[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1021 Reported in House (RH)]

                                                  Union Calendar No. 29
114th CONGRESS
  1st Session
                                H. R. 1021

                      [Report No. 114-46, Part I]

    To amend title XVIII of the Social Security Act to improve the 
       integrity of the Medicare program, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           February 24, 2015

Mr. Brady of Texas (for himself, Mr. McDermott, Mr. Levin, Mr. Rangel, 
    Mr. Lewis, Mr. Neal, Mr. Sam Johnson of Texas, Mr. Doggett, Mr. 
 Blumenauer, Mr. Danny K. Davis of Illinois, Mr. Pascrell, Mr. Tiberi, 
   Mr. Nunes, Ms. Linda T. Saanchez of California, Mr. Boustany, Mr. 
 Reichert, Mr. Buchanan, Mr. Roskam, Mr. Smith of Nebraska, Mr. Reed, 
  Mrs. Black, Mr. Kelly of Pennsylvania, Mr. Renacci, Mr. Meehan, Mr. 
Young of Indiana, Mr. Holding, and Mr. Carney) 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

                             March 18, 2015

   Additional sponsors: Mr. Diaz-Balart, Mr. Paulsen, Mrs. Noem, Mr. 
                 Rodney Davis of Illinois, and Mr. Ross

                             March 18, 2015

    Reported from the Committee on Ways and Means with an amendment
 [Strike out all after the enacting clause and insert the part printed 
                               in italic]

                             March 18, 2015

   The Committee on Energy and Commerce discharged; committed to the 
 Committee of the Whole House on the State of the Union and ordered to 
                               be printed
    [For text of introduced bill, see copy of bill as introduced on 
                           February 24, 2015]


_______________________________________________________________________

                                 A BILL


 
    To amend title XVIII of the Social Security Act to improve the 
       integrity of the Medicare program, and for other purposes.


 


    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Protecting the 
Integrity of Medicare Act of 2015''.
    (b) Table of Contents.--The table of contents for this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Prohibition of inclusion of Social Security account numbers on 
                            Medicare cards.
Sec. 3. Preventing wrongful Medicare payments for items and services 
                            furnished to incarcerated individuals, 
                            individuals not lawfully present, and 
                            deceased individuals.
Sec. 4. Consideration of measures regarding Medicare beneficiary smart 
                            cards.
Sec. 5. Modifying medicare durable medical equipment face-to-face 
                            encounter documentation requirement.
Sec. 6. Reducing improper Medicare payments.
Sec. 7. Improving senior Medicare patrol and fraud reporting rewards.
Sec. 8. Requiring valid prescriber National Provider Identifiers on 
                            pharmacy claims.
Sec. 9. Option to receive Medicare Summary Notice electronically.
Sec. 10. Renewal of MAC contracts.
Sec. 11. Study on pathway for incentives to States for State 
                            participation in medicaid data match 
                            program.
Sec. 12. Programs to prevent prescription drug abuse under Medicare 
                            part D.
Sec. 13. Guidance on application of Common Rule to clinical data 
                            registries.
Sec. 14. Eliminating certain civil money penalties; gainsharing study 
                            and report.
Sec. 15. Modification of Medicare home health surety bond condition of 
                            participation requirement.
Sec. 16. Oversight of Medicare coverage of manual manipulation of the 
                            spine to correct subluxation.
Sec. 17. National expansion of prior authorization model for repetitive 
                            scheduled non-emergent ambulance transport.
Sec. 18. Repealing duplicative Medicare secondary payor provision.
Sec. 19. Plan for expanding data in annual CERT report.
Sec. 20. Removing funds for Medicare Improvement Fund added by IMPACT 
                            Act of 2014.
Sec. 21. Rule of construction.

SEC. 2. PROHIBITION OF INCLUSION OF SOCIAL SECURITY ACCOUNT NUMBERS ON 
              MEDICARE CARDS.

    (a) In General.--Section 205(c)(2)(C) of the Social Security Act 
(42 U.S.C. 405(c)(2)(C)) is amended--
            (1) by moving clause (x), as added by section 1414(a)(2) of 
        the Patient Protection and Affordable Care Act, 6 ems to the 
        left;
            (2) by redesignating clause (x), as added by section 
        2(a)(1) of the Social Security Number Protection Act of 2010, 
        and clause (xi) as clauses (xi) and (xii), respectively; and
            (3) by adding at the end the following new clause:
    ``(xiii) The Secretary of Health and Human Services, in 
consultation with the Commissioner of Social Security, shall establish 
cost-effective procedures to ensure that a Social Security account 
number (or derivative thereof) is not displayed, coded, or embedded on 
the Medicare card issued to an individual who is entitled to benefits 
under part A of title XVIII or enrolled under part B of title XVIII and 
that any other identifier displayed on such card is not identifiable as 
a Social Security account number (or derivative thereof).''.
    (b) Implementation.--In implementing clause (xiii) of section 
205(c)(2)(C) of the Social Security Act (42 U.S.C. 405(c)(2)(C)), as 
added by subsection (a)(3), the Secretary of Health and Human Services 
shall do the following:
            (1) In general.--Establish a cost-effective process that 
        involves the least amount of disruption to, as well as 
        necessary assistance for, Medicare beneficiaries and health 
        care providers, such as a process that provides such 
        beneficiaries with access to assistance through a toll-free 
        telephone number and provides outreach to providers.
            (2) Consideration of medicare beneficiary identified.--
        Consider implementing a process, similar to the process 
        involving Railroad Retirement Board beneficiaries, under which 
        a Medicare beneficiary identifier which is not a Social 
        Security account number (or derivative thereof) is used 
        external to the Department of Health and Human Services and is 
        convertible over to a Social Security account number (or 
        derivative thereof) for use internal to such Department and the 
        Social Security Administration.
    (c) Funding for Implementation.--For purposes of implementing the 
provisions of and the amendments made by this section, the Secretary of 
Health and Human Services shall provide for the following transfers 
from the Federal Hospital Insurance Trust Fund under section 1817 of 
the Social Security Act (42 U.S.C. 1395i) and from the Federal 
Supplementary Medical Insurance Trust Fund established under section 
1841 of such Act (42 U.S.C. 1395t), in such proportions as the 
Secretary determines appropriate:
            (1) To the Centers for Medicare & Medicaid Program 
        Management Account, transfers of the following amounts:
                    (A) For fiscal year 2015, $65,000,000, to be made 
                available through fiscal year 2018.
                    (B) For each of fiscal years 2016 and 2017, 
                $53,000,000, to be made available through fiscal year 
                2018.
                    (C) For fiscal year 2018, $48,000,000, to be made 
                available until expended.
            (2) To the Social Security Administration Limitation on 
        Administration Account, transfers of the following amounts:
                    (A) For fiscal year 2015, $27,000,000, to be made 
                available through fiscal year 2018.
                    (B) For each of fiscal years 2016 and 2017, 
                $22,000,000, to be made available through fiscal year 
                2018.
                    (C) For fiscal year 2018, $27,000,000, to be made 
                available until expended.
            (3) To the Railroad Retirement Board Limitation on 
        Administration Account, the following amount:
                    (A) For fiscal year 2015, $3,000,000, to be made 
                available until expended.
    (d) Effective Date.--
            (1) In general.--Clause (xiii) of section 205(c)(2)(C) of 
        the Social Security Act (42 U.S.C. 405(c)(2)(C)), as added by 
        subsection (a)(3), shall apply with respect to Medicare cards 
        issued on and after an effective date specified by the 
        Secretary of Health and Human Services, but in no case shall 
        such effective date be later than the date that is four years 
        after the date of the enactment of this Act.
            (2) Reissuance.--The Secretary shall provide for the 
        reissuance of Medicare cards that comply with the requirements 
        of such clause not later than four years after the effective 
        date specified by the Secretary under paragraph (1).

