[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3961 Introduced in House (IH)]
111th CONGRESS
1st Session
H. R. 3961
To amend title XVIII of the Social Security Act to reform the Medicare
SGR payment system for physicians.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
October 29, 2009
Mr. Dingell (for himself, Mr. Rangel, Mr. Waxman, Mr. George Miller of
California, Mr. Stark, Mr. Pallone, and Mr. Andrews) 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 reform the Medicare
SGR payment system for physicians.
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 ``Medicare Physician Payment Reform
Act of 2009''.
SEC. 2. MEDICARE SUSTAINABLE GROWTH RATE REFORM.
(a) Transitional Update for 2010.--Section 1848(d) of the Social
Security Act (42 U.S.C. 1395w-4(d)) is amended by adding at the end the
following new paragraph:
``(10) Update for 2010.--The update to the single
conversion factor established in paragraph (1)(C) for 2010
shall be the percentage increase in the MEI (as defined in
section 1842(i)(3)) for that year.''.
(b) Rebasing SGR Using 2009; Limitation on Cumulative Adjustment
Period.--Section 1848(d)(4) of such Act (42 U.S.C. 1395w-4(d)(4)) is
amended--
(1) in subparagraph (B), by striking ``subparagraph (D)''
and inserting ``subparagraphs (D) and (G)''; and
(2) by adding at the end the following new subparagraph:
``(G) Rebasing using 2009 for future update
adjustments.--In determining the update adjustment
factor under subparagraph (B) for 2011 and subsequent
years--
``(i) the allowed expenditures for 2009
shall be equal to the amount of the actual
expenditures for physicians' services during
2009; and
``(ii) the reference in subparagraph
(B)(ii)(I) to `April 1, 1996' shall be treated
as a reference to `January 1, 2009 (or, if
later, the first day of the fifth year before
the year involved)'.''.
(c) Limitation on Physicians' Services Included in Target Growth
Rate Computation to Services Covered Under Physician Fee Schedule.--
Effective for services furnished on or after January 1, 2009, section
1848(f)(4)(A) of such Act is amended by striking ``(such as clinical''
and all that follows through ``in a physician's office'' and inserting
``for which payment under this part is made under the fee schedule
under this section, for services for practitioners described in section
1842(b)(18)(C) on a basis related to such fee schedule, or for services
described in section 1861(p) (other than such services when furnished
in the facility of a provider of services)''.
(d) Establishment of Separate Target Growth Rates for Categories of
Services.--
(1) Establishment of service categories.--Subsection (j) of
section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is
amended by adding at the end the following new paragraph:
``(5) Service categories.--For services furnished on or
after January 1, 2009, each of the following categories of
physicians' services (as defined in paragraph (3)) shall be
treated as a separate `service category':
``(A) Evaluation and management services that are
procedure codes (for services covered under this title)
for--
``(i) services in the category designated
Evaluation and Management in the Health Care
Common Procedure Coding System (established by
the Secretary under subsection (c)(5) as of
December 31, 2009, and as subsequently modified
by the Secretary); and
``(ii) preventive services (as defined in
section 1861(iii)) for which payment is made
under this section.
``(B) All other services not described in
subparagraph (A).
Service categories established under this paragraph shall apply
without regard to the specialty of the physician furnishing the
service.''.
(2) Establishment of separate conversion factors for each
service category.--Subsection (d)(1) of section 1848 of the
Social Security Act (42 U.S.C. 1395w-4) is amended--
(A) in subparagraph (A)--
(i) by designating the sentence beginning
``The conversion factor'' as clause (i) with
the heading ``Application of single conversion
factor.--'' and with appropriate indentation;
(ii) by striking ``The conversion factor''
and inserting ``Subject to clause (ii), the
conversion factor''; and
(iii) by adding at the end the following
new clause:
``(ii) Application of multiple conversion
factors beginning with 2011.--
``(I) In general.--In applying
clause (i) for years beginning with
2011, separate conversion factors shall
be established for each service
category of physicians' services (as
defined in subsection (j)(5)) and any
reference in this section to a
conversion factor for such years shall
be deemed to be a reference to the
conversion factor for each of such
categories.
``(II) Initial conversion
factors.--Such factors for 2011 shall
be based upon the single conversion
factor for the previous year multiplied
by the update established under
paragraph (11) for such category for
2011.
``(III) Updating of conversion
factors.--Such factor for a service
category for a subsequent year shall be
based upon the conversion factor for
such category for the previous year and
adjusted by the update established for
such category under paragraph (11) for
the year involved.''; and
(B) in subparagraph (D), by striking ``other
physicians' services'' and inserting ``for physicians'
services described in the service category described in
subsection (j)(5)(B)''.
