[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1530 Introduced in House (IH)]

114th CONGRESS
  1st Session
                                H. R. 1530

To amend title XVIII of the Social Security Act to refine how Medicare 
 pays for orthotics and prosthetics, to improve beneficiary experience 
 and outcomes with orthotic and prosthetic care, and to streamline the 
    Medicare administrative appeals process, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             March 23, 2015

     Mr. Thompson of Pennsylvania (for himself and Mr. Thompson 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 refine how Medicare 
 pays for orthotics and prosthetics, to improve beneficiary experience 
 and outcomes with orthotic and prosthetic care, and to streamline the 
    Medicare administrative appeals process, 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 ``Medicare Orthotics 
and Prosthetics Improvement 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. Eligibility for Medicare payment for health professionals based 
                            on qualifications.
Sec. 3. Modification of requirements applicable under Medicare to the 
                            designation of accreditation organizations 
                            for suppliers of orthotics and prosthetics.
Sec. 4. Application of existing accreditation and licensure 
                            requirements to certain prosthetics and 
                            custom-fabricated or custom-fitted 
                            orthotics.
Sec. 5. Eligibility for Medicare payment for orthotics and prosthetics 
                            based on supplier qualifications and 
                            complexity of care.
Sec. 6. Orthotist's and prosthetist's clinical notes as part of the 
                            patient's medical record.
Sec. 7. Distinguishing orthotists and prosthetists from suppliers of 
                            durable medical equipment and supplies.
Sec. 8. Greater accountability and transparency of recovery audit 
                            contractors.
Sec. 9. Maintaining due process and satisfying the ninety-day statutory 
                            period for administrative law judge 
                            decisions.
Sec. 10. Clarification about minimal self-adjustment for off-the-shelf 
                            orthotics.
Sec. 11. Regulations.

SEC. 2. ELIGIBILITY FOR MEDICARE PAYMENT FOR HEALTH PROFESSIONALS BASED 
              ON QUALIFICATIONS.

    (a) In General.--Title XVIII of the Social Security Act is amended 
by inserting after section 1863 (42 U.S.C. 1395z) the following new 
section:

       ``eligibility for medicare payment for suppliers based on 
                             qualifications

    ``Sec. 1863A. No payment may be made under this part for an item or 
service that is furnished (i) in a State that requires a provider or 
supplier to be licensed in order to furnish such item or service, 
unless the provider or supplier furnishing such item or service 
possesses all applicable licensure from the State, or (ii) in a State 
that does not require a provider or supplier to be licensed in order to 
furnish such item or service, unless the provider or supplier meets all 
applicable qualifications, as established by the Secretary. Applicable 
qualifications means all applicable accreditations, certifications, and 
credentials required under this part for providers and suppliers, 
including the requirements established under section 427 of the 
Medicare, Medicaid, and SCHIP Benefits Improvement and Protections Act 
of 2000, as enacted into law by section 1(a)(6) of Public Law 106-554, 
with these requirements to be applicable immediately in accordance with 
that statutory language even in advance of the Secretary issuing 
applicable regulations under this provision, as well as any and all 
applicable regulations as established by the Secretary, this being 
noted inasmuch as issuance of these regulations are approximately 
fourteen years beyond the statutory requirement for their being issued 
in final form by the Secretary, which it is anticipated the Secretary 
will remedy expeditiously.''.
    (b) Effective Date.--This section shall take effect on the date of 
enactment of this Act.

SEC. 3. MODIFICATION OF REQUIREMENTS APPLICABLE UNDER MEDICARE TO THE 
              DESIGNATION OF ACCREDITATION ORGANIZATIONS FOR SUPPLIERS 
              OF ORTHOTICS AND PROSTHETICS.