SEC. 3. PREVENTING WRONGFUL MEDICARE PAYMENTS FOR ITEMS AND SERVICES 
              FURNISHED TO INCARCERATED INDIVIDUALS, INDIVIDUALS NOT 
              LAWFULLY PRESENT, AND DECEASED INDIVIDUALS.

    (a) Requirement for the Secretary to Establish Policies and Claims 
Edits Relating to Incarcerated Individuals, Individuals Not Lawfully 
Present, and Deceased Individuals.--Section 1874 of the Social Security 
Act (42 U.S.C. 1395kk) is amended by adding at the end the following 
new subsection:
    ``(f) Requirement for the Secretary to Establish Policies and 
Claims Edits Relating to Incarcerated Individuals, Individuals Not 
Lawfully Present, and Deceased Individuals.--The Secretary shall 
establish and maintain procedures, including procedures for using 
claims processing edits, updating eligibility information to improve 
provider accessibility, and conducting recoupment activities such as 
through recovery audit contractors, in order to ensure that payment is 
not made under this title for items and services furnished to an 
individual who is one of the following:
            ``(1) An individual who is incarcerated.
            ``(2) An individual who is not lawfully present in the 
        United States and who is not eligible for coverage under this 
        title.
            ``(3) A deceased individual.''.
    (b) Report.--Not later than 18 months after the date of the 
enactment of this section, and periodically thereafter as determined 
necessary by the Office of Inspector General of the Department of 
Health and Human Services, such Office shall submit to Congress a 
report on the activities described in subsection (f) of section 1874 of 
the Social Security Act (42 U.S.C. 1395kk), as added by subparagraph 
(a), that have been conducted since such date of enactment.

SEC. 4. CONSIDERATION OF MEASURES REGARDING MEDICARE BENEFICIARY SMART 
              CARDS.

    To the extent the Secretary of Health and Human Services determines 
that it is cost effective and technologically viable to use electronic 
Medicare beneficiary and provider cards (such as cards that use smart 
card technology, including an embedded and secure integrated circuit 
chip), as presented in the Government Accountability Office report 
required by the conference report accompanying the Consolidated 
Appropriations Act, 2014 (Public Law 113-76), the Secretary shall 
consider such measures as determined appropriate by the Secretary to 
implement such use of such cards for beneficiary and provider use under 
title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). In the 
case that the Secretary considers measures under the preceding 
sentence, the Secretary shall submit to the Committees on Ways and 
Means and on Energy and Commerce of the House of Representatives, and 
to the Committee on Finance of the Senate, a report outlining the 
considerations undertaken by the Secretary under such sentence.

SEC. 5. MODIFYING MEDICARE DURABLE MEDICAL EQUIPMENT FACE-TO-FACE 
              ENCOUNTER DOCUMENTATION REQUIREMENT.

    (a) In General.--Section 1834(a)(11)(B)(ii) of the Social Security 
Act (42 U.S.C. 1395m(a)(11)(B)(ii)) is amended--
            (1) by striking ``the physician documenting that''; and
            (2) by striking ``has had a face-to-face encounter'' and 
        inserting ``documenting such physician, physician assistant, 
        practitioner, or specialist has had a face-to-face encounter''.
    (b) Implementation.--Notwithstanding any other provision of law, 
the Secretary of Health and Human Services may implement the amendments 
made by subsection (a) by program instruction or otherwise.

SEC. 6. REDUCING IMPROPER MEDICARE PAYMENTS.

    (a) Medicare Administrative Contractor Improper Payment Outreach 
and Education Program.--
            (1) In general.--Section 1874A of the Social Security Act 
        (42 U.S.C. 1395kk-1) is amended--
                    (A) in subsection (a)(4)--
                            (i) by redesignating subparagraph (G) as 
                        subparagraph (H); and
                            (ii) by inserting after subparagraph (F) 
                        the following new subparagraph:
                    ``(G) Improper payment outreach and education 
                program.--Having in place an improper payment outreach 
                and education program described in subsection (h).''; 
                and
                    (B) by adding at the end the following new 
                subsection:
    ``(h) Improper Payment Outreach and Education Program.--
            ``(1) In general.--In order to reduce improper payments 
        under this title, each medicare administrative contractor shall 
        establish and have in place an improper payment outreach and 
        education program under which the contractor, through outreach, 
        education, training, and technical assistance or other 
        activities, shall provide providers of services and suppliers 
        located in the region covered by the contract under this 
        section with the information described in paragraph (2). The 
        activities described in the preceding sentence shall be 
        conducted on a regular basis.
            ``(2) Information to be provided through activities.--The 
        information to be provided under such payment outreach and 
        education program shall include information the Secretary 
        determines to be appropriate which may include the following 
        information:
                    ``(A) A list of the providers' or suppliers' most 
                frequent and expensive payment errors over the last 
                quarter.
                    ``(B) Specific instructions regarding how to 
                correct or avoid such errors in the future.
                    ``(C) A notice of new topics that have been 
                approved by the Secretary for audits conducted by 
                recovery audit contractors under section 1893(h).
                    ``(D) Specific instructions to prevent future 
                issues related to such new audits.
                    ``(E) Other information determined appropriate by 
                the Secretary.
            ``(3) Priority.--A medicare administrative contractor shall 
        give priority to activities under such program that will reduce 
        improper payments that are one or more of the following:
                    ``(A) Are for items and services that have the 
                highest rate of improper payment.
                    ``(B) Are for items and service that have the 
                greatest total dollar amount of improper payments.
                    ``(C) Are due to clear misapplication or 
                misinterpretation of Medicare policies.
                    ``(D) Are clearly due to common and inadvertent 
                clerical or administrative errors.
                    ``(E) Are due to other types of errors that the 
                Secretary determines could be prevented through 
                activities under the program.
            ``(4) Information on improper payments from recovery audit 
        contractors.--
                    ``(A) In general.--In order to assist medicare 
                administrative contractors in carrying out improper 
                payment outreach and education programs, the Secretary 
                shall provide each contractor with a complete list of 
                the types of improper payments identified by recovery 
                audit contractors under section 1893(h) with respect to 
                providers of services and suppliers located in the 
                region covered by the contract under this section. Such 
                information shall be provided on a time frame the 
                Secretary determines appropriate which may be on a 
                quarterly basis.
                    ``(B) Information.--The information described in 
                subparagraph (A) shall include information such as the 
                following:
                            ``(i) Providers of services and suppliers 
                        that have the highest rate of improper 
                        payments.
                            ``(ii) Providers of services and suppliers 
                        that have the greatest total dollar amounts of 
                        improper payments.
                            ``(iii) Items and services furnished in the 
                        region that have the highest rates of improper 
                        payments.
                            ``(iv) Items and services furnished in the 
                        region that are responsible for the greatest 
                        total dollar amount of improper payments.
                            ``(v) Other information the Secretary 
                        determines would assist the contractor in 
                        carrying out the program.
            ``(5) Communications.--Communications with providers of 
        services and suppliers under an improper payment outreach and 
        education program are subject to the standards and requirements 
        of subsection (g).''.
    (b) Use of Certain Funds Recovered by RACs.--Section 1893(h) of the 
Social Security Act (42 U.S.C. 1395ddd(h)) is amended--
            (1) in paragraph (2), by inserting ``or paragraph (10)'' 
        after ``paragraph (1)(C)''; and
            (2) by adding at the end the following new paragraph:
            ``(10) Use of certain recovered funds.--
                    ``(A) In general.--After application of paragraph 
                (1)(C), the Secretary shall retain a portion of the 
                amounts recovered by recovery audit contractors for 
                each year under this section which shall be available 
                to the program management account of the Centers for 
                Medicare & Medicaid Services for purposes of, subject 
                to subparagraph (B), carrying out sections 1833(z), 
                1834(l)(16), and 1874A(a)(4)(G), carrying out section 
                16(b) of the Protecting the Integrity of Medicare Act 
                of 2015, and implementing strategies (such as claims 
                processing edits) to help reduce the error rate of 
                payments under this title. The amounts retained under 
                the preceding sentence shall not exceed an amount equal 
                to 15 percent of the amounts recovered under this 
                subsection, and shall remain available until expended.
                    ``(B) Limitation.--Except for uses that support 
                claims processing (including edits) or system 
                functionality for detecting fraud, amounts retained 
                under subparagraph (A) may not be used for 
                technological-related infrastructure, capital 
                investments, or information systems.
                    ``(C) No reduction in payments to recovery audit 
                contractors.--Nothing in subparagraph (A) shall reduce 
                amounts available for payments to recovery audit 
                contractors under this subsection.''.

