[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2570 Introduced in House (IH)]

114th CONGRESS
  1st Session
                                H. R. 2570

   To establish a demonstration program requiring the utilization of 
     Value-Based Insurance Design to demonstrate that reducing the 
    copayments or coinsurance charged to Medicare beneficiaries for 
selected high-value prescription medications and clinical services can 
increase their utilization and ultimately improve clinical outcomes and 
                    lower health care expenditures.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              May 22, 2015

  Mrs. Black (for herself, Mr. Blumenauer, and Mrs. McMorris Rodgers) 
 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

_______________________________________________________________________

                                 A BILL


 
   To establish a demonstration program requiring the utilization of 
     Value-Based Insurance Design to demonstrate that reducing the 
    copayments or coinsurance charged to Medicare beneficiaries for 
selected high-value prescription medications and clinical services can 
increase their utilization and ultimately improve clinical outcomes and 
                    lower health care expenditures.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Value Based Insurance Design for 
Better Care Act of 2015'' or the ``VBID for Better Care Act of 2015''.

SEC. 2. FINDINGS.

    Congress makes the following findings:
            (1) A growing body of evidence demonstrates that increases 
        in patient-level financial barriers (including deductibles, 
        copayments, and coinsurance) for high-value medical services 
        (such as prescription medications, clinician visits, diagnostic 
        tests, and procedures) systematically reduce their use. Savings 
        attributable to cost-related decreased utilization of specific 
        services may lead to an increase in total medical expenditures 
        due to increased use of other related clinical services, such 
        as hospitalizations and emergency room visits.
            (2) Empirical research studies demonstrate that reductions 
        in beneficiary out-of-pocket expenses for high-value 
        prescription medications and clinical services can mitigate the 
        adverse health and financial consequences attributable to cost-
        related decreased utilization of high-value services.
            (3) Financial barriers to prescription medications and 
        clinical services that are deemed to be high-value should be 
        reduced or eliminated to increase their use.
            (4) Value-Based Insurance Design is a methodology that 
        adjusts patient out-of-pocket costs for prescription 
        medications and clinical services according to the clinical 
        value--not exclusively the cost. Value-Based Insurance Design 
        is based on the concept of clinical nuance that recognizes--
                    (A) prescription medications and clinical services 
                differ in the clinical benefit provided; and
                    (B) the clinical benefit derived from a specific 
                prescription medication or clinical service depends on 
                the clinical situation, the provider, and where the 
                care is delivered.
            (5) The current ``one-size-fits-all'' copayment or 
        coinsurance design for prescription medications and clinical 
        services provided under the Medicare program does not recognize 
        the well-established value differences in health outcomes 
        produced by various medical interventions.
            (6) The establishment by Medicare of copayment and 
        coinsurance requirements using Value-Based Insurance Design 
        methodologies will improve patient-centered health outcomes, 
        enhance personal responsibility, and afford a more efficient 
        use of taxpayer dollars.

SEC. 3. DEMONSTRATION PROGRAM.

