I 111th CONGRESS 1st Session H. R. 902 IN THE HOUSE OF REPRESENTATIVES February 4, 2009 Mr. Smith of Washington (for himself, Mr. Dicks, Mr. McDermott, Mr. Inslee, Mr. Baird, and Mr. Larsen of Washington) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend title XVIII of the Social Security Act to improve the provision of items and services provided to Medicare beneficiaries residing in rural areas.

1.

Short title

This Act may be cited as the MediFair Act of 2009.

2.

Findings

Congress makes the following findings: (1)Regional inequities in medicare reimbursement have created barriers to care for seniors and the disabled. (2)The regional inequities in medicare reimbursement penalize States that have cost-effective health care delivery systems and reward those States with high utilization rates and that provide inefficient care. (3)Comparatively, in 2003, per capita spending under traditional Medicare was $5,661 for beneficiaries in Seattle, $9,752 for those in Los Angeles, and $11,340 for those in Miami. (4)Over a lifetime, regional inequities can mean as much as a $125,000 difference in the cost of care provided per beneficiary. (5)Regional inequities have resulted in creating very different Medicare programs and amount of care received for seniors and the disabled based on where they live. (6)Because the Medicare Advantage rate is based on the fee-for-service reimbursement rate, regional inequities have allowed some Medicare beneficiaries access to Medicare Advantage plans with significantly more benefits and reduced cost sharing. Beneficiaries in States with lower Medicare Advantage reimbursement rates have not benefitted to the same degree as beneficiaries in other parts of the country. (7)Regional inequities in medicare reimbursement have created an unfair competitive advantage for hospitals and other health care providers in States that receive above average payments. Higher payments mean that those providers can pay higher salaries in a tight, competitive market. (8)Regional inequities in medicare reimbursement, if left unchecked, will reduce access to medicare services and impact healthy outcomes for beneficiaries.

3.

Improving fairness of payments to providers under the Medicare fee-for-service program

Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is amended by adding at the end the following new section:

1899.

Improving payment equity under the original Medicare fee-for-service program

(a)

In general

Notwithstanding any other provision of law, the Secretary shall establish a system for making adjustments to the amount of payment made to entities and individuals for items and services provided under the original medicare fee-for-service program under parts A and B. (b)

System requirements

(1)

Increase for States below the national average

Under the system established under subsection (a), if a State average per beneficiary amount for a year is less than the national average per beneficiary amount for such year, then the Secretary (beginning in 2010) shall increase the amount of applicable payments in such a manner as will result (as estimated by the Secretary) in the State average per beneficiary amount for the subsequent year being equal to the national average per beneficiary amount for such subsequent year. (2)

Reduction for certain States above the national average to enhance quality care and maintain budget neutrality

(A)

In general

The Secretary shall ensure that the increase in payments under paragraph (1) does not cause the estimated amount of expenditures under this title for a year to increase or decrease from the estimated amount of expenditures under this title that would have been made in such year if this section had not been enacted by reducing the amount of applicable payments in each State that the Secretary determines has— (i)a State average per beneficiary amount for a year that is greater than the national average per beneficiary amount for such year; and (ii)healthy outcome measurements or quality care measurements that indicate that a reduction in applicable payments would encourage more efficient use of, and reduce overuse of, items and services for which payment is made under this title. (B)

Limitation

The Secretary shall not reduce applicable payments under subparagraph (A) to a State that— (i)has a State average per beneficiary amount for a year that is greater than the national average per beneficiary amount for such year; and (ii)has healthy outcome measurements or quality care measurements that indicate that the applicable payments are being used to improve the access of beneficiaries to quality care. (3)

Determination of averages

(A)

State average per beneficiary amount

Each year (beginning in 2009), the Secretary shall determine a State average per beneficiary amount for each State which shall be equal to the Secretary’s estimate of the average amount of expenditures under the original medicare fee-for-service program under parts A and B for the year for a beneficiary enrolled under such parts that resides in the State. (B)

National average per beneficiary amount

Each year (beginning in 2009), the Secretary shall determine the national average per beneficiary amount which shall be equal to the average of the State average per beneficiary amount determined under subparagraph (A) for the year. (4)

Definitions

In this section: (A)

Applicable payments

The term applicable payments means payments made to entities and individuals for items and services provided under the original medicare fee-for-service program under parts A and B to beneficiaries enrolled under such parts that reside in the State. (B)

State

The term State has the meaning given such term in section 210(h). (c)

Beneficiaries held harmless

The provisions of this section shall not affect— (1)the entitlement to items and services of a beneficiary under this title, including the scope of such items and services; or (2)any liability of the beneficiary with respect to such items and services. (d)

Regulations

(1)

In general

The Secretary, in consultation with the Medicare Payment Advisory Commission, shall promulgate regulations to carry out this section. (2)

Protecting rural communities

In promulgating the regulations pursuant to paragraph (1), the Secretary shall give special consideration to rural areas.

.

4.

MedPAC recommendations on healthy outcomes and quality care

(a)

Recommendations

The Medicare Payment Advisory Commission established under section 1805 of the Social Security Act (42 U.S.C. 1395b–6) shall develop recommendations on policies and practices that, if implemented, would encourage— (1)healthy outcomes and quality care under the medicare program in States with respect to which payments are reduced under section 1899(b)(2) of such Act (as added by section 3); and (2)the efficient use of payments made under the medicare program in such States. (b)

Submission

Not later than the date that is 9 months after the date of enactment of this Act, the Commission shall submit to Congress the recommendations developed under subsection (a).