SEC. 7. IMPROVING SENIOR MEDICARE PATROL AND FRAUD REPORTING REWARDS.

    (a) In General.--The Secretary of Health and Human Services (in 
this section referred to as the ``Secretary'') shall develop a plan to 
revise the incentive program under section 203(b) of the Health 
Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1395b- 
5(b)) to encourage greater participation by individuals to report fraud 
and abuse in the Medicare program. Such plan shall include 
recommendations for--
            (1) ways to enhance rewards for individuals reporting under 
        the incentive program, including rewards based on information 
        that leads to an administrative action; and
            (2) extending the incentive program to the Medicaid 
        program.
    (b) Public Awareness and Education Campaign.--The plan developed 
under subsection (a) shall also include recommendations for the use of 
the Senior Medicare Patrols authorized under section 411 of the Older 
Americans Act of 1965 (42 U.S.C. 3032) to conduct a public awareness 
and education campaign to encourage participation in the revised 
incentive program under subsection (a).
    (c) Submission of Plan.--Not later than 180 days after the date of 
enactment of this Act, the Secretary shall submit to Congress the plan 
developed under subsection (a).

SEC. 8. REQUIRING VALID PRESCRIBER NATIONAL PROVIDER IDENTIFIERS ON 
              PHARMACY CLAIMS.

    Section 1860D-4(c) of the Social Security Act (42 U.S.C. 1395w-
104(c)) is amended by adding at the end the following new paragraph:
            ``(4) Requiring valid prescriber national provider 
        identifiers on pharmacy claims.--
                    ``(A) In general.--For plan year 2016 and 
                subsequent plan years, the Secretary shall require a 
                claim for a covered part D drug for a part D eligible 
                individual enrolled in a prescription drug plan under 
                this part or an MA-PD plan under part C to include a 
                prescriber National Provider Identifier that is 
                determined to be valid under the procedures established 
                under subparagraph (B)(i).
                    ``(B) Procedures.--
                            ``(i) Validity of prescriber national 
                        provider identifiers.--The Secretary, in 
                        consultation with appropriate stakeholders, 
                        shall establish procedures for determining the 
                        validity of prescriber National Provider 
                        Identifiers under subparagraph (A).
                            ``(ii) Informing beneficiaries of reason 
                        for denial.--The Secretary shall establish 
                        procedures to ensure that, in the case that a 
                        claim for a covered part D drug of an 
                        individual described in subparagaph (A) is 
                        denied because the claim does not meet the 
                        requirements of this paragraph, the individual 
                        is properly informed at the point of service of 
                        the reason for the denial.
                    ``(C) Report.--Not later than January 1, 2018, the 
                Inspector General of the Department of Health and Human 
                Services shall submit to Congress a report on the 
                effectiveness of the procedures established under 
                subparagraph (B)(i).''.

SEC. 9. OPTION TO RECEIVE MEDICARE SUMMARY NOTICE ELECTRONICALLY.

    (a) In General.--Section 1806 of the Social Security Act (42 U.S.C. 
1395b-7) is amended by adding at the end the following new subsection:
    ``(c) Format of Statements From Secretary.--
            ``(1) Electronic option beginning in 2016.--Subject to 
        paragraph (2), for statements described in subsection (a) that 
        are furnished for a period in 2016 or a subsequent year, in the 
        case that an individual described in subsection (a) elects, in 
        accordance with such form, manner, and time specified by the 
        Secretary, to receive such statement in an electronic format, 
        such statement shall be furnished to such individual for each 
        period subsequent to such election in such a format and shall 
        not be mailed to the individual.
            ``(2) Limitation on revocation option.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                Secretary may determine a maximum number of elections 
                described in paragraph (1) by an individual that may be 
                revoked by the individual.
                    ``(B) Minimum of one revocation option.--In no case 
                may the Secretary determine a maximum number under 
                subparagraph (A) that is less than one.
            ``(3) Notification.--The Secretary shall ensure that, in 
        the most cost effective manner and beginning January 1, 2017, a 
        clear notification of the option to elect to receive statements 
        described in subsection (a) in an electronic format is made 
        available, such as through the notices distributed under 
        section 1804, to individuals described in subsection (a).''.
    (b) Encouraged Expansion of Electronic Statements.--To the extent 
to which the Secretary of Health and Human Services determines 
appropriate, the Secretary shall--
            (1) apply an option similar to the option described in 
        subsection (c)(1) of section 1806 of the Social Security Act 
        (42 U.S.C. 1395b-7) (relating to the provision of the Medicare 
        Summary Notice in an electronic format), as added by subsection 
        (a), to other statements and notifications under title XVIII of 
        such Act (42 U.S.C. 1395 et seq.); and
            (2) provide such Medicare Summary Notice and any such other 
        statements and notifications on a more frequent basis than is 
        otherwise required under such title.

SEC. 10. RENEWAL OF MAC CONTRACTS.

    (a) In General.--Section 1874A(b)(1)(B) of the Social Security Act 
(42 U.S.C. 1395kk-1(b)(1)(B)) is amended by striking ``5 years'' and 
inserting ``10 years''.
    (b) Application.--The amendments made by subsection (a) shall apply 
to contracts entered into on or after, and to contracts in effect as 
of, the date of the enactment of this Act.
    (c) Contractor Performance Transparency.--Section 1874A(b)(3)(A) of 
the Social Security Act (42 U.S.C. 1395kk-1(b)(3)(A)) is amended by 
adding at the end the following new clause:
                            ``(iv) Contractor performance 
                        transparency.--To the extent possible without 
                        compromising the process for entering into and 
                        renewing contracts with medicare administrative 
                        contractors under this section, the Secretary 
                        shall make available to the public the 
                        performance of each medicare administrative 
                        contractor with respect to such performance 
                        requirements and measurement standards.''.

SEC. 11. STUDY ON PATHWAY FOR INCENTIVES TO STATES FOR STATE 
              PARTICIPATION IN MEDICAID DATA MATCH PROGRAM.