    (a) In General.--Section 1834(a)(20)(B) of the Social Security Act 
(42 U.S.C. 1395m(a)(20)(B)) is amended--
            (1) by striking ``organizations.--Not later than'' and 
        inserting: ``organizations.--
                            ``(i) In general.--Subject to clause (ii), 
                        not later than''; and
            (2) by adding after clause (i), as added by paragraph (1), 
        the following new clauses:
                            ``(ii) Special requirements for 
                        accreditation of suppliers of orthotics and 
                        prosthetics.--For purposes of applying quality 
                        standards under subparagraph (A) for suppliers 
                        (other than suppliers described in clause 
                        (iii)) of items and services described in 
                        subparagraph (D)(ii), the Secretary shall 
                        designate and approve independent accreditation 
                        organizations under clause (i) only if such 
                        organizations are Boards or programs described 
                        in subsection (h)(1)(F)(iv). Not later than 
                        January 1, 2016, the Secretary shall ensure 
                        that at least one, and ideally multiple, 
                        independent accreditation organizations are 
                        designated and approved in accordance with this 
                        clause.
                            ``(iii) Exception.--Suppliers described in 
                        this clause are physicians, occupational 
                        therapists, or physical therapists who are 
                        licensed or otherwise regulated by the State in 
                        which they are practicing and who receive 
                        payment under this title, including regulations 
                        promulgated pursuant to this subsection.''.
    (b) Effective Date.--The designated and approved organizations must 
satisfy the requirement of section 1834(a)(20)(B)(ii), as added by 
subsection (a)(2), not later than January 1, 2016, regardless of 
whether such organizations are designated or approved as an independent 
accreditation organization before, on, or after the date of the 
enactment of this Act.

SEC. 4. APPLICATION OF EXISTING ACCREDITATION AND LICENSURE 
              REQUIREMENTS TO CERTAIN PROSTHETICS AND CUSTOM-FABRICATED 
              OR CUSTOM-FITTED ORTHOTICS.

    (a) In General.--Section 1834(h)(1)(F) of the Social Security Act 
(42 U.S.C. 1395m(h)(1)(F)) is amended--
            (1) in the heading, by inserting ``or custom-fitted'' after 
        ``custom-fabricated'';
            (2) in clause (i), by striking ``an item of custom-
        fabricated orthotics described in clause (ii) or for an item of 
        prosthetics unless such item is'' and inserting ``an item of 
        orthotics or prosthetics, including an item of custom-
        fabricated orthotics described in clause (ii), unless such item 
        is'';
            (3) in clause (ii)(II), by striking ``a list of items to 
        which this subparagraph applies'' and inserting ``a list of 
        items for purposes of clause (i)'';
            (4) in clause (iii)(III), by striking ``to provide or 
        manage the provision of prosthetics and custom-designed or -
        fabricated orthotics'' and inserting ``to provide or manage the 
        provision of orthotics and prosthetics (and custom-designed or 
        -fabricated orthotics, in the case of an item described in 
        clause (ii))''; and
            (5) by adding at the end the following new clause:
                            ``(v) Exemption of off-the-shelf orthotics 
                        included in a competitive acquisition 
                        program.--This subparagraph shall not apply to 
                        an item of orthotics described in paragraph 
                        (2)(C) of section 1847(a) furnished on or after 
                        January 1, 2016, that is included in a 
                        competitive acquisition area under such 
                        section.''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to orthotics and prosthetics furnished on or after January 1, 
2016.

SEC. 5. ELIGIBILITY FOR MEDICARE PAYMENT FOR ORTHOTICS AND PROSTHETICS 
              BASED ON SUPPLIER QUALIFICATIONS AND COMPLEXITY OF CARE.

    Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)) is 
amended--
            (1) in paragraph (1)(F)(iii), in the matter preceding 
        subclause (I), by striking ``other individual who'' and 
        inserting ``other individual who, with respect to the provision 
        of orthotics and prosthetics furnished on or after January 1, 
        2016, and subject to paragraph (5)(A), satisfies all applicable 
        criteria of the provider qualification designation for such 
        category described in the respective clause, and who'';
            (2) in paragraph (1)(F)(iv), by inserting before the period 
        the following: ``and, with respect to the provision of 
        orthotics and prosthetics furnished on or after January 1, 
        2016, and subject to paragraph (5)(A), satisfies all applicable 
        criteria of the provider qualification designation for such 
        orthotic or prosthetic''; and
            (3) by adding at the end the following new paragraph:
            ``(5) Eligibility for payment based on supplier 
        qualifications and complexity of care.--
                    ``(A) Considerations for eligibility for 
                payments.--
                            ``(i) In general.--In applying clauses 
                        (iii) and (iv) of paragraph (1)(F) for purposes 
                        of determining whether payment may be made 
                        under this subsection for orthotics and 
                        prosthetics furnished on or after January 1, 
                        2016, the Secretary shall take into account the 
                        complexity of the respective item and, subject 
                        to clauses (ii), (iii), and (iv), the 
                        qualifications of the individual or entity 
                        furnishing and fabricating such respective item 
                        in accordance with this paragraph.
                            ``(ii) Individuals and entities exempted 
                        from supplier qualification criteria.--With 
                        respect to the provision of orthotics or 
                        prosthetics, any criteria for supplier 
                        qualifications shall not apply to physicians, 
                        occupational therapists, or physical therapists 
                        who are licensed or otherwise regulated by the 
                        State in which they are practicing and who 
                        receive payment under this title, including 
                        regulations promulgated pursuant to this 
                        subsection, for the provision of orthotics and 
                        prosthetics.
                            ``(iii) Suppliers medicare-eligible prior 
                        to january 1, 2016 exempted.--In the case of a 
                        qualified supplier who is eligible to receive 
                        payment under this title before January 1, 
                        2016, with respect to the provision of 
                        orthotics and prosthetics, any new criteria for 
                        provider qualifications established after such 
                        date shall not apply to such supplier, for the 
                        furnishing or fabrication of such an item.
                            ``(iv) Modifications.--The Secretary shall, 
                        in consultation with the Boards and programs 
                        described in paragraph (1)(F)(iv), periodically 
                        review the criteria for supplier qualifications 
                        and may implement by regulation any 
                        modifications to such criteria, as determined 
                        appropriate in accordance with such 
                        consultation. Any such modifications shall take 
                        effect no earlier than January 1, 2016.
                    ``(B) Assignment of billing codes.--For purposes of 
                subparagraph (A), the Secretary, in consultation with 
                representatives of the fields of occupational therapy, 
                physical therapy, orthotics, and prosthetics, shall 
                utilize and incorporate the set of L-codes listed, as 
                of the date of enactment of this paragraph, in the 
                Centers for Medicare & Medicaid Services document 
                entitled Transmittal 656 (CMS Pub. 100-04, Change 
                Request 3959, August 19, 2005). Transmittal 656 shall 
                be the controlling source of category, product, and 
                code assignments for the orthotics and prosthetics 
                care, using the supplier qualification designation for 
                each HCPCS code as stated in such document. In the case 
                that Transmittal 656 is updated, reissued, or replaced 
                by a subsequent document, the previous sentence shall 
                be applied with respect to the most recent update, 
                reissuance, or replacement of such document.''.

SEC. 6. ORTHOTIST'S AND PROSTHETIST'S CLINICAL NOTES AS PART OF THE 
              PATIENT'S MEDICAL RECORD.

    Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)), as 
amended by section 5, is amended by adding at the end the following new 
paragraph:
            ``(6) Documentation created by orthotists and 
        prosthetists.--With respect to claims filed after August 11, 
        2011, for purposes of determining the reasonableness, medical 
        necessity, and functional level (applicable to prosthetics) of 
        prosthetic devices and orthotics and prosthetics, documentation 
        created by an orthotist or prosthetist shall be considered part 
        of the patient's medical record and, consistent with the 
        treatment of orthotic and prosthetic patient care delivery 
        stated in the health care professional exception provided in 
        clause (ii) of subsection (a)(20)(F), shall be given the same 
        consideration as documentation created by other health 
        professionals, including physicians, nurse practitioners, 
        occupational therapists, and physical therapists. For claims 
        filed before date of enactment of this Act, this paragraph 
        shall not apply to those appeals of claim denials that have 
        been waived, denied at the last level of appeal, or otherwise 
        settled.''.