    (a) In General.--The Secretary of Health and Human Services (in 
this section referred to as the ``Secretary'') shall establish a 3-year 
demonstration program to test the use of value-based insurance design 
methodologies (as defined in subsection (c)(1)) under eligible Medicare 
Advantage plans offered by Medicare Advantage organizations under part 
C of title XVIII of the Social Security Act (42 U.S.C. 1395w-21 et 
seq.).
    (b) Demonstration Program Design.--
            (1) Selection of medicare advantage sites and eligible 
        medicare advantage plans.--Not later than two years after the 
        date of the enactment of this Act, the Secretary shall--
                    (A) select at least two Medicare Advantage sites 
                with respect to which to conduct the demonstration 
                program under this section; and
                    (B) approve eligible Medicare Advantage plans to 
                participate in such demonstration program.
        In selecting Medicare Advantage sites under subparagraph (A), 
        the Secretary shall take into account area differences as well 
        as the availability of health maintenance organization plans 
        and preferred provider organization plans offered in such 
        sites.
            (2) Start of demonstration.--The demonstration program 
        shall begin not later than the third plan year beginning after 
        the date of the enactment of this Act.
            (3) Eligible medicare advantage plans.--For purposes of 
        this section, the term ``eligible Medicare Advantage plan'' 
        means a Medicare Advantage plan under part C of title XVIII of 
        the Social Security Act (42 U.S.C. 1395w-21 et seq.) that meets 
        the following requirements:
                    (A) The plan is an Medicare Advantage regional plan 
                (as defined in paragraph (4) of section 1859(b) of such 
                Act (42 U.S.C. 1395w-28(b))) or Medicare Advantage 
                local plan (as defined in paragraph (5) of such 
                section) offered in the Medicare Advantage region 
                selected under paragraph (1)(A).
                    (B) The plan has--
                            (i)(I) a quality rating under section 
                        1853(n)(4) of such Act (42 U.S.C. 1395w-
                        23(n)(4)) of 4 stars or higher based on the 
                        most recent data available for such year, or
                            (II) in the case of a specialized Medicare 
                        Advantage plan for special needs individuals, 
                        as defined in section 1859(b)(6)(A) of such Act 
                        (42 U.S.C. 1395w-28(b)(6)(A)), a quality rating 
                        under 1853(n)(4) of such Act (42 U.S.C. 1395w-
                        23(n)(4)) equal to or higher than the national 
                        average for special needs plans (excluding 
                        Institutional-Special needs plans) based on the 
                        most recent data available for such year; and
                            (ii) at least 20 percent of the population 
                        to whom the plan is offered consists of subsidy 
                        eligible individuals (as defined in section 
                        1860D-14(a)(3)(A) of the Social Security Act 
                        (42 U.S.C. 1395w-114(a)(3)(A))).
            (4) Disclosure to beneficiaries.--The Secretary shall 
        provide to each individual eligible to enroll under a Medicare 
        Advantage plan approved to participate under the demonstration 
        program during a plan year for which the plan is so selected--
                    (A) notification that the plan is participating in 
                such demonstration program;
                    (B) background information on the demonstration 
                program;
                    (C) clinical data derived from the studies 
                resulting from the demonstration program; and
                    (D) notification of the potential benefits that the 
                individual will receive, and of the other potential 
                impacts that the individual will experience, on account 
                of the participation of the plan in the demonstration 
                program.
    (c) Value-Based Insurance Design Methodologies.--
            (1) Definition.--For purposes of this section, the term 
        ``value-based insurance design methodology'' means a 
        methodology for identifying specific prescription medications, 
        and clinical services that are payable under title XVIII of the 
        Social Security Act, for which copayments, coinsurance, or 
        both, would improve the management of specific chronic clinical 
        conditions because of the high value and effectiveness of such 
        medications and services for such specific chronic clinical 
        conditions, as approved by the Secretary.
            (2) Use of methodologies to reduce copayments and 
        coinsurance.--A Medicare Advantage organization offering an 
        eligible Medicare Advantage plan approved to participate under 
        the demonstration program, for each plan year for which the 
        plan is so selected and using value-based insurance design 
        methodologies--
                    (A) shall identify each prescription medication and 
                clinical service covered under such plan for which the 
                plan proposes to reduce or eliminate the copayment or 
                coinsurance, with respect to the management of specific 
                chronic clinical conditions (as specified by the 
                Secretary) of Medicare Advantage eligible individuals 
                (as defined in section 1851(a)(3) of the Social 
                Security Act (42 U.S.C. 1395w-21(a)(3))) enrolled under 
                such plans, for such plan year;
                    (B) may, for such plan year, reduce or eliminate 
                copayments, coinsurance, or both for such prescription 
                medication and clinical services so identified with 
                respect to the management of such conditions of such 
                individuals--
                            (i) if such reduction or elimination is 
                        evidence-based and for the purpose of 
                        encouraging such individuals in such plan to 
                        use such prescription medications and clinical 
                        services (such as preventive care, primary 
                        care, specialty visits, diagnostic tests, 
                        procedures, and durable medical equipment) with 
                        respect to such conditions; and
                            (ii) for the purpose of encouraging such 
                        individuals in such plan to use health care 
                        providers that such organization has identified 
                        with respect to such plan year as being high 
                        value providers; and
                    (C) if a reduction or elimination is applied 
                pursuant to subparagraph (B), with respect to such 
                medication and clinical services, shall, for such plan 
                year, count toward the deductible applicable to such 
                individual under such plan amounts that would have been 
                payable by the individual as copayment or coinsurance 
                for such medication and services if the reduction or 
                elimination had not been applied.
            (3) Prohibition of increases of copayments and 
        coinsurance.--In no case may any Medicare Advantage plan 
        participating in the demonstration program increase, for any 
        plan year for which the plan is so participating, the amount of 
        copayments or coinsurance for any item or service covered under 
        such plan for purposes of discouraging the use of such item or 
        service.