    Section 1893(g) of the Social Security Act (42 U.S.C. 1395ddd(g)) 
is amended by adding at the end the following new paragraph:
            ``(3) Incentives for states.--The Secretary shall study 
        and, as appropriate, may specify incentives for States to work 
        with the Secretary for the purposes described in paragraph 
        (1)(A)(ii). The application of the previous sentence may 
        include use of the waiver authority described in paragraph 
        (2).''.

SEC. 12. PROGRAMS TO PREVENT PRESCRIPTION DRUG ABUSE UNDER MEDICARE 
              PART D.

    (a) Drug Management Program for At-risk Beneficiaries.--
            (1) In general.--Section 1860D-4(c) of the Social Security 
        Act (42 U.S.C. 1395w-10(c)), as amended by section 8, is 
        further amended by adding at the end the following:
            ``(5) Drug management program for at-risk beneficiaries.--
                    ``(A) Authority to establish.--A PDP sponsor may 
                establish a drug management program for at-risk 
                beneficiaries under which, subject to subparagraph (B), 
                the PDP sponsor may, in the case of an at-risk 
                beneficiary for prescription drug abuse who is an 
                enrollee in a prescription drug plan of such PDP 
                sponsor, limit such beneficiary's access to coverage 
                for frequently abused drugs under such plan to 
                frequently abused drugs that are prescribed for such 
                beneficiary by a prescriber selected under subparagraph 
                (D), and dispensed for such beneficiary by a pharmacy 
                selected under such subparagraph.
                    ``(B) Requirement for notices.--
                            ``(i) In general.--A PDP sponsor may not 
                        limit the access of an at-risk beneficiary for 
                        prescription drug abuse to coverage for 
                        frequently abused drugs under a prescription 
                        drug plan until such sponsor--
                                    ``(I) provides to the beneficiary 
                                an initial notice described in clause 
                                (ii) and a second notice described in 
                                clause (iii); and
                                    ``(II) verifies with the providers 
                                of the beneficiary that the beneficiary 
                                is an at-risk beneficiary for 
                                prescription drug abuse.
                            ``(ii) Initial notice.--An initial notice 
                        described in this clause is a notice that 
                        provides to the beneficiary--
                                    ``(I) notice that the PDP sponsor 
                                has identified the beneficiary as 
                                potentially being an at-risk 
                                beneficiary for prescription drug 
                                abuse;
                                    ``(II) information describing all 
                                State and Federal public health 
                                resources that are designed to address 
                                prescription drug abuse to which the 
                                beneficiary has access, including 
                                mental health services and other 
                                counseling services;
                                    ``(III) notice of, and information 
                                about, the right of the beneficiary to 
                                appeal such identification under 
                                subsection (h) and the option of an 
                                automatic escalation to external 
                                review;
                                    ``(IV) a request for the 
                                beneficiary to submit to the PDP 
                                sponsor preferences for which 
                                prescribers and pharmacies the 
                                beneficiary would prefer the PDP 
                                sponsor to select under subparagraph 
                                (D) in the case that the beneficiary is 
                                identified as an at-risk beneficiary 
                                for prescription drug abuse as 
                                described in clause (iii)(I);
                                    ``(V) an explanation of the meaning 
                                and consequences of the identification 
                                of the beneficiary as potentially being 
                                an at-risk beneficiary for prescription 
                                drug abuse, including an explanation of 
                                the drug management program established 
                                by the PDP sponsor pursuant to 
                                subparagraph (A);
                                    ``(VI) clear instructions that 
                                explain how the beneficiary can contact 
                                the PDP sponsor in order to submit to 
                                the PDP sponsor the preferences 
                                described in subclause (IV) and any 
                                other communications relating to the 
                                drug management program for at-risk 
                                beneficiaries established by the PDP 
                                sponsor; and
                                    ``(VII) contact information for 
                                other organizations that can provide 
                                the beneficiary with assistance 
                                regarding such drug management program 
                                (similar to the information provided by 
                                the Secretary in other standardized 
                                notices provided to part D eligible 
                                individuals enrolled in prescription 
                                drug plans under this part).
                            ``(iii) Second notice.--A second notice 
                        described in this clause is a notice that 
                        provides to the beneficiary notice--
                                    ``(I) that the PDP sponsor has 
                                identified the beneficiary as an at-
                                risk beneficiary for prescription drug 
                                abuse;
                                    ``(II) that such beneficiary is 
                                subject to the requirements of the drug 
                                management program for at-risk 
                                beneficiaries established by such PDP 
                                sponsor for such plan;
                                    ``(III) of the prescriber and 
                                pharmacy selected for such individual 
                                under subparagraph (D);
                                    ``(IV) of, and information about, 
                                the beneficiary's right to appeal such 
                                identification under subsection (h) and 
                                the option of an automatic escalation 
                                to external review;
                                    ``(V) that the beneficiary can, in 
                                the case that the beneficiary has not 
                                previously submitted to the PDP sponsor 
                                preferences for which prescribers and 
                                pharmacies the beneficiary would prefer 
                                the PDP sponsor select under 
                                subparagraph (D), submit such 
                                preferences to the PDP sponsor; and
                                    ``(VI) that includes clear 
                                instructions that explain how the 
                                beneficiary can contact the PDP 
                                sponsor.
                            ``(iv) Timing of notices.--
                                    ``(I) In general.--Subject to 
                                subclause (II), a second notice 
                                described in clause (iii) shall be 
                                provided to the beneficiary on a date 
                                that is not less than 60 days after an 
                                initial notice described in clause (ii) 
                                is provided to the beneficiary.
                                    ``(II) Exception.--In the case that 
                                the PDP sponsor, in conjunction with 
                                the Secretary, determines that concerns 
                                identified through rulemaking by the 
                                Secretary regarding the health or 
                                safety of the beneficiary or regarding 
                                significant drug diversion activities 
                                require the PDP sponsor to provide a 
                                second notice described in clause (iii) 
                                to the beneficiary on a date that is 
                                earlier than the date described in 
                                subclause (II), the PDP sponsor may 
                                provide such second notice on such 
                                earlier date.
                    ``(C) At-risk beneficiary for prescription drug 
                abuse.--
                            ``(i) In general.--For purposes of this 
                        paragraph, the term `at-risk beneficiary for 
                        prescription drug abuse' means a part D 
                        eligible individual who is not an exempted 
                        individual described in clause (ii) and--
                                    ``(I) who is identified through the 
                                use of clinical guidelines developed by 
                                the Secretary in consultation with PDP 
                                sponsors and other stakeholders 
                                described in section 12(f)(2)(A) of the 
                                Protecting the Integrity of Medicare 
                                Act of 2015; or
                                    ``(II) with respect to whom the PDP 
                                sponsor of a prescription drug plan, 
                                upon enrolling such individual in such 
                                plan, received notice from the 
                                Secretary that such individual was 
