security Act (42 U.S.C. 1320a-7a) is
amended--
(1) in subsection (i)(6)--
(A) in subparagraph (I), by striking ``or'' at the
end;
(B) in subparagraph (J)(iii), by striking the
period at the end and inserting ``; or''; and
(C) by adding at the end the following new
subparagraph:
``(K) the provision of transportation services by
an eligible entity, as defined in subsection (t), if--
``(i) the availability of the
transportation services--
``(I) is set forth in a policy that
the eligible entity, as defined in
subsection (t), applies uniformly and
consistently; and
``(II) is not determined in a
manner related to the past or
anticipated volume or value of Federal
health care program business;
``(ii) the eligible entity does not
publicly market or advertise the transportation
services;
``(iii) the driver who provides the
transportation services does not market health
care items or services during the course of the
transportation or at any time;
``(iv) the driver or individual arranging
for the transportation services is not paid on
a per-beneficiary-transported basis;
``(v) the eligible entity makes the
transportation services available only to an
individual who--
``(I) is an established patient, as
defined in subsection (t), of the
eligible entity that is providing or
facilitating free or discounted
transportation;
``(II) resides--
``(aa) within a 75 miles
radius of the radiation therapy
provider or radiation therapy
supplier to or from which the
patient would be transported;
or
``(bb) in a rural area, as
defined in subsection (t); and
``(III) is receiving radiation
therapy services for the purpose of
obtaining medically necessary items and
services; and
``(vi) the eligible entity that makes the
transportation services available bears the
costs of the transportation services and does
not shift the burden of those costs onto any
Federal health care program, other payers, or
individuals.''; and
(2) by adding at the end the following new subsection:
``(t) For purposes of subsection (i)(6)(K), the following
definitions apply:
``(1) The term `eligible entity' means any individual or
entity, or any individual or entity acting on behalf of such
individual or entity that does not supply health care items as
the primary occupation of the individual or entity.
``(2) The term `established patient' means an individual
who--
``(A) has selected and scheduled an appointment
with a radiation therapy provider or radiation therapy
supplier; or
``(B) has attended an appointment with such
provider or supplier.
``(3) The terms `radiation therapy provider', `radiation
therapy services', and `radiation therapy supplier' have the
meaning given such terms in section 1866G(k).
``(4) The term `rural area' means an area that is not an
urban area.
``(5) The term `transportation services'--
``(A) means the provision of free or discounted
transportation made available to Federal health care
program beneficiaries receiving radiation therapy
services;
``(B) includes car services, ride shares, and
public transportation; and
``(C) does not include air, luxury, or ambulance-
level transportation.
``(6) The term `urban area' means--
``(A) a Metropolitan Statistical Area or New
England County Metropolitan Area, as defined by the
Office of Management and Budget;
``(B) Litchfield County, Connecticut;
``(C) York County, Maine;
``(D) Sagadahoc County, Maine;
``(E) Merrimack County, New Hampshire; and
``(F) Newport County, Rhode Island.''.
SEC. 5. EXEMPTION OF RADIATION ONCOLOGY CASE RATE VALUE BASED PAYMENT
PROGRAM FROM BUDGET NEUTRALITY ADJUSTMENT REQUIREMENTS.
(a) Payment of Benefits.--Section 1833(t) of the Social Security
Act (42 U.S.C. 1395l(t)) is amended by adding at the end the following
new paragraph:
``(23) Non budget neutral application of reduced
expenditures resulting from the radiation oncology case rate
value based payment program.--The Secretary shall not take into
account the reduced expenditures that result from the
implementation of section 1899C in making any budget neutrality
adjustments under this subsection.''.
(b) Payment for Physicians' Services.--Section 1848(c)(2)(B) of the
Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)) is amended--
(1) in clause (iv)--
(A) in subclause (V), by striking ``and'' at the
end;
(B) in subclause (VI), by striking the period at
the end and inserting ``; and''; and
(C) by adding at the end the following new
subclause:
``(VII) section 1899C shall not be
taken into account in applying clause
(ii)(II) for a year following the
enactment of section 1899C.''; and
(2) in clause (v), by adding at the end the following new
subclause:
``(XII) Reduced expenditures
attributable to the radiation oncology
case rate value based payment
program.--Effective for fee schedules
established following the enactment of
section 1899C, reduced expenditures
attributable to the Radiation Oncology
Case Rate Value Based Payment Program
under section 1899C.''.
<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.
Referred to the Subcommittee on Health.
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