    (d) Report on Implementation.--
            (1) In general.--Not later than 1 year after the date on 
        which the demonstration program under this section begins under 
        subsection (b)(2), the Secretary shall submit to Congress a 
        report on the status of the implementation of the demonstration 
        program.
            (2) Elements.--The report required by paragraph (1) shall, 
        with respect to eligible Medicare Advantage plans participating 
        in the demonstration program for the first plan year of such 
        program, include the following:
                    (A) A list of each medication and service 
                identified pursuant to subsection (c)(2)(A) for such 
                plan with respect to such plan year.
                    (B) For each such medication or service so 
                identified, the amount of the copayment or coinsurance 
                required under such plan with respect to such plan year 
                for such medication or service and the amount of the 
                reduction of such copayment or coinsurance from a 
                previous plan year.
                    (C) For each provider identified pursuant to 
                subsection (c)(2)(B)(ii) for such plan with respect to 
                such plan year, a statement of the amount of the 
                copayment or coinsurance required under such plan with 
                respect to such plan year and the amount of the 
                reduction of such copayment or coinsurance from the 
                previous plan year.
    (e) Review and Assessment of Utilization of Value-Based Insurance 
Design Methodologies.--
            (1) In general.--The Secretary shall enter into a contract 
        or agreement with an independent entity to review and assess 
        the implementation of the demonstration program under this 
        section. The review and assessment shall include the following:
                    (A) An assessment of the utilization of value-based 
                insurance design methodologies by Medicare Advantage 
                plans participating under such program.
                    (B) An analysis of whether reducing or eliminating 
                the copayment or coinsurance for each medication and 
                clinical service identified pursuant to subsection 
                (c)(2)(A) resulted in increased adherence to medication 
                regimens, increased service utilization, improvement in 
                quality metrics, better health outcomes, and enhanced 
                beneficiary experience.
                    (C) An analysis of the extent to which costs to 
                Medicare Advantage plans under part C of title XVIII of 
                the Social Security Act participating in the 
                demonstration program is less than costs to Medicare 
                Advantage plans under such part that are not 
                participating in the demonstration program.
                    (D) An analysis of whether reducing or eliminating 
                the copayment or coinsurance for providers identified 
                pursuant to subsection (c)(2)(B)(ii) resulted in 
                improvement in quality metrics, better health outcomes, 
                and enhanced beneficiary experience.
                    (E) An analysis, for each provider so identified, 
                the extent to which costs to Medicare Advantage plans 
                under part C of title XVIII of the Social Security Act 
                participating in the demonstration program is less than 
                costs to Medicare Advantage plans under such part that 
                are not participating in the demonstration program.
                    (F) Such other matters as the Secretary considers 
                appropriate.
            (2) Report.--The contract or agreement entered into under 
        paragraph (1) shall require such entity to submit to the 
        Secretary a report on the review and assessment conducted by 
        the entity under such paragraph in time for the inclusion of 
        the results of such report in the report required by paragraph 
        (3). Such report shall include a description, in clear 
        language, of the manner in which the entity conducted the 
        review and assessment.
            (3) Report to congress.--Not later than 4 years after the 
        date on which the demonstration program begins under subsection 
        (b)(2), the Secretary shall submit to Congress a report on the 
        review and assessment of the demonstration program conducted 
        under this subsection. The report shall include the following:
                    (A) A description of the results of the review and 
                assessment included in the report submitted pursuant to 
                paragraph (2).
                    (B) Such recommendations as the Secretary considers 
                appropriate for enhancing the utilization of the 
                methodologies applied under the demonstration program 
                to all Medicare Advantage plans under part C of title 
                XVIII of the Social Security Act so as to reduce 
                copayments and coinsurance under such plans paid by 
                Medicare beneficiaries for high-value prescription 
                medications and clinical services for which coverage is 
                provided under such plans and to otherwise improve the 
                quality of health care provided under such plans.
            (4) Oversight report.--Not later than three years after the 
        date of the enactment of this Act, the Comptroller General of 
        the United States shall submit to Congress a report on the 
        demonstration program that includes an assessment, with respect 
        to individuals enrolled under Medicare Advantage plans approved 
        to participate under the demonstration program, of the impact 
        that the age, co-morbidities, and geographic regions of such 
        individuals had upon the implementation of the demonstration 
        program by the plans with respect to such individuals.
    (f) Savings.--In no case may any reduction in beneficiary 
copayments or coinsurance resulting from the implementation of the 
demonstration program under this section result in expenditures under 
parts A, B, and D of the title XVIII of the Social Security Act that 
are greater than such expenditures without application of this section.
    (g) Expansion of Demonstration Program.--Taking into account the 
review and assessment conducted under subsection (e), the Secretary 
may, through notice and comment rulemaking, expand (including 
implementation on a nationwide basis) the duration and scope of the 
demonstration program under title XVIII of the Social Security Act, 
other than under the original Medicare fee-for-service program under 
parts A and B of such title, to the extent determined appropriate by 
the Secretary, if the requirements of paragraphs (1), (2) and (3) of 
subsection (c) of section 1115A of the Social Security Act (42 U.S.C. 
1315a), as applied to the testing of a model under subsection (b) of 
such section, applied to the demonstration under this section.
    (h) Waiver Authority.--The Secretary may waive such provisions of 
titles XI and XVIII of the Social Security Act as may be necessary to 
carry out the demonstration program under this section.
    (i) Implementation Funding.--For purposes of carrying out the 
demonstration program under this section, the Secretary shall provide 
for the transfer from the Federal Hospital Insurance Trust Fund under 
section 1817 of the Social Security Act (42 U.S.C. 1395i) and the 
Federal Supplementary Insurance Trust Fund under section 1841 of the 
Social Security Act (42 U.S.C. 1395t), including the Medicare 
Prescription Drug Account in such Trust Fund, in such proportion as 
determined appropriate by the Secretary, of such sums as may be 
necessary.
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