                                identified under this paragraph to be 
                                an at-risk beneficiary for prescription 
                                drug abuse under the prescription drug 
                                plan in which such individual was most 
                                recently previously enrolled and such 
                                identification has not been terminated 
                                under subparagraph (F).
                            ``(ii) Exempted individual described.--An 
                        exempted individual described in this clause is 
                        an individual who--
                                    ``(I) receives hospice care under 
                                this title; or
                                    ``(II) the Secretary elects to 
                                treat as an exempted individual for 
                                purposes of clause (i).
                    ``(D) Selection of prescribers.--
                            ``(i) In general.--With respect to each at-
                        risk beneficiary for prescription drug abuse 
                        enrolled in a prescription drug plan offered by 
                        such sponsor, a PDP sponsor shall, based on the 
                        preferences submitted to the PDP sponsor by the 
                        beneficiary pursuant to clauses (ii)(IV) and 
                        (iii)(V) of subparagraph (B), select--
                                    ``(I) one or more individuals who 
                                are authorized to prescribe frequently 
                                abused drugs (referred to in this 
                                paragraph as `prescribers') who may 
                                write prescriptions for such drugs for 
                                such beneficiary; and
                                    ``(II) one or more pharmacies that 
                                may dispense such drugs to such 
                                beneficiary.
                            ``(ii) Reasonable access.--In making the 
                        selection under this subparagraph, a PDP 
                        sponsor shall ensure that the beneficiary 
                        continues to have reasonable access to drugs 
                        described in subparagraph (G), taking into 
                        account geographic location, beneficiary 
                        preference, impact on cost-sharing, and 
                        reasonable travel time.
                            ``(iii) Beneficiary preferences.--
                                    ``(I) In general.--If an at-risk 
                                beneficiary for prescription drug abuse 
                                submits preferences for which in-
                                network prescribers and pharmacies the 
                                beneficiary would prefer the PDP 
                                sponsor select in response to a notice 
                                under subparagraph (B), the PDP sponsor 
                                shall--
                                            ``(aa) review such 
                                        preferences;
                                            ``(bb) select or change the 
                                        selection of a prescriber or 
                                        pharmacy for the beneficiary 
                                        based on such preferences; and
                                            ``(cc) inform the 
                                        beneficiary of such selection 
                                        or change of selection.
                                    ``(II) Exception.--In the case that 
                                the PDP sponsor determines that a 
                                change to the selection of a prescriber 
                                or pharmacy under item (bb) by the PDP 
                                sponsor is contributing or would 
                                contribute to prescription drug abuse 
                                or drug diversion by the beneficiary, 
                                the PDP sponsor may change the 
                                selection of a prescriber or pharmacy 
                                for the beneficiary without regard to 
                                the preferences of the beneficiary 
                                described in subclause (I).
                            ``(iv) Confirmation.--Before selecting a 
                        prescriber or pharmacy under this subparagraph, 
                        a PDP sponsor must request and receive 
                        confirmation from the prescriber or pharmacy 
                        acknowledging and accepting that the 
                        beneficiary involved is in the drug management 
                        program for at-risk beneficiaries.
                    ``(E) Terminations and appeals.--The identification 
                of an individual as an at-risk beneficiary for 
                prescription drug abuse under this paragraph, a 
                coverage determination made under a drug management 
                program for at-risk beneficiaries, and the selection of 
                a prescriber or pharmacy under subparagraph (D) with 
                respect to such individual shall be subject to 
                reconsideration and appeal under subsection (h) and the 
                option of an automatic escalation to external review to 
                the extent provided by the Secretary.
                    ``(F) Termination of identification.--
                            ``(i) In general.--The Secretary shall 
                        develop standards for the termination of 
                        identification of an individual as an at-risk 
                        beneficiary for prescription drug abuse under 
                        this paragraph. Under such standards such 
                        identification shall terminate as of the 
                        earlier of--
                                    ``(I) the date the individual 
                                demonstrates that the individual is no 
                                longer likely, in the absence of the 
                                restrictions under this paragraph, to 
                                be an at-risk beneficiary for 
                                prescription drug abuse described in 
                                subparagraph (C)(i); or
                                    ``(II) the end of such maximum 
                                period of identification as the 
                                Secretary may specify.
                            ``(ii) Rule of construction.--Nothing in 
                        clause (i) shall be construed as preventing a 
                        plan from identifying an individual as an at-
                        risk beneficiary for prescription drug abuse 
                        under subparagraph (C)(i) after such 
                        termination on the basis of additional 
                        information on drug use occurring after the 
                        date of notice of such termination.
                    ``(G) Frequently abused drug.--For purposes of this 
                subsection, the term `frequently abused drug' means a 
                drug that is determined by the Secretary to be 
                frequently abused or diverted and that is--
                            ``(i) a Controlled Drug Substance in 
                        Schedule CII; or
                            ``(ii) within the same class or category of 
                        drugs as a Controlled Drug Substance in 
                        Schedule CII, as determined through notice and 
                        comment rulemaking.
                    ``(H) Data disclosure.--In the case of an at-risk 
                beneficiary for prescription drug abuse whose access to 
                coverage for frequently abused drugs under a 
                prescription drug plan has been limited by a PDP 
                sponsor under this paragraph, such PDP sponsor shall 
                disclose data, including any necessary individually 
                identifiable health information, in a form and manner 
                specified by the Secretary, about the decision to 
                impose such limitations and the limitations imposed by 
                the sponsor under this part.
                    ``(I) Education.--The Secretary shall provide 
                education to enrollees in prescription drug plans of 
                PDP sponsors and providers regarding the drug 
                management program for at-risk beneficiaries described 
                in this paragraph, including education--
                            ``(i) provided by medicare administrative 
                        contractors through the improper payment 
                        outreach and education program described in 
                        section 1874A(h); and
                            ``(ii) through current education efforts 
                        (such as State health insurance assistance 
                        programs described in subsection (a)(1)(A) of 
                        section 119 of the Medicare Improvements for 
                        Patients and Providers Act of 2008 (42 U.S.C. 
                        1395b-3 note)) and materials directed toward 
                        such enrollees.''.
            (2) Information for consumers.--Section 1860D-4(a)(1)(B) of 
        the Social Security Act (42 U.S.C. 1395w-104(a)(1)(B)) is 
        amended by adding at the end the following:
                            ``(v) The drug management program for at-
                        risk beneficiaries under subsection (c)(5).''.
    (b) Utilization Management Programs.--Section 1860D-4(c) of the 
Social Security Act (42 U.S.C. 1395w-104(c)), as amended by subsection 
(a)(1) and section 8, is further amended--
            (1) in paragraph (1), by inserting after subparagraph (D) 
        the following new subparagraph:
                    ``(E) A utilization management tool to prevent drug 
                abuse (as described in paragraph (6)(A)).''; and
            (2) by adding at the end the following new paragraph:
            ``(6) Utilization management tool to prevent drug abuse.--
                    ``(A) In general.--A tool described in this 
                paragraph is any of the following:
                            ``(i) A utilization tool designed to 
                        prevent the abuse of frequently abused drugs by 
                        individuals and to prevent the diversion of 
                        such drugs at pharmacies.
                            ``(ii) Retrospective utilization review to 
                        identify--
                                    ``(I) individuals that receive 
