[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2 Engrossed in House (EH)]
114th CONGRESS
1st Session
H. R. 2
_______________________________________________________________________
AN ACT
To amend title XVIII of the Social Security Act to repeal the Medicare
sustainable growth rate and strengthen Medicare access by improving
physician payments and making other improvements, to reauthorize the
Children's Health Insurance 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 ``Medicare Access
and CHIP Reauthorization Act of 2015''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--SGR REPEAL AND MEDICARE PROVIDER PAYMENT MODERNIZATION
Sec. 101. Repealing the sustainable growth rate (SGR) and improving
Medicare payment for physicians' services.
Sec. 102. Priorities and funding for measure development.
Sec. 103. Encouraging care management for individuals with chronic care
needs.
Sec. 104. Empowering beneficiary choices through continued access to
information on physicians' services.
Sec. 105. Expanding availability of Medicare data.
Sec. 106. Reducing administrative burden and other provisions.
TITLE II--MEDICARE AND OTHER HEALTH EXTENDERS
Subtitle A--Medicare Extenders
Sec. 201. Extension of work GPCI floor.
Sec. 202. Extension of therapy cap exceptions process.
Sec. 203. Extension of ambulance add-ons.
Sec. 204. Extension of increased inpatient hospital payment adjustment
for certain low-volume hospitals.
Sec. 205. Extension of the Medicare-dependent hospital (MDH) program.
Sec. 206. Extension for specialized Medicare Advantage plans for
special needs individuals.
Sec. 207. Extension of funding for quality measure endorsement, input,
and selection.
Sec. 208. Extension of funding outreach and assistance for low-income
programs.
Sec. 209. Extension and transition of reasonable cost reimbursement
contracts.
Sec. 210. Extension of home health rural add-on.
Subtitle B--Other Health Extenders
Sec. 211. Permanent extension of the qualifying individual (QI)
program.
Sec. 212. Permanent extension of transitional medical assistance (TMA).
Sec. 213. Extension of special diabetes program for type I diabetes and
for Indians.
Sec. 214. Extension of abstinence education.
Sec. 215. Extension of personal responsibility education program
(PREP).
Sec. 216. Extension of funding for family-to-family health information
centers.
Sec. 217. Extension of health workforce demonstration project for low-
income individuals.
Sec. 218. Extension of maternal, infant, and early childhood home
visiting programs.
Sec. 219. Tennessee DSH allotment for fiscal years 2015 through 2025.
Sec. 220. Delay in effective date for Medicaid amendments relating to
beneficiary liability settlements.
Sec. 221. Extension of funding for community health centers, the
National Health Service Corps, and teaching
health centers.
TITLE III--CHIP
Sec. 301. 2-year extension of the Children's Health Insurance Program.
Sec. 302. Extension of express lane eligibility.
Sec. 303. Extension of outreach and enrollment program.
Sec. 304. Extension of certain programs and demonstration projects.
Sec. 305. Report of Inspector General of HHS on use of express lane
option under Medicaid and CHIP.
TITLE IV--OFFSETS
Subtitle A--Medicare Beneficiary Reforms
Sec. 401. Limitation on certain medigap policies for newly eligible
Medicare beneficiaries.
Sec. 402. Income-related premium adjustment for parts B and D.
Subtitle B--Other Offsets
Sec. 411. Medicare payment updates for post-acute providers.
Sec. 412. Delay of reduction to Medicaid DSH allotments.
Sec. 413. Levy on delinquent providers.
Sec. 414. Adjustments to inpatient hospital payment rates.
TITLE V--MISCELLANEOUS
Subtitle A--Protecting the Integrity of Medicare
Sec. 501. Prohibition of inclusion of Social Security account numbers
on Medicare cards.
Sec. 502. Preventing wrongful Medicare payments for items and services
furnished to incarcerated individuals,
individuals not lawfully present, and
deceased individuals.
Sec. 503. Consideration of measures regarding Medicare beneficiary
smart cards.
Sec. 504. Modifying Medicare durable medical equipment face-to-face
encounter documentation requirement.
Sec. 505. Reducing improper Medicare payments.
Sec. 506. Improving senior Medicare patrol and fraud reporting rewards.
Sec. 507. Requiring valid prescriber National Provider Identifiers on
pharmacy claims.
Sec. 508. Option to receive Medicare Summary Notice electronically.
Sec. 509. Renewal of MAC contracts.
Sec. 510. Study on pathway for incentives to States for State
participation in medicaid data match
program.
Sec. 511. Guidance on application of Common Rule to clinical data
registries.
Sec. 512. Eliminating certain civil money penalties; gainsharing study
and report.
Sec. 513. Modification of Medicare home health surety bond condition of
participation requirement.
Sec. 514. Oversight of Medicare coverage of manual manipulation of the
spine to correct subluxation.
Sec. 515. National expansion of prior authorization model for
repetitive scheduled non-emergent ambulance
transport.
Sec. 516. Repealing duplicative Medicare secondary payor provision.
Sec. 517. Plan for expanding data in annual CERT report.
Sec. 518. Removing funds for Medicare Improvement Fund added by IMPACT
Act of 2014.
Sec. 519. Rule of construction.
Subtitle B--Other Provisions
Sec. 521. Extension of two-midnight PAMA rules on certain medical
review activities.
Sec. 522. Requiring bid surety bonds and State licensure for entities
submitting bids under the Medicare DMEPOS
competitive acquisition program.
Sec. 523. Payment for global surgical packages.
Sec. 524. Extension of Secure Rural Schools and Community Self-
Determination Act of 2000.
Sec. 525. Exclusion from PAYGO scorecards.
TITLE I--SGR REPEAL AND MEDICARE PROVIDER PAYMENT MODERNIZATION
SEC. 101. REPEALING THE SUSTAINABLE GROWTH RATE (SGR) AND IMPROVING
MEDICARE PAYMENT FOR PHYSICIANS' SERVICES.
(a) Stabilizing Fee Updates.--
(1) Repeal of sgr payment methodology.--Section 1848 of the
Social Security Act (42 U.S.C. 1395w-4) is amended--
(A) in subsection (d)--
(i) in paragraph (1)(A)--
(I) by inserting ``and ending with
2025'' after ``beginning with 2001'';
and
(II) by inserting ``or a subsequent
paragraph'' after ``paragraph (4)'';
and
(ii) in paragraph (4)--
(I) in the heading, by inserting
``and ending with 2014'' after ``years
beginning with 2001''; and
(II) in subparagraph (A), by
inserting ``and ending with 2014''
after ``a year beginning with 2001'';
and
(B) in subsection (f)--
(i) in paragraph (1)(B), by inserting
``through 2014'' after ``of each succeeding
year''; and
(ii) in paragraph (2), in the matter
preceding subparagraph (A), by inserting ``and
ending with 2014'' after ``beginning with
2000''.
