[Congressional Bills 112th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6548 Introduced in House (IH)]

112th CONGRESS
  2d Session
                                H. R. 6548

  To amend title XVIII of the Social Security Act to provide coverage 
      under the Medicare program for diabetes prevention services.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           September 21, 2012

 Mr. Shuler (for himself and Mrs. Davis of California) 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 provide coverage 
      under the Medicare program for diabetes prevention 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 ``Diabetes Prevention Act of 2012''.

SEC. 2. MEDICARE COVERAGE FOR DIABETES PREVENTION SERVICES.

    Title XVIII of the Social Security Act is amended by adding at the 
end the following new section:

``SEC. 1899B. DIABETES PREVENTION PROGRAM.

    ``(a) Payments for Diabetes Prevention Services.--
            ``(1) In general.--Beginning not later than January 1, 
        2013, the Secretary shall make payments to qualified third-
        party intermediaries for diabetes prevention services furnished 
        to prediabetic Medicare beneficiaries by eligible entities in 
        local communities that are networked and managed by such third-
        party intermediaries, for the purpose of preventing such 
        beneficiaries from developing diabetes.
            ``(2) Source.--The payments under paragraph (1) shall be 
        made from the Federal Supplementary Medical Insurance Trust 
        Fund.
            ``(3) Special consideration for the dual eligible 
        individuals.--In implementing this section, the Secretary of 
        Health and Human Services shall give special consideration to 
        the needs of dual eligible individuals (as such term is defined 
        in section 1915(h)(2)(B)).
    ``(b) Diabetes Prevention Services and Prediabetic Medicare 
Beneficiary Defined.--For purposes of this section:
            ``(1) Diabetes prevention services.--The term `diabetes 
        prevention services' means services that--
                    ``(A) are furnished to prediabetic Medicare 
                beneficiaries by an eligible entity; and
                    ``(B) are components of a diabetes prevention 
                program that meets the requirements, goals, and 
                objectives of the National Diabetes Program of the 
                Centers for Disease Control and Prevention (including 
                use of the curriculum of such program).
            ``(2) Prediabetic medicare beneficiary.--The term 
        `prediabetic Medicare beneficiary' means an individual who is 
        entitled to benefits under part A, or enrolled for benefits 
        under part B and who meets criteria that the Secretary may 
        establish, in consultation with the Director of the Centers for 
        Disease Control and Prevention. Such criteria shall be similar 
        to the criteria for participation in the National Diabetes 
        Program of the Centers for Disease Control and Prevention.
    ``(c) Eligible Entities.--For purposes of this section:
            ``(1) In general.--The term `eligible entity' means an 
        entity (such as a provider of services, physician, or other 
        health care practitioner, a trained lifestyle coach, community-
        based organization, or a health insurance or services company) 
        that the Secretary determines--
                    ``(A) can appropriately furnish diabetes prevention 
                services through a diabetes prevention program that 
                satisfies the requirements of subsection (b)(1)(B);
                    ``(B)(i) has entered into a contract with a 
                qualified third-party intermediary that meets the 
                requirements of subsection (e); or
                    ``(ii) is a third-party intermediary and meets the 
                requirements of subsection (d)(1)(A)(ii); and
                    ``(C) is recognized by the Centers for Disease 
                Control and Prevention under the Diabetes Prevention 
                Recognition Program and such recognition has not 
                expired.
            ``(2) Trained lifestyle coach.--The term `trained lifestyle 
        coach' means an individual who has received adequate training, 
        as determined by the Secretary, in the curriculum of the 
        National Diabetes Program of the Centers for Disease Control 
        and Prevention to provide diabetes prevention services.
    ``(d) Qualified Third-Party Intermediary.--
            ``(1) In general.--For purposes of this section, the term 
        `qualified third-party intermediary' means a third-party 
        intermediary that has entered into a contract with the 
        Secretary to conduct the following activities:
                    ``(A) Managed network of eligible entities.--The 
                third-party intermediary--
                            ``(i) has entered into a contract that 
                        meets the requirements of subsection (e) with 
                        one or more eligible entities; or
                            ``(ii) is an eligible entity.
                    ``(B) Tracking, processing, and engagement.--The 
                third-party intermediary shall--
                            ``(i) if such intermediary has not entered 