                                frequently abused drugs at a frequency 
                                or in amounts that are not clinically 
                                appropriate; and
                                    ``(II) providers of services or 
                                suppliers that may facilitate the abuse 
                                or diversion of frequently abused drugs 
                                by beneficiaries.
                            ``(iii) Consultation with the Contractor 
                        described in subparagraph (B) to verify if an 
                        individual enrolling in a prescription drug 
                        plan offered by a PDP sponsor has been 
                        previously identified by another PDP sponsor as 
                        an individual described in clause (ii)(I).
                    ``(B) Reporting.--A PDP sponsor offering a 
                prescription drug plan in a State shall submit to the 
                Secretary and the Medicare drug integrity contractor 
                with which the Secretary has entered into a contract 
                under section 1893 with respect to such State a report, 
                on a monthly basis, containing information on--
                            ``(i) any provider of services or supplier 
                        described in subparagraph (A)(ii)(II) that is 
                        identified by such plan sponsor during the 30-
                        day period before such report is submitted; and
                            ``(ii) the name and prescription records of 
                        individuals described in paragraph (5)(C).''.
    (c) Expanding Activities of Medicare Drug Integrity Contractors 
(MEDICs).--Section 1893 of the Social Security Act (42 U.S.C. 1395ddd) 
is amended by adding at the end the following new subsection:
    ``(j) Expanding Activities of Medicare Drug Integrity Contractors 
(MEDICs).--
            ``(1) Access to information.--Under contracts entered into 
        under this section with Medicare drug integrity contractors, 
        the Secretary shall authorize such contractors to directly 
        accept prescription and necessary medical records from entities 
        such as pharmacies, prescription drug plans, and physicians 
        with respect to an individual in order for such contractors to 
        provide information relevant to the determination of whether 
        such individual is an at-risk beneficiary for prescription drug 
        abuse, as defined in section 1860D-4(c)(5)(C).
            ``(2) Requirement for acknowledgment of referrals.--If a 
        PDP sponsor refers information to a contractor described in 
        paragraph (1) in order for such contractor to assist in the 
        determination described in such paragraph, the contractor 
        shall--
                    ``(A) acknowledge to the PDP sponsor receipt of the 
                referral; and
                    ``(B) in the case that any PDP sponsor contacts the 
                contractor requesting to know the determination by the 
                contractor of whether or not an individual has been 
                determined to be an individual described such 
                paragraph, shall inform such PDP sponsor of such 
                determination on a date that is not later than 15 days 
                after the date on which the PDP sponsor contacts the 
                contractor.
            ``(3) Making data available to other entities.--
                    ``(A) In general.--For purposes of carrying out 
                this subsection, subject to subparagraph (B), the 
                Secretary shall authorize MEDICs to respond to requests 
                for information from PDP sponsors, State prescription 
                drug monitoring programs, and other entities delegated 
                by PDP sponsors using available programs and systems in 
                the effort to prevent fraud, waste, and abuse.
                    ``(B) HIPAA compliant information only.--
                Information may only be disclosed by a MEDIC under 
                subparagraph (A) if the disclosure of such information 
                is permitted under the Federal regulations (concerning 
                the privacy of individually identifiable health 
                information) promulgated under section 264(c) of the 
                Health Insurance Portability and Accountability Act of 
                1996 (42 U.S.C. 1320d-2 note).''.
    (d) Treatment of Certain Complaints for Purposes of Quality or 
Performance Assessment.--Section 1860D-42 of the Social Security Act 
(42 U.S.C. 1395w-152) is amended by adding at the end the following new 
subsection:
    ``(d) Treatment of Certain Complaints for Purposes of Quality or 
Performance Assessment.--In conducting a quality or performance 
assessment of a PDP sponsor, the Secretary shall develop or utilize 
existing screening methods for reviewing and considering complaints 
that are received from enrollees in a prescription drug plan offered by 
such PDP sponsor and that are complaints regarding the lack of access 
by the individual to prescription drugs due to a drug management 
program for at-risk beneficiaries.''.
    (e) GAO Studies and Reports.--
            (1) Studies.--The Comptroller General of the United States 
        shall conduct a study on each of the following:
                    (A) The implementation of the amendments made by 
                this section.
                    (B) The effectiveness of the at-risk beneficiaries 
                for prescription drug abuse drug management programs 
                authorized by section 1860D-4(c)(5) of the Social 
                Security Act (42 U.S.C. 1395w-10(c)(5)), as added by 
                subsection (a)(1), including an analysis of--
                            (i) the impediments, if any, that impair 
                        the ability of individuals described in 
                        subparagraph (C) of such section 1860D-4(c)(5) 
                        to access clinically appropriate levels of 
                        prescription drugs; and
                            (ii) the types of--
                                    (I) individuals who, in the 
                                implementation of such section, are 
                                determined to be individuals described 
                                in such subparagraph; and
                                    (II) prescribers and pharmacies 
                                that are selected under subparagraph 
                                (D) of such section.
            (2) Reports.--Not later than January 1, 2016, the 
        Comptroller General of the United States shall begin work, with 
        respect to each study described in paragraph (1), on a report 
        that describes the result of such study. Upon the completion of 
        each such report, such Comptroller General shall submit the 
        report to each of the committees described in paragraph (3).
            (3) Committees described.--The committees described in this 
        paragraph are the following:
                    (A) The Committee on Ways and Means of the House of 
                Representatives.
                    (B) The Committee on Energy and Commerce of the 
                House of Representatives.
                    (C) The Committee on Finance of the Senate.
                    (D) The Committee on Health, Education, Labor, and 
                Pensions of the Senate.
                    (E) The Special Committee on Aging of the Senate.
    (f) Effective Date.--
            (1) In general.--The amendments made by this section shall 
        apply to prescription drug plans for plan years beginning on or 
        after January 1, 2017.
            (2) Stakeholder meetings prior to effective date.--
                    (A) In general.--Not later than January 1, 2016, 
                the Secretary shall convene stakeholders, including 
                individuals entitled to benefits under part A of title 
                XVIII of the Social Security Act or enrolled under part 
                B of such title of such Act, advocacy groups 
                representing such individuals, clinicians, plan 
                sponsors, entities delegated by plan sponsors, and 
                biopharmaceutical manufacturers for input regarding the 
                topics described in subparagraph (B).
                    (B) Topics described.--The topics described in this 
                subparagraph are the topics of--
                            (i) the impact on cost-sharing and ensuring 
                        accessibility to prescription drugs for 
                        enrollees in prescription drug plans of PDP 
                        sponsors who are at-risk beneficiaries for 
                        prescription drug abuse (as defined in 
                        paragraph (5)(C) of section 1860D-4(c) of the 
                        Social Security Act (42 U.S.C. 1395w-10(c)));
                            (ii) the use of an expedited appeals 
                        process under which such an enrollee may appeal 
                        an identification of such enrollee as an at-
                        risk beneficiary for prescription drug abuse 
                        under such paragraph (similar to the processes 
                        established under the Medicare Advantage 
                        program under part C of title XVIII of the 
                        Social Security Act that allow an automatic 
                        escalation to external review of claims 
                        submitted under such part);
                            (iii) the types of enrollees that should be 
                        treated as exempted individuals, as described 
                        in clause (ii) of such paragraph;
                            (iv) the manner in which terms and 
                        definitions in paragraph (5) of such section 
                        1860D-4(c) should be applied, such as the use 
                        of clinical appropriateness in determining 
                        whether an enrollee is an at-risk beneficiary 
                        for prescription drug abuse as defined in 
                        subparagraph (C) of such paragraph (5);
                            (v) the information to be included in the 
                        notices described in subparagraph (B) of such 
                        section and the standardization of such 
                        notices; and
                            (vi) with respect to a PDP sponsor that 
                        establishes a drug management program for at-
                        risk beneficiaries under such paragraph (5), 
                        the responsibilities of such PDP sponsor with 
                        respect to the implementation of such program.
    (g) Rulemaking.--The Secretary shall promulgate regulations based 
on the input gathered pursuant to subsection (f)(2)(A).