SEC. 7. DISTINGUISHING ORTHOTISTS AND PROSTHETISTS FROM SUPPLIERS OF 
              DURABLE MEDICAL EQUIPMENT AND SUPPLIES.

    (a) Requirements for Suppliers of Medical Equipment and Supplies.--
Section 1834(j)(5) of the Social Security Act (42 U.S.C. 1395m(j)(5)) 
is amended by striking subparagraph (C).
    (b) Requirements for Orthotists and Prosthetists.--Section 1834 of 
the Social Security Act (42 U.S.C. 1395m) is amended by adding at the 
end the following new subsection:
    ``(r) Requirements for Orthotists and Prosthetists.--
            ``(1) Issuance and renewal of supplier number.--
                    ``(A) Payment.--
                            ``(i) In general.--No payment may be made 
                        under this part to an orthotic or prosthetic 
                        supplier unless such orthotic or prosthetic 
                        supplier obtains (and renews at such intervals 
                        as the Secretary may require) a supplier 
                        number; provided, however, that providers 
                        otherwise permitted to receive payment for 
                        orthotics and prosthetics under Part A may 
                        continue to receive such payment without 
                        interruption.
                    ``(B) Standards for possessing a supplier number.--
                An orthotic and/or prosthetic supplier may not obtain a 
                supplier number unless the supplier meets standards 
                prescribed by the Secretary that include requirements 
                that the orthotic/prosthetic supplier (and, where 
                applicable, the orthotist or prosthetist)--
                            ``(i) comply with all applicable State and 
                        Federal licensure and regulatory requirements;
                            ``(ii) acquire accreditation from the 
                        American Board for Certification in Orthotics, 
                        Prosthetics and Pedorthics, Inc. (ABC) or the 
                        Board of Certification/Accreditation, 
                        International (BOC), or other accreditation 
                        entity deemed by the HHS Secretary to have 
                        standards that are essentially equivalent to 
                        such boards;
                            ``(iii) maintain a physical facility on an 
                        appropriate site;
                            ``(iv) have proof of appropriate liability 
                        insurance; and
                            ``(v) meet such other requirements as the 
                        Secretary shall specify.
                    ``(C) Prohibition against multiple supplier 
                numbers.--The Secretary may not issue more than one 
                supplier number to any orthotic and/or prosthetic 
                supplier unless the Secretary finds that the issuance 
                of more than one number is appropriate to identify 
                other entities under the orthotic or prosthetic 
                supplier's ownership or control.
            ``(2) Order for orthotics or prosthetics.--
                    ``(A) Information provided by orthotists and 
                prosthetists on detailed orders for orthotics and 
                prosthetics.--An orthotist or prosthetist may 
                distribute to physicians, or to an individual entitled 
                to benefits under this part, a detailed written order 
                for orthotics or prosthetics (as defined in paragraph 
                (4)) for commercial purposes that contains the 
                following information:
                            ``(i) An identification of the orthotic or 
                        prosthetic supplier and the beneficiary to whom 
                        such orthotics or prosthetics are furnished.
                            ``(ii) An identification of the treating 
                        physician, including the name, Medicare 
                        provider number, address, and telephone number.
                            ``(iii) Signature of the physician 
                        identified in (ii).
                            ``(iv) A description of such orthotics or 
                        prosthetics.
                            ``(v) Any billing code identifying such 
                        orthotics or prosthetics.
                            ``(vi) Diagnosis codes, a description of 
                        the beneficiary's medical and functional 
                        condition, and information about the need for 
                        the orthotics or prosthetics.
                            ``(vii) Any other administrative 