                        into a contract described in subparagraph 
                        (A)(i), furnish diabetes prevention services;
                            ``(ii) track, using adequate information 
                        technology systems, the outcomes (including 
                        class attendance and weight loss) of the 
                        diabetes prevention services furnished to 
                        prediabetic Medicare beneficiaries by such 
                        intermediary or by any eligible entity with a 
                        contract with the intermediary under 
                        subparagraph (A)(i);
                            ``(iii) implement business processes to 
                        manage workflow (such as eligibility, 
                        reporting, claims billing, class scheduling, 
                        and enrollment) related to the provision of 
                        diabetes prevention services to prediabetic 
                        Medicare beneficiaries by the intermediary or 
                        eligible entities with contracts with the 
                        intermediary under subparagraph (A)(i);
                            ``(iv) perform various forms of engagement 
                        with, and outreach to, prediabetic Medicare 
                        beneficiaries, including individuals receiving 
                        diabetes prevention services from eligible 
                        entities with contracts with the intermediary 
                        under subparagraph (A)(i);
                            ``(v) comply with all program integrity 
                        requirements established by the Secretary; and
                            ``(vi) perform such other functions as 
                        required by the Secretary through the contract 
                        under this paragraph.
                    ``(C) Claims billing.--The third-party intermediary 
                will promptly and accurately submit billing information 
                to the Secretary for diabetes prevention services 
                furnished to a prediabetic Medicare beneficiary by an 
                eligible entity with which the third-party intermediary 
                has a contract under subparagraph (A)(i).
                    ``(D) Outreach to health care providers.--The 
                third-party intermediary provides outreach and 
                education for health care providers (as such term is 
                defined in section 1855(d)(5)) about the availability 
                of diabetes prevention services and the benefits of 
                patient participation in such services.
                    ``(E) Reporting on services provided.--The third-
                party intermediary shall report to the Secretary the 
                following information:
                            ``(i) Information on the participation of 
                        prediabetic Medicare beneficiaries in the 
                        diabetes prevention services furnished--
                                    ``(I) by each eligible entity with 
                                which such intermediary has a contract 
                                under subparagraph (A)(i); and
                                    ``(II) the third-party beneficiary, 
                                if the third-party intermediary is an 
                                eligible entity.
                            ``(ii) Information on the impact of such 
                        participation on such beneficiaries (including 
                        weight loss).
                            ``(iii) Any information required by the 
                        Secretary for purposes of ensuring that the 
                        third-party intermediary is conducting the 
                        oversight required under subsection (e)(5). 
                    ``(F) Organizational structure.--The third-party 
                intermediary meets such requirements for organizational 
                structure as the Secretary may specify, to ensure that 
                such third-party intermediary can meet the requirements 
                of this Act.
            ``(2) Types of third-party intermediaries.--The term 
        `third-party intermediary' may include--
                    ``(A) an accountable care organization under 
                section 1899;
                    ``(B) a technology company;
                    ``(C) a provider of services (as such term is 
                defined in section 1861(u));
                    ``(D) a health insurance or services company 
                (including population health or disease management 
                companies);
                    ``(E) a community-based organization or a network 
                of community-based organizations;
                    ``(F) a faith-based organization; or
                    ``(G) any other organization that the Secretary 
                determines is capable of managing a network of eligible 
                entities and meeting the requirements for a qualified 
                third-party intermediary under paragraph (1).
            ``(3) Oversight.--The Secretary shall monitor the third-
        party intermediaries to prevent fraud and abuse in the 