(2) Update of rates for 2015 and subsequent years.--
Subsection (d) of section 1848 of the Social Security Act (42
U.S.C. 1395w-4) is amended--
(A) in paragraph (1)(A), by adding at the end the
following: ``There shall be two separate conversion
factors for each year beginning with 2026, one for
items and services furnished by a qualifying APM
participant (as defined in section 1833(z)(2))
(referred to in this subsection as the `qualifying APM
conversion factor') and the other for other items and
services (referred to in this subsection as the
`nonqualifying APM conversion factor'), equal to the
respective conversion factor for the previous year (or,
in the case of 2026, equal to the single conversion
factor for 2025) multiplied by the update established
under paragraph (20) for such respective conversion
factor for such year.'';
(B) in paragraph (1)(D), by inserting ``(or,
beginning with 2026, applicable conversion factor)''
after ``single conversion factor''; and
(C) by striking paragraph (16) and inserting the
following new paragraphs:
``(16) Update for january through june of 2015.--Subject to
paragraphs (7)(B), (8)(B), (9)(B), (10)(B), (11)(B), (12)(B),
(13)(B), (14)(B), and (15)(B), in lieu of the update to the
single conversion factor established in paragraph (1)(C) that
would otherwise apply for 2015 for the period beginning on
January 1, 2015, and ending on June 30, 2015, the update to the
single conversion factor shall be 0.0 percent.
``(17) Update for july through december of 2015.--The
update to the single conversion factor established in paragraph
(1)(C) for the period beginning on July 1, 2015, and ending on
December 31, 2015, shall be 0.5 percent.
``(18) Update for 2016 through 2019.--The update to the
single conversion factor established in paragraph (1)(C) for
2016 and each subsequent year through 2019 shall be 0.5
percent.
``(19) Update for 2020 through 2025.--The update to the
single conversion factor established in paragraph (1)(C) for
2020 and each subsequent year through 2025 shall be 0.0
percent.
``(20) Update for 2026 and subsequent years.--For 2026 and
each subsequent year, the update to the qualifying APM
conversion factor established under paragraph (1)(A) is 0.75
percent, and the update to the nonqualifying APM conversion
factor established under such paragraph is 0.25 percent.''.
(3) MedPAC reports.--
(A) Initial report.--Not later than July 1, 2017,
the Medicare Payment Advisory Commission shall submit
to Congress a report on the relationship between--
(i) physician and other health professional
utilization and expenditures (and the rate of
increase of such utilization and expenditures)
of items and services for which payment is made
under section 1848 of the Social Security Act
(42 U.S.C. 1395w-4); and
(ii) total utilization and expenditures
(and the rate of increase of such utilization
and expenditures) under parts A, B, and D of
title XVIII of such Act.
Such report shall include a methodology to describe
such relationship and the impact of changes in such
physician and other health professional practice and
service ordering patterns on total utilization and
expenditures under parts A, B, and D of such title.
(B) Final report.--Not later than July 1, 2021, the
Medicare Payment Advisory Commission shall submit to
Congress a report on the relationship described in
subparagraph (A), including the results determined from
applying the methodology included in the report
submitted under such subparagraph.
(C) Report on update to physicians' services under
medicare.--Not later than July 1, 2019, the Medicare
Payment Advisory Commission shall submit to Congress a
report on--
(i) the payment update for professional
services applied under the Medicare program
under title XVIII of the Social Security Act
for the period of years 2015 through 2019;
(ii) the effect of such update on the
efficiency, economy, and quality of care
provided under such program;
(iii) the effect of such update on ensuring
a sufficient number of providers to maintain
access to care by Medicare beneficiaries; and
(iv) recommendations for any future payment
updates for professional services under such
program to ensure adequate access to care is
maintained for Medicare beneficiaries.
(b) Consolidation of Certain Current Law Performance Programs With
New Merit-Based Incentive Payment System.--
(1) EHR meaningful use incentive program.--
(A) Sunsetting separate meaningful use payment
adjustments.--Section 1848(a)(7)(A) of the Social
Security Act (42 U.S.C. 1395w-4(a)(7)(A)) is amended--
(i) in clause (i), by striking ``2015 or
any subsequent payment year'' and inserting
``each of 2015 through 2018'';
(ii) in clause (ii)(III), by striking
``each subsequent year'' and inserting
``2018''; and
(iii) in clause (iii)--
(I) in the heading, by striking
``and subsequent years'';
(II) by striking ``and each
subsequent year''; and
(III) by striking ``, but in no
case shall the applicable percent be
less than 95 percent''.
(B) Continuation of meaningful use determinations
for mips.--Section 1848(o)(2) of the Social Security
Act (42 U.S.C. 1395w-4(o)(2)) is amended--
(i) in subparagraph (A), in the matter
preceding clause (i)--
(I) by striking ``For purposes of
paragraph (1), an'' and inserting
``An''; and
(II) by inserting ``, or pursuant
to subparagraph (D) for purposes of
subsection (q), for a performance
period under such subsection for a
year'' after ``under such subsection
for a year''; and
(ii) by adding at the end the following new
subparagraph:
``(D) Continued application for purposes of mips.--
With respect to 2019 and each subsequent payment year,
the Secretary shall, for purposes of subsection (q) and
in accordance with paragraph (1)(F) of such subsection,
determine whether an eligible professional who is a
MIPS eligible professional (as defined in subsection
(q)(1)(C)) for such year is a meaningful EHR user under
this paragraph for the performance period under
subsection (q) for such year.''.
(2) Quality reporting.--
(A) Sunsetting separate quality reporting
incentives.--Section 1848(a)(8)(A) of the Social
Security Act (42 U.S.C. 1395w-4(a)(8)(A)) is amended--
(i) in clause (i), by striking ``2015 or
any subsequent year'' and inserting ``each of
2015 through 2018''; and
(ii) in clause (ii)(II), by striking ``and
each subsequent year'' and inserting ``, 2017,
and 2018''.
(B) Continuation of quality measures and processes
for mips.--Section 1848 of the Social Security Act (42
U.S.C. 1395w-4) is amended--
(i) in subsection (k), by adding at the end
the following new paragraph:
``(9) Continued application for purposes of mips and for
certain professionals volunteering to report.--The Secretary
shall, in accordance with subsection (q)(1)(F), carry out the
provisions of this subsection--
``(A) for purposes of subsection (q); and
``(B) for eligible professionals who are not MIPS
eligible professionals (as defined in subsection
(q)(1)(C)) for the year involved.''; and
(ii) in subsection (m)--
(I) by redesignating paragraph (7)
added by section 10327(a) of Public Law
111-148 as paragraph (8); and
(II) by adding at the end the
following new paragraph:
``(9) Continued application for purposes of mips and for
certain professionals volunteering to report.--The Secretary
shall, in accordance with subsection (q)(1)(F), carry out the
processes under this subsection--
``(A) for purposes of subsection (q); and
``(B) for eligible professionals who are not MIPS
eligible professionals (as defined in subsection
(q)(1)(C)) for the year involved.''.