                        information identified by the Secretary.
                    ``(B) Information on coding and descriptors of 
                components provided.--If an orthotist or prosthetist 
                distributes a detailed written order for orthotics or 
                prosthetics, the orthotist or prosthetist also shall 
                list on the order the HCPCS codes and summary 
                descriptors of the items and services being recommended 
                prior to distribution of such order to the treating 
                physician.
                    ``(C) Written physician order.--A detailed written 
                order for orthotics or prosthetics must be signed by 
                the treating physician identified in (a)(ii) of this 
                subsection, and be included in the orthotist or 
                prosthetist's order.
            ``(3) Limitation on patient liability.--If an orthotist or 
        prosthetist--
                    ``(A) furnishes an orthotic or prosthetic to a 
                beneficiary for which no payment may be made under this 
                part; or
                    ``(B) subject to section 1879, furnishes an 
                orthosis or prosthesis to a beneficiary for which 
                payment is denied under section 1862(a)(1) of this 
                title,
        any expenses incurred for such orthotics or prosthetics 
        furnished to an individual by the orthotist or prosthetist not 
        on an assigned basis shall be the responsibility of such 
        orthotist or prosthetist. The individual shall have no 
        financial responsibility for such expenses and the orthotist or 
        prosthetist shall refund on a timely basis to the individual 
        (and shall be liable to the individual for) any amounts 
        collected from the individual for such items and services. The 
        provisions of subsection (a)(18) of this section shall apply to 
        refunds required under the previous sentence in the same manner 
        as such provisions apply to refunds under such subsection.
            ``(4) Patient liability.--If an orthotist or prosthetist 
        furnishes an orthotic or prosthetic to a beneficiary for which 
        payment is denied in advance under subsection (a)(15) of this 
        section, expenses incurred for such orthotic or prosthetic 
        furnished to the beneficiary by the orthotist or prosthetist 
        shall be the responsibility of the beneficiary.
            ``(5) Definitions.--For purposes of this paragraph--
                    ``(A) `Orthotist or prosthetist' shall mean an 
                individual who is specifically trained and educated in 
                the provision of, and patient care management related 
                to, prosthetics and custom-fabricated or custom-fit 
                orthotics, and--
                            ``(i) in the case of a State that provides 
                        for the licensing of orthotists and 
                        prosthetists, is licensed by the State in which 
                        the orthotics or prosthetics were supplied; or
                            ``(ii) in the case of a State that does not 
                        provide for the licensing of orthotists and 
                        prosthetists, is certified by the American 
                        Board of Certification in Orthotics, 
                        Prosthetics and Pedorthics, Inc. or by the 
                        Board of Certification/Accreditation, 
                        International, or certified and approved by a 
                        program that the Secretary determines has 
                        certification and approval standards that are 
                        essentially equivalent to those of such Boards 
                        listed in this subsection.
                    ``(B) `Orthotics and prosthetics' shall have the 
                meaning given such term in 1834(h)(4)(C).
                    ``(C) `Detailed Written Order for orthotics or 
                prosthetics' shall mean a form or other document 
                prepared by an orthotist or prosthetist and signed by 
                the physician (as defined by section 1861(r) of the 
                Social Security Act) that contains information required 
                by the Secretary to be submitted to show that an 
                orthotic or prosthetic is reasonable and necessary for 
                the treatment of an illness or injury or to improve the 
                functioning of a malformed body member.''.
    (c) Effective Date.--The amendments made by this section shall take 
effect on the date of enactment of this Act, and apply to items and 
services furnished on or after such date.