        provision of diabetes prevention services to prediabetic 
        Medicare beneficiaries.
    ``(e) Contracts Between Eligible Entities and Third-Party 
Intermediaries.--A contract between an eligible entity and a third-
party intermediary meets the requirements of this subsection if the 
contract provides for the following:
            ``(1) Payment for services.--The third-party intermediary 
        shall provide payment to the eligible entity for diabetes 
        prevention services furnished to prediabetic Medicare 
        beneficiaries by such entity.
            ``(2) Eligibility and enrollment.--The third-party 
        intermediary shall conduct the following activities (unless the 
        contract specifically assigns any of these activities to the 
        eligible entity):
                    ``(A) Determine whether individuals are prediabetic 
                Medicare beneficiaries who are eligible to receive 
                diabetes prevention services pursuant to this section.
                    ``(B) Scheduling and enrollment for diabetes 
                prevention services furnished by the eligible entity.
                    ``(C) Develop and manage a process to assist health 
                care providers (as such term is defined in section 
                1855(d)(5)) in referring prediabetic Medicare 
                beneficiaries to eligible entities for diabetes 
                prevention services.
            ``(3) Outreach and customer service for beneficiaries.--The 
        third-party intermediary shall--
                    ``(A) use a variety of methods to identify 
                individuals who are likely to be prediabetic Medicare 
                beneficiaries and inform such beneficiaries of diabetes 
                prevention services offered by the eligible entity (and 
                other eligible entities with which such third-party 
                intermediary has a contract under this subsection); and
                    ``(B) provide customer service and support for 
                prediabetic Medicare beneficiaries who are seeking or 
                receiving diabetes prevention services furnished by the 
                eligible entity.
            ``(4) Performance.--The third-party intermediary shall 
        monitor the performance of the eligible entity with respect to 
        diabetes prevention services furnished to prediabetic Medicare 
        beneficiaries by such entity and ensure that such performance 
        is consistent with the requirements of this section.
            ``(5) Oversight.--The third-party intermediary shall 
        monitor the eligible entity to prevent fraud and abuse in the 
        provision of diabetes prevention services to prediabetic 
        Medicare beneficiaries.
            ``(6) Audits.--
                    ``(A) In general.--The third-party intermediary may 
                conduct audits of the eligible entity to ensure--
                            ``(i) that such entity--
                                    ``(I) is providing diabetes 
                                prevention services that meet the 
                                requirements, goals, and objectives of 
                                the National Diabetes Program of the 
                                Centers for Disease Control and 
                                Prevention; and
                                    ``(II) is complying with the 
                                requirements of subsection (g) (related 
                                to privacy);
                            ``(ii) that individuals receiving diabetes 
                        prevention services for which payment is made 
                        pursuant to a contract under this section to 
                        the eligible entity are prediabetic Medicare 
                        beneficiaries; and
                            ``(iii) that the claims for payment 
                        submitted by the eligible entity to the third-
                        party intermediary are accurate and comply with 
                        the requirements of the contract under this 
                        subsection.
                    ``(B) Access.--The eligible entity shall provide 
                the third-party intermediary with access to information 
                necessary to complete the audits under subparagraph 
                (A).
    ``(f) Payments for Diabetes Prevention Program Services.--
            ``(1) In general.--Under the contract under subsection 
        (d)(1) the Secretary shall agree to make payments to the third-
        party intermediary for diabetes prevention services furnished 
        to prediabetic Medicare beneficiaries by eligible entities with 
        contracts with such third-party intermediary (or in the case of 
        a third-party intermediary that is an eligible entity, diabetes 
        prevention services furnished to such beneficiaries by such 
        third-party intermediary).
            ``(2) Amount of payment for 2013.--With respect to diabetes 
        prevention program services furnished to a prediabetic Medicare 
        beneficiary, the amount of payment made under paragraph (1) for 
        2013 is the sum of any of the following amounts that are 
        applicable to such beneficiary:
                    ``(A) $100 for the enrollment of such individual in 