(3) Value-based payments.--
(A) Sunsetting separate value-based payments.--
Clause (iii) of section 1848(p)(4)(B) of the Social
Security Act (42 U.S.C. 1395w-4(p)(4)(B)) is amended to
read as follows:
``(iii) Application.--The Secretary shall
apply the payment modifier established under
this subsection for items and services
furnished on or after January 1, 2015, with
respect to specific physicians and groups of
physicians the Secretary determines
appropriate, and for services furnished on or
after January 1, 2017, with respect to all
physicians and groups of physicians. Such
payment modifier shall not be applied for items
and services furnished on or after January 1,
2019.''.
(B) Continuation of value-based payment modifier
measures for mips.--Section 1848(p) of the Social
Security Act (42 U.S.C. 1395w-4(p)) is amended--
(i) in paragraph (2), by adding at the end
the following new subparagraph:
``(C) Continued application for purposes of mips.--
The Secretary shall, in accordance with subsection
(q)(1)(F), carry out subparagraph (B) for purposes of
subsection (q).''; and
(ii) in paragraph (3), by adding at the end
the following: ``With respect to 2019 and each
subsequent year, the Secretary shall, in
accordance with subsection (q)(1)(F), carry out
this paragraph for purposes of subsection
(q).''.
(c) Merit-Based Incentive Payment System.--
(1) In general.--Section 1848 of the Social Security Act
(42 U.S.C. 1395w-4) is amended by adding at the end the
following new subsection:
``(q) Merit-Based Incentive Payment System.--
``(1) Establishment.--
``(A) In general.--Subject to the succeeding
provisions of this subsection, the Secretary shall
establish an eligible professional Merit-based
Incentive Payment System (in this subsection referred
to as the `MIPS') under which the Secretary shall--
``(i) develop a methodology for assessing
the total performance of each MIPS eligible
professional according to performance standards
under paragraph (3) for a performance period
(as established under paragraph (4)) for a
year;
``(ii) using such methodology, provide for
a composite performance score in accordance
with paragraph (5) for each such professional
for each performance period; and
``(iii) use such composite performance
score of the MIPS eligible professional for a
performance period for a year to determine and
apply a MIPS adjustment factor (and, as
applicable, an additional MIPS adjustment
factor) under paragraph (6) to the professional
for the year.
Notwithstanding subparagraph (C)(ii), under the MIPS,
the Secretary shall permit any eligible professional
(as defined in subsection (k)(3)(B)) to report on
applicable measures and activities described in
paragraph (2)(B).
``(B) Program implementation.--The MIPS shall apply
to payments for items and services furnished on or
after January 1, 2019.
``(C) MIPS eligible professional defined.--
``(i) In general.--For purposes of this
subsection, subject to clauses (ii) and (iv),
the term `MIPS eligible professional' means--
``(I) for the first and second
years for which the MIPS applies to
payments (and for the performance
period for such first and second year),
a physician (as defined in section
1861(r)), a physician assistant, nurse
practitioner, and clinical nurse
specialist (as such terms are defined
in section 1861(aa)(5)), a certified
registered nurse anesthetist (as
defined in section 1861(bb)(2)), and a
group that includes such professionals;
and
``(II) for the third year for which
the MIPS applies to payments (and for
the performance period for such third
year) and for each succeeding year (and
for the performance period for each
such year), the professionals described
in subclause (I), such other eligible
professionals (as defined in subsection
(k)(3)(B)) as specified by the
Secretary, and a group that includes
such professionals.
``(ii) Exclusions.--For purposes of clause
(i), the term `MIPS eligible professional' does
not include, with respect to a year, an
eligible professional (as defined in subsection
(k)(3)(B)) who--
``(I) is a qualifying APM
participant (as defined in section
1833(z)(2));
``(II) subject to clause (vii), is
a partial qualifying APM participant
(as defined in clause (iii)) for the
most recent period for which data are
available and who, for the performance
period with respect to such year, does
not report on applicable measures and
activities described in paragraph
(2)(B) that are required to be reported
by such a professional under the MIPS;
or
``(III) for the performance period
with respect to such year, does not
exceed the low-volume threshold
measurement selected under clause (iv).
``(iii) Partial qualifying apm
participant.--For purposes of this
subparagraph, the term `partial qualifying APM
participant' means, with respect to a year, an
eligible professional for whom the Secretary
determines the minimum payment percentage (or
percentages), as applicable, described in
paragraph (2) of section 1833(z) for such year
have not been satisfied, but who would be
considered a qualifying APM participant (as
defined in such paragraph) for such year if--
``(I) with respect to 2019 and
2020, the reference in subparagraph (A)
of such paragraph to 25 percent was
instead a reference to 20 percent;
``(II) with respect to 2021 and
2022--
``(aa) the reference in
subparagraph (B)(i) of such
paragraph to 50 percent was
instead a reference to 40
percent; and
``(bb) the references in
subparagraph (B)(ii) of such
paragraph to 50 percent and 25
percent of such paragraph were
instead references to 40
percent and 20 percent,
respectively; and
``(III) with respect to 2023 and
subsequent years--
``(aa) the reference in
subparagraph (C)(i) of such
paragraph to 75 percent was
instead a reference to 50
percent; and
``(bb) the references in
subparagraph (C)(ii) of such
paragraph to 75 percent and 25
percent of such paragraph were
instead references to 50
percent and 20 percent,
respectively.
``(iv) Selection of low-volume threshold
measurement.--The Secretary shall select a low-
volume threshold to apply for purposes of
clause (ii)(III), which may include one or more
or a combination of the following:
``(I) The minimum number (as
determined by the Secretary) of
individuals enrolled under this part
who are treated by the eligible
professional for the performance period
involved.
``(II) The minimum number (as
determined by the Secretary) of items
and services furnished to individuals
enrolled under this part by such
professional for such performance
period.
``(III) The minimum amount (as
determined by the Secretary) of allowed
charges billed by such professional
under this part for such performance
period.
``(v) Treatment of new medicare enrolled
eligible professionals.--In the case of a
professional who first becomes a Medicare
enrolled eligible professional during the
performance period for a year (and had not
previously submitted claims under this title
such as a person, an entity, or a part of a
physician group or under a different billing
number or tax identifier), such professional
shall not be treated under this subsection as a
MIPS eligible professional until the subsequent
year and performance period for such subsequent
year.
``(vi) Clarification.--In the case of items
and services furnished during a year by an
individual who is not a MIPS eligible
professional (including pursuant to clauses
(ii) and (v)) with respect to a year, in no
case shall a MIPS adjustment factor (or
additional MIPS adjustment factor) under
paragraph (6) apply to such individual for such
year.
``(vii) Partial qualifying apm participant
clarifications.--
``(I) Treatment as mips eligible
professional.--In the case of an
eligible professional who is a partial
qualifying APM participant, with
respect to a year, and who, for the
performance period for such year,
reports on applicable measures and
activities described in paragraph
(2)(B) that are required to be reported
by such a professional under the MIPS,
such eligible professional is
considered to be a MIPS eligible
professional with respect to such year.