SEC. 13. GUIDANCE ON APPLICATION OF COMMON RULE TO CLINICAL DATA 
              REGISTRIES.

    Not later than one year after the date of the enactment of this 
section, the Secretary of Health and Human Services shall issue a 
clarification or modification with respect to the application of 
subpart A of part 46 of title 45, Code of Federal Regulations, 
governing the protection of human subjects in research (and commonly 
known as the ``Common Rule''), to activities, including quality 
improvement activities, involving clinical data registries, including 
entities that are qualified clinical data registries pursuant to 
section 1848(m)(3)(E) of the Social Security Act (42 U.S.C. 1395w-
4(m)(3)(E)).

SEC. 14. ELIMINATING CERTAIN CIVIL MONEY PENALTIES; GAINSHARING STUDY 
              AND REPORT.

    (a) Eliminating Civil Money Penalties for Inducements to Physicians 
to Limit Services That Are Not Medically Necessary.--
            (1) In general.--Section 1128A(b)(1) of the Social Security 
        Act (42 U.S.C. 1320a-7a(b)(1)) is amended by inserting 
        ``medically necessary'' after ``reduce or limit''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to payments made on or after the date of the 
        enactment of this Act.
    (b) Gainsharing Study and Report.--Not later than 12 months after 
the date of the enactment of this Act, the Secretary of Health and 
Human Services, in consultation with the Inspector General of the 
Department of Health and Human Services, shall submit to Congress a 
report with options for amending existing fraud and abuse laws in, and 
regulations related to, titles XI and XVIII of the Social Security Act 
(42 U.S.C. 301 et seq.), through exceptions, safe harbors, or other 
narrowly targeted provisions, to permit gainsharing arrangements that 
otherwise would be subject to the civil money penalties described in 
paragraphs (1) and (2) of section 1128A(b) of such Act (42 U.S.C. 
1320a-7a(b)), or similar arrangements between physicians and hospitals, 
and that improve care while reducing waste and increasing efficiency. 
The report shall--
            (1) consider whether such provisions should apply to 
        ownership interests, compensation arrangements, or other 
        relationships;
            (2) describe how the recommendations address 
        accountability, transparency, and quality, including how best 
        to limit inducements to stint on care, discharge patients 
        prematurely, or otherwise reduce or limit medically necessary 
        care; and
            (3) consider whether a portion of any savings generated by 
        such arrangements (as compared to an historical benchmark or 
        other metric specified by the Secretary to determine the impact 
        of delivery and payment system changes under such title XVIII 
        on expenditures made under such title) should accrue to the 
        Medicare program under title XVIII of the Social Security Act.

SEC. 15. MODIFICATION OF MEDICARE HOME HEALTH SURETY BOND CONDITION OF 
              PARTICIPATION REQUIREMENT.

    Section 1861(o)(7) of the Social Security Act (42 U.S.C. 
1395x(o)(7)) is amended to read as follows:
            ``(7) provides the Secretary with a surety bond--
                    ``(A) in a form specified by the Secretary and in 
                an amount that is not less than the minimum of $50,000; 
                and
                    ``(B) that the Secretary determines is commensurate 
                with the volume of payments to the home health agency; 
                and''.

SEC. 16. OVERSIGHT OF MEDICARE COVERAGE OF MANUAL MANIPULATION OF THE 
              SPINE TO CORRECT SUBLUXATION.

    (a) In General.--Section 1833 of the Social Security Act (42 U.S.C. 
1395l) is amended by adding at the end the following new subsection:
    ``(z) Medical Review of Spinal Subluxation Services.--
            ``(1) In general.--The Secretary shall implement a process 
        for the medical review (as described in paragraph (2)) of 
        treatment by a chiropractor described in section 1861(r)(5) by 
        means of manual manipulation of the spine to correct a 
        subluxation (as described in such section) of an individual who 
        is enrolled under this part and apply such process to such 
        services furnished on or after January 1, 2017, focusing on 
        services such as--
                    ``(A) services furnished by a such a chiropractor 
                whose pattern of billing is aberrant compared to peers; 
                and
                    ``(B) services furnished by such a chiropractor 
                who, in a prior period, has a services denial 
                percentage in the 85th percentile or greater, taking 
                into consideration the extent that service denials are 
                overturned on appeal.
            ``(2) Medical review.--
                    ``(A) Prior authorization medical review.--
                            ``(i) In general.--Subject to clause (ii), 
                        the Secretary shall use prior authorization 
                        medical review for services described in 
                        paragraph (1) that are furnished to an 
                        individual by a chiropractor described in 
                        section 1861(r)(5) that are part of an episode 
                        of treatment that includes more than 12 
                        services. For purposes of the preceding 
                        sentence, an episode of treatment shall be 
                        determined by the underlying cause that 
                        justifies the need for services, such as a 
                        diagnosis code.
                            ``(ii) Ending application of prior 
                        authorization medical review.--The Secretary 
                        shall end the application of prior 
                        authorization medical review under clause (i) 
                        to services described in paragraph (1) by such 
                        a chiropractor if the Secretary determines that 
                        the chiropractor has a low denial rate under 
                        such prior authorization medical review. The 
                        Secretary may subsequently reapply prior 
                        authorization medical review to such 
                        chiropractor if the Secretary determines it to 
                        be appropriate and the chiropractor has, in the 
                        time period subsequent to the determination by 
                        the Secretary of a low denial rate with respect 
                        to the chiropractor, furnished such services 
                        described in paragraph (1).
                            ``(iii) Early request for prior 
                        authorization review permitted.--Nothing in 
                        this subsection shall be construed to prevent 
                        such a chiropractor from requesting prior 
                        authorization for services described in 
                        paragraph (1) that are to be furnished to an 
                        individual before the chiropractor furnishes 
                        the twelfth such service to such individual for 
                        an episode of treatment.
                    ``(B) Type of review.--The Secretary may use pre-
                payment review or post-payment review of services 
                described in section 1861(r)(5) that are not subject to 
                prior authorization medical review under subparagraph 
                (A).
                    ``(C) Relationship to law enforcement activities.--
                The Secretary may determine that medical review under 
                this subsection does not apply in the case where 
                potential fraud may be involved.
            ``(3) No payment without prior authorization.--With respect 
        to a service described in paragraph (1) for which prior 
        authorization medical review under this subsection applies, the 
        following shall apply:
                    ``(A) Prior authorization determination.--The 
                Secretary shall make a determination, prior to the 
                service being furnished, of whether the service would 
                or would not meet the applicable requirements of 
                section 1862(a)(1)(A).
                    ``(B) Denial of payment.--Subject to paragraph (5), 
                no payment may be made under this part for the service 
                unless the Secretary determines pursuant to 
                subparagraph (A) that the service would meet the 
                applicable requirements of such section 1862(a)(1)(A).
            ``(4) Submission of information.--A chiropractor described 
        in section 1861(r)(5) may submit the information necessary for 
        medical review by fax, by mail, or by electronic means. The 
        Secretary shall make available the electronic means described 
        in the preceding sentence as soon as practicable.
            ``(5) Timeliness.--If the Secretary does not make a prior 
        authorization determination under paragraph (3)(A) within 14 
        business days of the date of the receipt of medical 
        documentation needed to make such determination, paragraph 
        (3)(B) shall not apply.
            ``(6) Application of limitation on beneficiary liability.--
        Where payment may not be made as a result of the application of 
        paragraph (2)(B), section 1879 shall apply in the same manner 
        as such section applies to a denial that is made by reason of 
        section 1862(a)(1).
            ``(7) Review by contractors.--The medical review described 
        in paragraph (2) may be conducted by medicare administrative 
        contractors pursuant to section 1874A(a)(4)(G) or by any other 
        contractor determined appropriate by the Secretary that is not 
        a recovery audit contractor.
            ``(8) Multiple services.--The Secretary shall, where 
        practicable, apply the medical review under this subsection in 
        a manner so as to allow an individual described in paragraph 
        (1) to obtain, at a single time rather than on a service-by-
        service basis, an authorization in accordance with paragraph 
        (3)(A) for multiple services.
            ``(9) Construction.--With respect to a service described in 
        paragraph (1) that has been affirmed by medical review under 
        this subsection, nothing in this subsection shall be construed 
        to preclude the subsequent denial of a claim for such service 
        that does not meet other applicable requirements under this 
        Act.
            ``(10) Implementation.--
                    ``(A) Authority.--The Secretary may implement the 
                provisions of this subsection by interim final rule 
                with comment period.
                    ``(B) Administration.--Chapter 35 of title 44, 
                United States Code, shall not apply to medical review 
                under this subsection.''.
    (b) Improving Documentation of Services.--
            (1) In general.--The Secretary of Health and Human Services 
        shall, in consultation with stakeholders (including the 
        American Chiropractic Association) and representatives of 
        medicare administrative contractors (as defined in section 
        1874A(a)(3)(A) of the Social Security Act (42 U.S.C. 1395kk-
        1(a)(3)(A))), develop educational and training programs to 
        improve the ability of chiropractors to provide documentation 
        to the Secretary of services described in section 1861(r)(5) in 
        a manner that demonstrates that such services are, in 
        accordance with section 1862(a)(1) of such Act (42 U.S.C. 
        1395y(a)(1)), reasonable and necessary for the diagnosis or 
        treatment of illness or injury or to improve the functioning of 
        a malformed body member.
            (2) Timing.--The Secretary shall make the educational and 
        training programs described in paragraph (1) publicly available 
        not later than January 1, 2016.
            (3) Funding.--The Secretary shall use funds made available 
        under section 1893(h)(10) of the Social Security Act (42 U.S.C. 
        1395ddd(h)(10)), as added by section 6, to carry out this 
        subsection.
    (c) GAO Study and Report.--
            (1) Study.--The Comptroller General of the United States 
        shall conduct a study on the effectiveness of the process for 
        medical review of services furnished as part of a treatment by 
        means of manual manipulation of the spine to correct a 
        subluxation implemented under subsection (z) of section 1833 of 
        the Social Security Act (42 U.S.C. 1395l), as added by 
        subsection (a). Such study shall include an analysis of--
                    (A) aggregate data on--
                            (i) the number of individuals, 
                        chiropractors, and claims for services subject 
                        to such review; and
                            (ii) the number of reviews conducted under 
                        such section; and
                    (B) the outcomes of such reviews.
            (2) Report.--Not later than four years after the date of 
        enactment of this Act, the Comptroller General shall submit to 
        Congress a report containing the results of the study conducted 
        under paragraph (1), including recommendations for such 
        legislation and administrative action with respect to the 
        process for medical review implemented under subsection (z) of 
        section 1833 of the Social Security Act (42 U.S.C. 1395l) as 
        the Comptroller General determines appropriate.