                a diabetes prevention program that meets the 
                requirements, goals, and objectives of the National 
                Diabetes Program of the Centers for Disease Control and 
                Prevention (including use of the curriculum of such 
                program) and is provided by an eligible entity with 
                which the third-party intermediary has a contract under 
                subsection (e) or by the third-party intermediary 
                directly, if the third-party intermediary is an 
                eligible entity.
                    ``(B) $150 for any such individual who attends at 
                least 4 class sessions, as specified in such 
                curriculum.
                    ``(C) $200 for any such individual who attends at 
                least 9 class sessions (including the 4 class sessions 
                described in subparagraph (B)), as specified in such 
                curriculum.
                    ``(D) $120 for any such individual who--
                            ``(i) attends all of the sessions described 
                        in subparagraphs (B) and (C); and
                            ``(ii) loses at least 5 percent of the 
                        individual's total body weight during the time 
                        period that begins on the date of the first 
                        such session attended by such individual, and 
                        ends 60 days after the completion of the last 
                        such session attended by such individual.
                    ``(E) An additional $40 for any individual who 
                meets the requirements of subparagraph (D)(i) and who 
                loses at least 9 percent of total body weight during 
                the time period described in subparagraph (D)(ii).
            ``(3) Payment amounts for 2014 and subsequent years.--For 
        2014 and subsequent years, with respect to diabetes prevention 
        program services furnished to a prediabetic Medicare 
        beneficiary, the amount of payment under this subsection shall 
        be the amount payable under this subsection in the previous 
        year, increased by an appropriate amount, as determined by the 
        Secretary, to account for inflation. The amount of such 
        increase shall not be less than the percentage change in the 
        Consumer Price Index for all urban consumers (U.S. city 
        average) for such year.
    ``(g) Privacy and Security Requirements.--Each eligible entity and 
third-party intermediary shall, to the extent such entity or 
intermediary handles individually identifiable health information 
related to furnishing diabetes prevention services under this section, 
be treated as a covered entity for purposes of the application of the 
provisions of (and regulations promulgated under) part C of title XI, 
section 264(c) of the Health Insurance Portability and Accountability 
Act of 1996 (42 U.S.C. 1320d-2 note), and subtitle D of title XIII of 
the American Recovery and Reinvestment Act of 2009.
    ``(h) No Cost Sharing.--No premium, deductible, coinsurance, or 
other cost-sharing requirement shall apply to any diabetes prevention 
service furnished to a prediabetic Medicare beneficiary under this 
section.
    ``(i) Evaluation and Report to Congress.--
            ``(1) Evaluation.--The Secretary shall conduct an 
        evaluation on the coverage of diabetes prevention services 
        under this title. Such evaluation shall include the analysis 
        of--
                    ``(A) the impact of the provision of such coverage 
                on Medicare beneficiaries, including the impact on 
                various populations, such as individuals who are dual 
                eligible individuals (as such term is defined in 
                section 1915(h)(2)(B)), and the impact of the provision 
                of such coverage on health disparities;
                    ``(B) the rate at which physicians refer 
                prediabetic Medicare beneficiaries to eligible entities 
                and third-party intermediaries providing such diabetes 
                prevention services;
                    ``(C) the rate at which Medicare beneficiaries 
                access such services and the awareness of Medicare 
                beneficiaries of coverage for such services under this 
                title;
                    ``(D) the health outcomes resulting from the 
                participation of prediabetic Medicare beneficiaries in 
                diabetes prevention services under this title;
                    ``(E) recommendations for important program 
                integrity protections related to the payment for 
                diabetes prevention services under this title; and
                    ``(F) other topics determined appropriate by the 
                Secretary.
            ``(2) Report.--Not later than January 1, 2018, the 
        Secretary shall submit to Congress a report that contains--
                    ``(A) the results of the evaluation conducted under 
                paragraph (1); and
                    ``(B) recommendations for any legislative or 
                administration actions that the Secretary determines 
                appropriate.''.
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