``(II) Not eligible for qualifying
apm participant payments.--In no case
shall an eligible professional who is a
partial qualifying APM participant,
with respect to a year, be considered a
qualifying APM participant (as defined
in paragraph (2) of section 1833(z))
for such year or be eligible for the
additional payment under paragraph (1)
of such section for such year.
``(D) Application to group practices.--
``(i) In general.--Under the MIPS:
``(I) Quality performance
category.--The Secretary shall
establish and apply a process that
includes features of the provisions of
subsection (m)(3)(C) for MIPS eligible
professionals in a group practice with
respect to assessing performance of
such group with respect to the
performance category described in
clause (i) of paragraph (2)(A).
``(II) Other performance
categories.--The Secretary may
establish and apply a process that
includes features of the provisions of
subsection (m)(3)(C) for MIPS eligible
professionals in a group practice with
respect to assessing the performance of
such group with respect to the
performance categories described in
clauses (ii) through (iv) of such
paragraph.
``(ii) Ensuring comprehensiveness of group
practice assessment.--The process established
under clause (i) shall to the extent
practicable reflect the range of items and
services furnished by the MIPS eligible
professionals in the group practice involved.
``(E) Use of registries.--Under the MIPS, the
Secretary shall encourage the use of qualified clinical
data registries pursuant to subsection (m)(3)(E) in
carrying out this subsection.
``(F) Application of certain provisions.--In
applying a provision of subsection (k), (m), (o), or
(p) for purposes of this subsection, the Secretary
shall--
``(i) adjust the application of such
provision to ensure the provision is consistent
with the provisions of this subsection; and
``(ii) not apply such provision to the
extent that the provision is duplicative with a
provision of this subsection.
``(G) Accounting for risk factors.--
``(i) Risk factors.--Taking into account
the relevant studies conducted and
recommendations made in reports under section
2(d) of the Improving Medicare Post-Acute Care
Transformation Act of 2014, and, as
appropriate, other information, including
information collected before completion of such
studies and recommendations, the Secretary, on
an ongoing basis, shall, as the Secretary
determines appropriate and based on an
individual's health status and other risk
factors--
``(I) assess appropriate
adjustments to quality measures,
resource use measures, and other
measures used under the MIPS; and
``(II) assess and implement
appropriate adjustments to payment
adjustments, composite performance
scores, scores for performance
categories, or scores for measures or
activities under the MIPS.
``(2) Measures and activities under performance
categories.--
``(A) Performance categories.--Under the MIPS, the
Secretary shall use the following performance
categories (each of which is referred to in this
subsection as a performance category) in determining
the composite performance score under paragraph (5):
``(i) Quality.
``(ii) Resource use.
``(iii) Clinical practice improvement
activities.
``(iv) Meaningful use of certified EHR
technology.
``(B) Measures and activities specified for each
category.--For purposes of paragraph (3)(A) and subject
to subparagraph (C), measures and activities specified
for a performance period (as established under
paragraph (4)) for a year are as follows:
``(i) Quality.--For the performance
category described in subparagraph (A)(i), the
quality measures included in the final measures
list published under subparagraph (D)(i) for
such year and the list of quality measures
described in subparagraph (D)(vi) used by
qualified clinical data registries under
subsection (m)(3)(E).
``(ii) Resource use.--For the performance
category described in subparagraph (A)(ii), the
measurement of resource use for such period
under subsection (p)(3), using the methodology
under subsection (r) as appropriate, and, as
feasible and applicable, accounting for the
cost of drugs under part D.
``(iii) Clinical practice improvement
activities.--For the performance category
described in subparagraph (A)(iii), clinical
practice improvement activities (as defined in
subparagraph (C)(v)(III)) under subcategories
specified by the Secretary for such period,
which shall include at least the following:
``(I) The subcategory of expanded
practice access, such as same day
appointments for urgent needs and after
hours access to clinician advice.
``(II) The subcategory of
population management, such as
monitoring health conditions of
individuals to provide timely health
care interventions or participation in
a qualified clinical data registry.
``(III) The subcategory of care
coordination, such as timely
communication of test results, timely
exchange of clinical information to
patients and other providers, and use
of remote monitoring or telehealth.
``(IV) The subcategory of
beneficiary engagement, such as the
establishment of care plans for
individuals with complex care needs,
beneficiary self-management assessment
and training, and using shared
decision-making mechanisms.
``(V) The subcategory of patient
safety and practice assessment, such as
through use of clinical or surgical
checklists and practice assessments
related to maintaining certification.
``(VI) The subcategory of
participation in an alternative payment
model (as defined in section
1833(z)(3)(C)).
In establishing activities under this clause,
the Secretary shall give consideration to the
circumstances of small practices (consisting of
15 or fewer professionals) and practices
located in rural areas and in health
professional shortage areas (as designated
under section 332(a)(1)(A) of the Public Health
Service Act).
``(iv) Meaningful ehr use.--For the
performance category described in subparagraph
(A)(iv), the requirements established for such
period under subsection (o)(2) for determining
whether an eligible professional is a
meaningful EHR user.
``(C) Additional provisions.--
``(i) Emphasizing outcome measures under
the quality performance category.--In applying
subparagraph (B)(i), the Secretary shall, as
feasible, emphasize the application of outcome
measures.
``(ii) Application of additional system
measures.--The Secretary may use measures used
for a payment system other than for physicians,
such as measures for inpatient hospitals, for
purposes of the performance categories
described in clauses (i) and (ii) of
subparagraph (A). For purposes of the previous
sentence, the Secretary may not use measures
for hospital outpatient departments, except in
the case of items and services furnished by
emergency physicians, radiologists, and
anesthesiologists.
``(iii) Global and population-based
measures.--The Secretary may use global
measures, such as global outcome measures, and
population-based measures for purposes of the
performance category described in subparagraph
(A)(i).
``(iv) Application of measures and
activities to non-patient-facing
professionals.--In carrying out this paragraph,
with respect to measures and activities
specified in subparagraph (B) for performance
categories described in subparagraph (A), the
Secretary--
``(I) shall give consideration to
the circumstances of professional types
(or subcategories of those types
determined by practice characteristics)
who typically furnish services that do
not involve face-to-face interaction
with a patient; and
``(II) may, to the extent feasible
and appropriate, take into account such
circumstances and apply under this
subsection with respect to MIPS
eligible professionals of such
professional types or subcategories,
alternative measures or activities that
fulfill the goals of the applicable
performance category.
In carrying out the previous sentence, the
Secretary shall consult with professionals of
such professional types or subcategories.
``(v) Clinical practice improvement
activities.--
``(I) Request for information.--In
initially applying subparagraph
(B)(iii), the Secretary shall use a
request for information to solicit
recommendations from stakeholders to
identify activities described in such
subparagraph and specifying criteria
for such activities.
