I 112th CONGRESS 2d Session H. R. 6548 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.
1.
Short title
This Act may be cited as the Diabetes Prevention Act of 2012.
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:
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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