SEC. 8. GREATER ACCOUNTABILITY AND TRANSPARENCY OF RECOVERY AUDIT 
              CONTRACTORS.

    (a) In General.--Section 1893(h) of the Social Security Act (42 
U.S.C. 1395ddd(h)) is amended by adding at the end the following:
            ``(9) Public reporting of recovery audit contractor 
        performance.--
                    ``(A) In general.--With respect to each recovery 
                audit contractor with a contract under this section for 
                a contract year the Secretary shall publish on the 
                Internet website of the Centers for Medicare & Medicaid 
                Services the following information with respect to the 
                performance of each such recovery audit contractor:
                            ``(i) Audit rates.
                            ``(ii) Appeals outcomes rates at each stage 
                        of the appeals process under section 1869.
                    ``(B) Separate categories of providers of services 
                and suppliers for information reported.--When compiling 
                and publicly reporting the information described in 
                subparagraph (A), the Secretary shall create separate 
                categories of providers and suppliers, including a 
                separate category for orthotics and prosthetics instead 
                of aggregating orthotics and prosthetics with durable 
                medical equipment and supplies.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply not later than contract years beginning on or after the date of 
enactment of this Act.

SEC. 9. MAINTAINING DUE PROCESS AND SATISFYING THE NINETY-DAY STATUTORY 
              PERIOD FOR ADMINISTRATIVE LAW JUDGE DECISIONS.

    (a) Timely Decisions.--Subject to subsection (b), the Secretary 
shall not recoup more than 50 percent of any overpayments for qualified 
providers and hospitals in response to an audit carried out by a 
recovery audit contractor under this section until an administrative 
law judge has rendered a decision, until such time as the Secretary 
certifies that, in the majority of requests for hearing filed by 
providers and suppliers under section 1869(d) of the Social Security 
Act (42 U.S.C. 1395ff(d)), an administrative law judge has rendered a 
decision within the 90-day period beginning on the date a request for 
hearing has been timely filed.
            (1) For purposes of this subsection, a qualifying provider 
        is one that--
                    (A) meets the requirements as a Medicare provider 
                or supplier;
                    (B) has maintained a Medicare provider number for a 
                minimum of six years;
                    (C) is in good standing with applicable Federal and 
                State laws and regulations;
                    (D) has a good record of proper payments under 
                Medicare, as determined by the Secretary; and
                    (E) the beneficiary was treated in person.
            (2) This subsection shall be voluntary for providers and 
        shall not prohibit providers from choosing a different course 
        of action.
    (b) Exception for Audits Related to Fraudulent Activity.--
Notwithstanding subsection (a), the Secretary may recoup overpayments 
related to or resulting from fraudulent activity on the part of a 
Medicare provider or supplier.
    (c) Effective Date.--This section shall take effect on the date of 
enactment of this Act.

SEC. 10. CLARIFICATION ABOUT MINIMAL SELF-ADJUSTMENT FOR OFF-THE-SHELF 
              ORTHOTICS.

    (a) In General.--Section 1847(a)(2)(C) of the Social Security Act 
(42 U.S.C. 1395w-3(a)(2)(C)) is amended--
            (1) by inserting ``furnished to a patient'' after ``section 
        1861(s)(9) of this title'';
            (2) by inserting ``by that patient (and not by any other 
        person)'' after ``minimal self-adjustment''; and
            (3) by striking ``to fit to the individual'' and inserting 
        ``to fit to that patient''.
    (b) Inclusion in Medical and Other Health Services.--Section 
1861(s)(9) of the Social Security Act (42 U.S.C. 1395) is amended--
            (1) by striking ``leg, arm'' and inserting ``(A) leg, 
        arm'';
            (2) in subparagraph (A), as added by paragraph (1), by 
        striking the semicolon and inserting ``; and''; and
            (3) by adding the following new subparagraph:
                    ``(B) off-the-shelf orthotics (as defined in 
                section 1847(a)(2)(C)).''.
    (c) Effective Date.--The amendments made by this section shall take 
effect on April 1, 2007, and apply to items and services furnished on 
or after such date.

SEC. 11. REGULATIONS.

    No later than 120 days after enactment of this Act, the Secretary 
shall promulgate regulations to implement--
            (1) the provisions of, and amendments made by, this Act; 
        and
            (2) the provisions of, and amendments made by, section 427 
        of the Medicare, Medicaid and SCHIP Benefits Improvement and 
        Protections Act of 2000, as enacted into law by section 1(a)(6) 
        of Public Law 106-554.
                                 <all>