``(II) Contract authority for
clinical practice improvement
activities performance category.--In
applying subparagraph (B)(iii), the
Secretary may contract with entities to
assist the Secretary in--
``(aa) identifying
activities described in
subparagraph (B)(iii);
``(bb) specifying criteria
for such activities; and
``(cc) determining whether
a MIPS eligible professional
meets such criteria.
``(III) Clinical practice
improvement activities defined.--For
purposes of this subsection, the term
`clinical practice improvement
activity' means an activity that
relevant eligible professional
organizations and other relevant
stakeholders identify as improving
clinical practice or care delivery and
that the Secretary determines, when
effectively executed, is likely to
result in improved outcomes.
``(D) Annual list of quality measures available for
mips assessment.--
``(i) In general.--Under the MIPS, the
Secretary, through notice and comment
rulemaking and subject to the succeeding
clauses of this subparagraph, shall, with
respect to the performance period for a year,
establish an annual final list of quality
measures from which MIPS eligible professionals
may choose for purposes of assessment under
this subsection for such performance period.
Pursuant to the previous sentence, the
Secretary shall--
``(I) not later than November 1 of
the year prior to the first day of the
first performance period under the
MIPS, establish and publish in the
Federal Register a final list of
quality measures; and
``(II) not later than November 1 of
the year prior to the first day of each
subsequent performance period, update
the final list of quality measures from
the previous year (and publish such
updated final list in the Federal
Register), by--
``(aa) removing from such
list, as appropriate, quality
measures, which may include the
removal of measures that are no
longer meaningful (such as
measures that are topped out);
``(bb) adding to such list,
as appropriate, new quality
measures; and
``(cc) determining whether
or not quality measures on such
list that have undergone
substantive changes should be
included in the updated list.
``(ii) Call for quality measures.--
``(I) In general.--Eligible
professional organizations and other
relevant stakeholders shall be
requested to identify and submit
quality measures to be considered for
selection under this subparagraph in
the annual list of quality measures
published under clause (i) and to
identify and submit updates to the
measures on such list. For purposes of
the previous sentence, measures may be
submitted regardless of whether such
measures were previously published in a
proposed rule or endorsed by an entity
with a contract under section 1890(a).
``(II) Eligible professional
organization defined.--In this
subparagraph, the term `eligible
professional organization' means a
professional organization as defined by
nationally recognized specialty boards
of certification or equivalent
certification boards.
``(iii) Requirements.--In selecting quality
measures for inclusion in the annual final list
under clause (i), the Secretary shall--
``(I) provide that, to the extent
practicable, all quality domains (as
defined in subsection (s)(1)(B)) are
addressed by such measures; and
``(II) ensure that such selection
is consistent with the process for
selection of measures under subsections
(k), (m), and (p)(2).
``(iv) Peer review.--Before including a new
measure in the final list of measures published
under clause (i) for a year, the Secretary
shall submit for publication in applicable
specialty-appropriate, peer-reviewed journals
such measure and the method for developing and
selecting such measure, including clinical and
other data supporting such measure.
``(v) Measures for inclusion.--The final
list of quality measures published under clause
(i) shall include, as applicable, measures
under subsections (k), (m), and (p)(2),
including quality measures from among--
``(I) measures endorsed by a
consensus-based entity;
``(II) measures developed under
subsection (s); and
``(III) measures submitted under
clause (ii)(I).
Any measure selected for inclusion in such list
that is not endorsed by a consensus-based
entity shall have a focus that is evidence-
based.
``(vi) Exception for qualified clinical
data registry measures.--Measures used by a
qualified clinical data registry under
subsection (m)(3)(E) shall not be subject to
the requirements under clauses (i), (iv), and
(v). The Secretary shall publish the list of
measures used by such qualified clinical data
registries on the Internet website of the
Centers for Medicare & Medicaid Services.
``(vii) Exception for existing quality
measures.--Any quality measure specified by the
Secretary under subsection (k) or (m),
including under subsection (m)(3)(E), and any
measure of quality of care established under
subsection (p)(2) for the reporting period or
performance period under the respective
subsection beginning before the first
performance period under the MIPS--
``(I) shall not be subject to the
requirements under clause (i) (except
under items (aa) and (cc) of subclause
(II) of such clause) or to the
requirement under clause (iv); and
``(II) shall be included in the
final list of quality measures
published under clause (i) unless
removed under clause (i)(II)(aa).
``(viii) Consultation with relevant
eligible professional organizations and other
relevant stakeholders.--Relevant eligible
professional organizations and other relevant
stakeholders, including State and national
medical societies, shall be consulted in
carrying out this subparagraph.
``(ix) Optional application.--The process
under section 1890A is not required to apply to
the selection of measures under this
subparagraph.
``(3) Performance standards.--
``(A) Establishment.--Under the MIPS, the Secretary
shall establish performance standards with respect to
measures and activities specified under paragraph
(2)(B) for a performance period (as established under
paragraph (4)) for a year.
``(B) Considerations in establishing standards.--In
establishing such performance standards with respect to
measures and activities specified under paragraph
(2)(B), the Secretary shall consider the following:
``(i) Historical performance standards.
``(ii) Improvement.
``(iii) The opportunity for continued
improvement.
``(4) Performance period.--The Secretary shall establish a
performance period (or periods) for a year (beginning with
2019). Such performance period (or periods) shall begin and end
prior to the beginning of such year and be as close as possible
to such year. In this subsection, such performance period (or
periods) for a year shall be referred to as the performance
period for the year.
``(5) Composite performance score.--
``(A) In general.--Subject to the succeeding
provisions of this paragraph and taking into account,
as available and applicable, paragraph (1)(G), the
Secretary shall develop a methodology for assessing the
total performance of each MIPS eligible professional
according to performance standards under paragraph (3)
with respect to applicable measures and activities
specified in paragraph (2)(B) with respect to each
performance category applicable to such professional
for a performance period (as established under
paragraph (4)) for a year. Using such methodology, the
Secretary shall provide for a composite assessment
(using a scoring scale of 0 to 100) for each such
professional for the performance period for such year.
In this subsection such a composite assessment for such
a professional with respect to a performance period
shall be referred to as the `composite performance
score' for such professional for such performance
period.
``(B) Incentive to report; encouraging use of
certified ehr technology for reporting quality
measures.--
``(i) Incentive to report.--Under the
methodology established under subparagraph (A),
the Secretary shall provide that in the case of
a MIPS eligible professional who fails to
report on an applicable measure or activity
that is required to be reported by the
professional, the professional shall be treated
as achieving the lowest potential score
applicable to such measure or activity.