SEC. 17. NATIONAL EXPANSION OF PRIOR AUTHORIZATION MODEL FOR REPETITIVE 
              SCHEDULED NON-EMERGENT AMBULANCE TRANSPORT.

    (a) Initial Expansion.--
            (1) In general.--In implementing the model described in 
        paragraph (2) proposed to be tested under subsection (b) of 
        section 1115A of the Social Security Act (42 U.S.C. 1315a), the 
        Secretary of Health and Human Services shall revise the testing 
        under subsection (b) of such section to cover, effective not 
        later than January 1, 2016, States located in medicare 
        administrative contractor (MAC) regions L and 11 (consisting of 
        Delaware, the District of Columbia, Maryland, New Jersey, 
        Pennsylvania, North Carolina, South Carolina, West Virginia, 
        and Virginia).
            (2) Model described.--The model described in this paragraph 
        is the testing of a model of prior authorization for repetitive 
        scheduled non-emergent ambulance transport proposed to be 
        carried out in New Jersey, Pennsylvania, and South Carolina.
            (3) Funding.--The Secretary shall allocate funds made 
        available under section 1115A(f)(1)(B) of the Social Security 
        Act (42 U.S.C. 1315a(f)(1)(B)) to carry out this subsection.
    (b) National Expansion.--Section 1834(l) of the Social Security Act 
(42 U.S.C. 1395m(l)) is amended by adding at the end the following new 
paragraph:
            ``(16) Prior authorization for repetitive scheduled non-
        emergent ambulance transports.--
                    ``(A) In general.--Beginning January 1, 2017, if 
                the expansion to all States of the model of prior 
                authorization described in paragraph (2) of section 
                18(a) of the Protecting the Integrity of Medicare Act 
                of 2015 meets the requirements described in paragraphs 
                (1) through (3) of section 1115A(c), then the Secretary 
                shall expand such model to all States.
                    ``(B) Funding.--The Secretary shall use funds made 
                available under section 1893(h)(10) to carry out this 
                paragraph.
                    ``(C) Clarification regarding budget neutrality.--
                Nothing in this paragraph may be construed to limit or 
                modify the application of section 1115A(b)(3)(B) to 
                models described in such section, including with 
                respect to the model described in subparagraph (A) and 
                expanded beginning on January 1, 2017, under such 
                subparagraph.''.

SEC. 18. REPEALING DUPLICATIVE MEDICARE SECONDARY PAYOR PROVISION.

    (a) In General.--Section 1862(b)(5) of the Social Security Act (42 
U.S.C. 1395y(b)(5)) is amended by inserting at the end the following 
new subparagraph:
                    ``(E) End date.--The provisions of this paragraph 
                shall not apply to information required to be provided 
                on or after July 1, 2016.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
take effect on the date of the enactment of this Act and shall apply to 
information required to be provided on or after January 1, 2016.

SEC. 19. PLAN FOR EXPANDING DATA IN ANNUAL CERT REPORT.

    Not later than June 30, 2015, the Secretary of Health and Human 
Services shall submit to the Committee on Finance of the Senate, and to 
the Committees on Energy and Commerce and on Ways and Means of the 
House of Representatives--
            (1) a plan for including, in the annual report of the 
        Comprehensive Error Rate Testing (CERT) program, data on 
        services (or groupings of services) (other than medical visits) 
        paid under the physician fee schedule under section 1848 of the 
        Social Security Act (42 U.S.C. 1395w-4) where the fee schedule 
        amount is in excess of 250 dollars and where the error rate is 
        in excess of 20 percent; and
            (2) to the extent practicable by such date, specific 
        examples of services described in paragraph (1).

SEC. 20. REMOVING FUNDS FOR MEDICARE IMPROVEMENT FUND ADDED BY IMPACT 
              ACT OF 2014.

    Section 1898(b)(1) of the Social Security Act (42 U.S.C. 
1395iii(b)(1)), as amended by section 3(e)(3) of the IMPACT Act of 2014 
(Public Law 113-185), is amended by striking ``$195,000,000'' and 
inserting ``$0''.

SEC. 21. RULE OF CONSTRUCTION.

    Except as explicitly provided in this Act, nothing in this Act, 
including the amendments made by this Act, shall be construed as 
preventing the use of notice and comment rulemaking in the 
implementation of the provisions of, and the amendments made by, this 
Act.
                                                  Union Calendar No. 29

114th CONGRESS

  1st Session

                               H. R. 1021

                      [Report No. 114-46, Part I]

_______________________________________________________________________

                                 A BILL

    To amend title XVIII of the Social Security Act to improve the 
       integrity of the Medicare program, and for other purposes.

_______________________________________________________________________

                             March 18, 2015

    Reported from the Committee on Ways and Means with an amendment

                             March 18, 2015

   The Committee on Energy and Commerce discharged; committed to the 
 Committee of the Whole House on the State of the Union and ordered to 
                               be printed