(3) Establishing updates for conversion factors for service
categories.--Section 1848(d) of the Social Security Act (42
U.S.C. 1395w-4(d)), as amended by subsection (a), is amended--
(A) in paragraph (4)(C)(iii), by striking ``The
allowed'' and inserting ``Subject to paragraph (11)(B),
the allowed''; and
(B) by adding at the end the following new
paragraph:
``(11) Updates for service categories beginning with
2011.--
``(A) In general.--In applying paragraph (4) for a
year beginning with 2011, the following rules apply:
``(i) Application of separate update
adjustments for each service category.--
Pursuant to paragraph (1)(A)(ii)(I), the update
shall be made to the conversion factor for each
service category (as defined in subsection
(j)(5)) based upon an update adjustment factor
for the respective category and year and the
update adjustment factor shall be computed, for
a year, separately for each service category.
``(ii) Computation of allowed and actual
expenditures based on service categories.--In
computing the prior year adjustment component
and the cumulative adjustment component under
clauses (i) and (ii) of paragraph (4)(B), the
following rules apply:
``(I) Application based on service
categories.--The allowed expenditures
and actual expenditures shall be the
allowed and actual expenditures for the
service category, as determined under
subparagraph (B).
``(II) Application of category
specific target growth rate.--The
growth rate applied under clause
(ii)(II) of such paragraph shall be the
target growth rate for the service
category involved under subsection
(f)(5).
``(B) Determination of allowed expenditures.--In
applying paragraph (4) for a year beginning with 2010,
notwithstanding subparagraph (C)(iii) of such
paragraph, the allowed expenditures for a service
category for a year is an amount computed by the
Secretary as follows:
``(i) For 2010.--For 2010:
``(I) Total 2009 actual
expenditures for all services included
in sgr computation for each service
category.--Compute total actual
expenditures for physicians' services
(as defined in subsection (f)(4)(A))
for 2009 for each service category.
``(II) Increase by growth rate to
obtain 2010 allowed expenditures for
service category.--Compute allowed
expenditures for the service category
for 2010 by increasing the allowed
expenditures for the service category
for 2009 computed under subclause (I)
by the target growth rate for such
service category under subsection (f)
for 2010.
``(ii) For subsequent years.--For a
subsequent year, take the amount of allowed
expenditures for such category for the
preceding year (under clause (i) or this
clause) and increase it by the target growth
rate determined under subsection (f) for such
category and year.''.
(4) Application of separate target growth rates for each
category.--
(A) In general.--Section 1848(f) of the Social
Security Act (42 U.S.C. 1395w-4(f)) is amended by
adding at the end the following new paragraph:
``(5) Application of separate target growth rates for each
service category beginning with 2010.--The target growth rate
for a year beginning with 2010 shall be computed and applied
separately under this subsection for each service category (as
defined in subsection (j)(5)) and shall be computed using the
same method for computing the target growth rate except that
the factor described in paragraph (2)(C) for--
``(A) the service category described in subsection
(j)(5)(A) shall be increased by 0.02; and
``(B) the service category described in subsection
(j)(5)(B) shall be increased by 0.01.''.
(B) Use of target growth rates.--Section 1848 of
such Act is further amended--
(i) in subsection (d)--
(I) in paragraph (1)(E)(ii), by
inserting ``or target'' after
``sustainable''; and
(II) in paragraph (4)(B)(ii)(II),
by inserting ``or target'' after
``sustainable'';
(ii) in the heading of subsection (f), by
inserting ``and Target Growth Rate'' after
``Sustainable Growth Rate'';
(iii) in subsection (f)(1)--
(I) by striking ``and'' at the end
of subparagraph (A);
(II) in subparagraph (B), by
inserting ``before 2010'' after ``each
succeeding year'' and by striking the
period at the end and inserting ``;
and''; and
(III) by adding at the end the
following new subparagraph:
``(C) November 1 of each succeeding year the target
growth rate for such succeeding year and each of the 2
preceding years.''; and
(iv) in subsection (f)(2), in the matter
before subparagraph (A), by inserting after
``beginning with 2000'' the following: ``and
ending with 2009''.
(e) Application to Health Care Group Demonstration Program and
Successor Accountable Care Organization Pilot Program.--In applying the
target growth rate under subsections (d) and (f) of section 1848 of the
Social Security Act to services furnished by a practitioner to
beneficiaries who are attributable to a health care group under the
demonstration program provided under section 1886A of such Act (or to
an accountable care organization under a pilot program that is a
succcessor to such demonstration program under a section of such Act),
the Secretary of Health and Human Services shall develop, not later
than January 1, 2012, for application beginning with 2012, a method
that--
(1) allows each such group or organization to have its own
expenditure targets and updates for such practitioners, with
respect to beneficiaries who are attributable to that group or
organization, that are consistent with the methodologies
described in such subsection (f); and
(2) provides that the target growth rate applicable to
other physicians shall not apply to such physicians to the
extent that the physicians' services are furnished through the
group or organization.
In applying paragraph (1), the Secretary of Health and Human Services
may apply the difference in the update under such paragraph on a claim-
by-claim or lump sum basis and such a payment shall be taken into
account under the demonstration or pilot program.
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