``(ii) Encouraging use of certified ehr
technology and qualified clinical data
registries for reporting quality measures.--
Under the methodology established under
subparagraph (A), the Secretary shall--
``(I) encourage MIPS eligible
professionals to report on applicable
measures with respect to the
performance category described in
paragraph (2)(A)(i) through the use of
certified EHR technology and qualified
clinical data registries; and
``(II) with respect to a
performance period, with respect to a
year, for which a MIPS eligible
professional reports such measures
through the use of such EHR technology,
treat such professional as satisfying
the clinical quality measures reporting
requirement described in subsection
(o)(2)(A)(iii) for such year.
``(C) Clinical practice improvement activities
performance score.--
``(i) Rule for certification.--A MIPS
eligible professional who is in a practice that
is certified as a patient-centered medical home
or comparable specialty practice, as determined
by the Secretary, with respect to a performance
period shall be given the highest potential
score for the performance category described in
paragraph (2)(A)(iii) for such period.
``(ii) APM participation.--Participation by
a MIPS eligible professional in an alternative
payment model (as defined in section
1833(z)(3)(C)) with respect to a performance
period shall earn such eligible professional a
minimum score of one-half of the highest
potential score for the performance category
described in paragraph (2)(A)(iii) for such
performance period.
``(iii) Subcategories.--A MIPS eligible
professional shall not be required to perform
activities in each subcategory under paragraph
(2)(B)(iii) or participate in an alternative
payment model in order to achieve the highest
potential score for the performance category
described in paragraph (2)(A)(iii).
``(D) Achievement and improvement.--
``(i) Taking into account improvement.--
Beginning with the second year to which the
MIPS applies, in addition to the achievement of
a MIPS eligible professional, if data
sufficient to measure improvement is available,
the methodology developed under subparagraph
(A)--
``(I) in the case of the
performance score for the performance
category described in clauses (i) and
(ii) of paragraph (2)(A), shall take
into account the improvement of the
professional; and
``(II) in the case of performance
scores for other performance
categories, may take into account the
improvement of the professional.
``(ii) Assigning higher weight for
achievement.--Subject to clause (i), under the
methodology developed under subparagraph (A),
the Secretary may assign a higher scoring
weight under subparagraph (F) with respect to
the achievement of a MIPS eligible professional
than with respect to any improvement of such
professional applied under clause (i) with
respect to a measure, activity, or category
described in paragraph (2).
``(E) Weights for the performance categories.--
``(i) In general.--Under the methodology
developed under subparagraph (A), subject to
subparagraph (F)(i) and clause (ii), the
composite performance score shall be determined
as follows:
``(I) Quality.--
``(aa) In general.--Subject
to item (bb), thirty percent of
such score shall be based on
performance with respect to the
category described in clause
(i) of paragraph (2)(A). In
applying the previous sentence,
the Secretary shall, as
feasible, encourage the
application of outcome measures
within such category.
``(bb) First 2 years.--For
the first and second years for
which the MIPS applies to
payments, the percentage
applicable under item (aa)
shall be increased in a manner
such that the total percentage
points of the increase under
this item for the respective
year equals the total number of
percentage points by which the
percentage applied under
subclause (II)(bb) for the
respective year is less than 30
percent.
``(II) Resource use.--
``(aa) In general.--Subject
to item (bb), thirty percent of
such score shall be based on
performance with respect to the
category described in clause
(ii) of paragraph (2)(A).
``(bb) First 2 years.--For
the first year for which the
MIPS applies to payments, not
more than 10 percent of such
score shall be based on
performance with respect to the
category described in clause
(ii) of paragraph (2)(A). For
the second year for which the
MIPS applies to payments, not
more than 15 percent of such
score shall be based on
performance with respect to the
category described in clause
(ii) of paragraph (2)(A).
``(III) Clinical practice
improvement activities.--Fifteen
percent of such score shall be based on
performance with respect to the
category described in clause (iii) of
paragraph (2)(A).
``(IV) Meaningful use of certified
ehr technology.--Twenty-five percent of
such score shall be based on
performance with respect to the
category described in clause (iv) of
paragraph (2)(A).
``(ii) Authority to adjust percentages in
case of high ehr meaningful use adoption.--In
any year in which the Secretary estimates that
the proportion of eligible professionals (as
defined in subsection (o)(5)) who are
meaningful EHR users (as determined under
subsection (o)(2)) is 75 percent or greater,
the Secretary may reduce the percent applicable
under clause (i)(IV), but not below 15 percent.
If the Secretary makes such reduction for a
year, subject to subclauses (I)(bb) and
(II)(bb) of clause (i), the percentages
applicable under one or more of subclauses (I),
(II), and (III) of clause (i) for such year
shall be increased in a manner such that the
total percentage points of the increase under
this clause for such year equals the total
number of percentage points reduced under the
preceding sentence for such year.
``(F) Certain flexibility for weighting performance
categories, measures, and activities.--Under the
methodology under subparagraph (A), if there are not
sufficient measures and activities (described in
paragraph (2)(B)) applicable and available to each type
of eligible professional involved, the Secretary shall
assign different scoring weights (including a weight of
0)--
``(i) which may vary from the scoring
weights specified in subparagraph (E), for each
performance category based on the extent to
which the category is applicable to the type of
eligible professional involved; and
``(ii) for each measure and activity
specified under paragraph (2)(B) with respect
to each such category based on the extent to
which the measure or activity is applicable and
available to the type of eligible professional
involved.
``(G) Resource use.--Analysis of the performance
category described in paragraph (2)(A)(ii) shall
include results from the methodology described in
subsection (r)(5), as appropriate.
``(H) Inclusion of quality measure data from other
payers.--In applying subsections (k), (m), and (p) with
respect to measures described in paragraph (2)(B)(i),
analysis of the performance category described in
paragraph (2)(A)(i) may include data submitted by MIPS
eligible professionals with respect to items and
services furnished to individuals who are not
individuals entitled to benefits under part A or
enrolled under part B.
``(I) Use of voluntary virtual groups for certain
assessment purposes.--
``(i) In general.--In the case of MIPS
eligible professionals electing to be a virtual
group under clause (ii) with respect to a
performance period for a year, for purposes of
applying the methodology under subparagraph (A)
with respect to the performance categories
described in clauses (i) and (ii) of paragraph
(2)(A)--
``(I) the assessment of performance
provided under such methodology with
respect to such performance categories
that is to be applied to each such
professional in such group for such
performance period shall be with
respect to the combined performance of
all such professionals in such group
for such period; and
``(II) with respect to the
composite performance score provided
under this paragraph for such
performance period for each such MIPS
eligible professional in such virtual
group, the components of the composite
performance score that assess
performance with respect to such
performance categories shall be based
on the assessment of the combined
performance under subclause (I) for
such performance categories and
performance period.
``(ii) Election of practices to be a
virtual group.--The Secretary shall, in
accordance with the requirements under clause
(iii), establish and have in place a process to
allow an individual MIPS eligible professional
or a group practice consisting of not more than
10 MIPS eligible professionals to elect, with
respect to a performance period for a year to
be a virtual group under this subparagraph with
at least one other such individual MIPS
eligible professional or group practice. Such a
virtual group may be based on appropriate
classifications of providers, such as by
geographic areas or by provider specialties
defined by nationally recognized specialty
boards of certification or equivalent
certification boards.
