[Congressional Bills 112th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3315 Introduced in House (IH)]

112th CONGRESS
  1st Session
                                H. R. 3315

 To establish a pilot program providing for monthly fee-based payments 
   for direct primary care medical homes for Medicare-Medicaid dual 
              eligibles and other Medicare beneficiaries.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            November 2, 2011

 Mr. Cassidy 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 establish a pilot program providing for monthly fee-based payments 
   for direct primary care medical homes for Medicare-Medicaid dual 
              eligibles and other Medicare beneficiaries.

    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 ``Direct M.D. Care Act of 2011''.

SEC. 2. QUALIFIED DIRECT PRIMARY CARE MEDICAL HOME PILOT FOR MEDICARE 
              PART B BENEFICIARIES.

    (a) In General.--The Secretary of Health and Human Services (in 
this section referred to as the ``Secretary'') shall establish a 
program of pilot projects (each in this section referred to as the 
``pilot project'') under part B of title XVIII of the Social Security 
Act under which the Secretary reimburses a qualified direct primary 
care medical home practice, as described in section 1301(a)(3) of the 
Patient Protection and Affordable Care Act (as amended by section 
10104(a) of such Act), using a monthly fee-based payment methodology.
    (b) Affordable Primary Care.--No pilot project may be established 
under this section with respect to a medical home if the monthly fee 
under this section for an enrolled individual exceeds $100 (or $125 in 
the case of a dual eligible individual (as defined in subsection (i)). 
The Secretary shall adjust from time to time the dollar amounts 
specified in the previous sentence for inflation.
    (c) Scope of Services.--Each pilot project shall employ the 
following activities and functions associated with direct primary care 
medical homes:
            (1) Provision of preventive care.
            (2) Wellness counseling.
            (3) Primary care.
            (4) Coordination of primary care with specialty and 
        hospital care.
            (5) Urgent care services.
            (6) Availability of office appointments 7 days per week.
            (7) E-mail and telephone consultation.
            (8) Availability of telephone access for urgent care 
        consultation on a 7-day per week, 24-hour per day basis.
            (9) Use of a primary care provider panel size that promotes 
        the ability of participating providers to appropriately provide 
        the scope of services described in this subparagraph.
    (d) Priorities.--
            (1) Qualified state.--At least one such pilot project shall 
        be conducted in a State that--
                    (A) has enacted legislation to enable direct 
                primary care practices to deliver monthly fee-based 
                primary care without being regulated as an insurer or 
                health maintenance organization; and
                    (B) has direct primary care practices which enroll, 
                in the aggregate as of September 1, 2011, at least 
                3,000 individuals using the monthly fee-based primary 
                care model.
            (2) Projects including dual eligibles.--Subject to 
        paragraph (1), the Secretary shall provide priority to pilot 
        projects that seek to enroll individuals who are dual eligible 
        individuals.
    (e) No Insurance.--Care provided under a pilot project shall not be 
considered an insurance product and shall not be subject to regulation 
as insurance product or health maintenance organization by State 
insurance commissioners.
    (f) Application of Provisions.--The provisions of subsections 
(b)(3) and (d) of section 1115A of the Social Security Act (42 U.S.C. 
1315a) shall apply in carrying out the program of pilot projects under 
this section in the same manner as such provisions apply to testing 
models under subsection (b)(1) of such section and, notwithstanding any 
other provision of law, funds appropriated under subsection (f)(1)(B) 
of such section for activities under such section shall be available to 
carry out pilot projects under this section.
    (g) Reporting to Secretary.--An entity that establishes a pilot 
project shall submit to the Secretary an annual report that measures 
the progress, of patients enrolled in the project with one or more 
chronic conditions, on the following:
            (1) Emergency room visits.
            (2) Hospitalizations.
            (3) Surgeries (including type of surgery).
            (4) Specialist visits.
            (5) Use of advanced radiology (other than mammograms and 
        DEXA scans).
    (h) Provision of Data.--The Secretary shall provide the entities 
operating pilot projects with all necessary and relevant patient data, 
including any prior claims data, needed for clinical purposes and for 
the purpose of providing an evaluation of such projects.
    (i) Dual Eligible Individual Defined.--In this section, the term 
``dual eligible individual'' means a Medicare beneficiary who is 
described in subparagraph (A)(ii) of section 1935(c)(6) of the Social 
Security Act (42 U.S.C. 1396u-5(c)(6)), taking into account the 
application of subparagraph (B) of such section.
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