``(iii) Requirements.--The requirements for
the process under clause (ii) shall--
``(I) provide that an election
under such clause, with respect to a
performance period, shall be made
before the beginning of such
performance period and may not be
changed during such performance period;
``(II) provide that an individual
MIPS eligible professional and a group
practice described in clause (ii) may
elect to be in no more than one virtual
group for a performance period and
that, in the case of such a group
practice that elects to be in such
virtual group for such performance
period, such election applies to all
MIPS eligible professionals in such
group practice;
``(III) provide that a virtual
group be a combination of tax
identification numbers;
``(IV) provide for formal written
agreements among MIPS eligible
professionals electing to be a virtual
group under this subparagraph; and
``(V) include such other
requirements as the Secretary
determines appropriate.
``(6) MIPS payments.--
``(A) MIPS adjustment factor.--Taking into account
paragraph (1)(G), the Secretary shall specify a MIPS
adjustment factor for each MIPS eligible professional
for a year. Such MIPS adjustment factor for a MIPS
eligible professional for a year shall be in the form
of a percent and shall be determined--
``(i) by comparing the composite
performance score of the eligible professional
for such year to the performance threshold
established under subparagraph (D)(i) for such
year;
``(ii) in a manner such that the adjustment
factors specified under this subparagraph for a
year result in differential payments under this
paragraph reflecting that--
``(I) MIPS eligible professionals
with composite performance scores for
such year at or above such performance
threshold for such year receive zero or
positive payment adjustment factors for
such year in accordance with clause
(iii), with such professionals having
higher composite performance scores
receiving higher adjustment factors;
and
``(II) MIPS eligible professionals
with composite performance scores for
such year below such performance
threshold for such year receive
negative payment adjustment factors for
such year in accordance with clause
(iv), with such professionals having
lower composite performance scores
receiving lower adjustment factors;
``(iii) in a manner such that MIPS eligible
professionals with composite scores described
in clause (ii)(I) for such year, subject to
clauses (i) and (ii) of subparagraph (F),
receive a zero or positive adjustment factor on
a linear sliding scale such that an adjustment
factor of 0 percent is assigned for a score at
the performance threshold and an adjustment
factor of the applicable percent specified in
subparagraph (B) is assigned for a score of
100; and
``(iv) in a manner such that--
``(I) subject to subclause (II),
MIPS eligible professionals with
composite performance scores described
in clause (ii)(II) for such year
receive a negative payment adjustment
factor on a linear sliding scale such
that an adjustment factor of 0 percent
is assigned for a score at the
performance threshold and an adjustment
factor of the negative of the
applicable percent specified in
subparagraph (B) is assigned for a
score of 0; and
``(II) MIPS eligible professionals
with composite performance scores that
are equal to or greater than 0, but not
greater than \1/4\ of the performance
threshold specified under subparagraph
(D)(i) for such year, receive a
negative payment adjustment factor that
is equal to the negative of the
applicable percent specified in
subparagraph (B) for such year.
``(B) Applicable percent defined.--For purposes of
this paragraph, the term `applicable percent' means--
``(i) for 2019, 4 percent;
``(ii) for 2020, 5 percent;
``(iii) for 2021, 7 percent; and
``(iv) for 2022 and subsequent years, 9
percent.
``(C) Additional mips adjustment factors for
exceptional performance.--For 2019 and each subsequent
year through 2024, in the case of a MIPS eligible
professional with a composite performance score for a
year at or above the additional performance threshold
under subparagraph (D)(ii) for such year, in addition
to the MIPS adjustment factor under subparagraph (A)
for the eligible professional for such year, subject to
subparagraph (F)(iv), the Secretary shall specify an
additional positive MIPS adjustment factor for such
professional and year. Such additional MIPS adjustment
factors shall be in the form of a percent and
determined by the Secretary in a manner such that
professionals having higher composite performance
scores above the additional performance threshold
receive higher additional MIPS adjustment factors.
``(D) Establishment of performance thresholds.--
``(i) Performance threshold.--For each year
of the MIPS, the Secretary shall compute a
performance threshold with respect to which the
composite performance score of MIPS eligible
professionals shall be compared for purposes of
determining adjustment factors under
subparagraph (A) that are positive, negative,
and zero. Such performance threshold for a year
shall be the mean or median (as selected by the
Secretary) of the composite performance scores
for all MIPS eligible professionals with
respect to a prior period specified by the
Secretary. The Secretary may reassess the
selection of the mean or median under the
previous sentence every 3 years.
``(ii) Additional performance threshold for
exceptional performance.--In addition to the
performance threshold under clause (i), for
each year of the MIPS, the Secretary shall
compute an additional performance threshold for
purposes of determining the additional MIPS
adjustment factors under subparagraph (C). For
each such year, the Secretary shall apply
either of the following methods for computing
such additional performance threshold for such
a year:
``(I) The threshold shall be the
score that is equal to the 25th
percentile of the range of possible
composite performance scores above the
performance threshold determined under
clause (i).
``(II) The threshold shall be the
score that is equal to the 25th
percentile of the actual composite
performance scores for MIPS eligible
professionals with composite
performance scores at or above the
performance threshold with respect to
the prior period described in clause
(i).
``(iii) Special rule for initial 2 years.--
With respect to each of the first two years to
which the MIPS applies, the Secretary shall,
prior to the performance period for such years,
establish a performance threshold for purposes
of determining MIPS adjustment factors under
subparagraph (A) and a threshold for purposes
of determining additional MIPS adjustment
factors under subparagraph (C). Each such
performance threshold shall--
``(I) be based on a period prior to
such performance periods; and
``(II) take into account--
``(aa) data available with
respect to performance on
measures and activities that
may be used under the
performance categories under
subparagraph (2)(B); and
``(bb) other factors
determined appropriate by the
Secretary.
``(E) Application of mips adjustment factors.--In
the case of items and services furnished by a MIPS
eligible professional during a year (beginning with
2019), the amount otherwise paid under this part with
respect to such items and services and MIPS eligible
professional for such year, shall be multiplied by--
``(i) 1, plus
``(ii) the sum of--
``(I) the MIPS adjustment factor
determined under subparagraph (A)
divided by 100, and
``(II) as applicable, the
additional MIPS adjustment factor
determined under subparagraph (C)
divided by 100.
``(F) Aggregate application of mips adjustment
factors.--
``(i) Application of scaling factor.--
``(I) In general.--With respect to
positive MIPS adjustment factors under
subparagraph (A)(ii)(I) for eligible
professionals whose composite
performance score is above the
performance threshold under
subparagraph (D)(i) for such year,
subject to subclause (II), the
Secretary shall increase or decrease
such adjustment factors by a scaling
factor in order to ensure that the
budget neutrality requirement of clause
(ii) is met.
``(II) Scaling factor limit.--In no
case may the scaling factor applied
under this clause exceed 3.0.
``(ii) Budget neutrality requirement.--
``(I) In general.--Subject to
clause (iii), the Secretary shall
ensure that the estimated amount
described in subclause (II) for a year
is equal to the estimated amount
described in subclause (III) for such
year.
``(II) Aggregate increases.--The
amount described in this subclause is
the estimated increase in the aggregate
allowed charges resulting from the
application of positive MIPS adjustment
factors under subparagraph (A) (after
application of the scaling factor
described in clause (i)) to MIPS
eligible professionals whose composite
performance score for a year is above
the performance threshold under
subparagraph (D)(i) for such year.
``(III) Aggregate decreases.--The
amount described in this subclause is
the estimated decrease in the aggregate
allowed charges resulting from the
application of negative MIPS adjustment
factors under subparagraph (A) to MIPS
eligible professionals whose composite
performance score for a year is below
the performance threshold under
subparagraph (D)(i) for such year.
``(iii) Exceptions.--
``(I) In the case that all MIPS
eligible professionals receive
composite performance scores for a year
that are below the performance
threshold under subparagraph (D)(i) for
such year, the negative MIPS adjustment
factors under subparagraph (A) shall
apply with respect to such MIPS
eligible professionals and the budget
neutrality requirement of clause (ii)
and the additional adjustment factors
under clause (iv) shall not apply for
such year.
``(II) In the case that, with
respect to a year, the application of
clause (i) results in a scaling factor
equal to the maximum scaling factor
specified in clause (i)(II), such
scaling factor shall apply and the
budget neutrality requirement of clause
(ii) shall not apply for such year.
``(iv) Additional incentive payment
adjustments.--
``(I) In general.--Subject to
subclause (II), in specifying the MIPS
additional adjustment factors under
subparagraph (C) for each applicable
MIPS eligible professional for a year,
the Secretary shall ensure that the
estimated aggregate increase in
payments under this part resulting from
the application of such additional
adjustment factors for MIPS eligible
professionals in a year shall be equal
(as estimated by the Secretary) to
$500,000,000 for each year beginning
with 2019 and ending with 2024.
``(II) Limitation on additional
incentive payment adjustments.--The
MIPS additional adjustment factor under
subparagraph (C) for a year for an
applicable MIPS eligible professional
whose composite performance score is
above the additional performance
threshold under subparagraph (D)(ii)
for such year shall not exceed 10
percent. The application of the
previous sentence may result in an
aggregate amount of additional
incentive payments that are less than
the amount specified in subclause (I).
``(7) Announcement of result of adjustments.--Under the
MIPS, the Secretary shall, not later than 30 days prior to
January 1 of the year involved, make available to MIPS eligible
professionals the MIPS adjustment factor (and, as applicable,
the additional MIPS adjustment factor) under paragraph (6)
applicable to the eligible professional for items and services
furnished by the professional for such year. The Secretary may
include such information in the confidential feedback under
paragraph (12).
``(8) No effect in subsequent years.--The MIPS adjustment
factors and additional MIPS adjustment factors under paragraph
(6) shall apply only with respect to the year involved, and the
Secretary shall not take into account such adjustment factors
in making payments to a MIPS eligible professional under this
part in a subsequent year.
``(9) Public reporting.--
``(A) In general.--The Secretary shall, in an
easily understandable format, make available on the
Physician Compare Internet website of the Centers for
Medicare & Medicaid Services the following:
``(i) Information regarding the performance
of MIPS eligible professionals under the MIPS,
which--
``(I) shall include the composite
score for each such MIPS eligible
professional and the performance of
each such MIPS eligible professional
with respect to each performance
category; and
``(II) may include the performance
of each such MIPS eligible professional
with respect to each measure or
activity specified in paragraph (2)(B).
``(ii) The names of eligible professionals
in eligible alternative payment models (as
defined in section 1833(z)(3)(D)) and, to the
extent feasible, the names of such eligible
alternative payment models and performance of
such models.
``(B) Disclosure.--The information made available
under this paragraph shall indicate, where appropriate,
that publicized information may not be representative
of the eligible professional's entire patient
population, the variety of services furnished by the
eligible professional, or the health conditions of
individuals treated.
``(C) Opportunity to review and submit
corrections.--The Secretary shall provide for an
opportunity for a professional described in
subparagraph (A) to review, and submit corrections for,
the information to be made public with respect to the
professional under such subparagraph prior to such
information being made public.
``(D) Aggregate information.--The Secretary shall
periodically post on the Physician Compare Internet
website aggregate information on the MIPS, including
the range of composite scores for all MIPS eligible
professionals and the range of the performance of all
MIPS eligible professionals with respect to each
performance category.
``(10) Consultation.--The Secretary shall consult with
stakeholders in carrying out the MIPS, including for the
identification of measures and activities under paragraph
(2)(B) and the methodologies developed under paragraphs (5)(A)
and (6) and regarding the use of qualified clinical data
registries. Such consultation shall include the use of a
request for information or other mechanisms determined
appropriate.
``(11) Technical assistance to small practices and
practices in health professional shortage areas.--
``(A) In general.--The Secretary shall enter into
contracts or agreements with appropriate entities (such
as quality improvement organizations, regional
extension centers (as described in section 3012(c) of
the Public Health Service Act), or regional health
collaboratives) to offer guidance and assistance to
MIPS eligible professionals in practices of 15 or fewer
professionals (with priority given to such practices
located in rural areas, health professional shortage
areas (as designated under in section 332(a)(1)(A) of
such Act), and medically underserved areas, and
practices with low composite scores) with respect to--
``(i) the performance categories described
in clauses (i) through (iv) of paragraph
(2)(A); or
``(ii) how to transition to the
implementation of and participation in an
alternative payment model as described in
section 1833(z)(3)(C).
``(B) Funding for technical assistance.--For
purposes of implementing subparagraph (A), the
Secretary shall provide for the transfer from the
Federal Supplementary Medical Insurance Trust Fund
established under section 1841 to the Centers for
Medicare & Medicaid Services Program Management Account
of $20,000,000 for each of fiscal years 2016 through
2020. Amounts transferred under this subparagraph for a
fiscal year shall be available until expended.
``(12) Feedback and information to improve performance.--
``(A) Performance feedback.--
``(i) In general.--Beginning July 1, 2017,
the Secretary--
``(I) shall make available timely
(such as quarterly) confidential
feedback to MIPS eligible professionals
on the performance of such
professionals with respect to the
performance categories under clauses
(i) and (ii) of paragraph (2)(A); and
``(II) may make available
confidential feedback to such
professionals on the performance of
such professionals with respect to the
performance categories under clauses
(iii) and (iv) of such paragraph.
``(ii) Mechanisms.--The Secretary may use
one or more mechanisms to make feedback
available under clause (i), which may include
use of a web-based portal or other mechanisms
determined appropriate by the Secretary. With
respect to the performance category described
in paragraph (2)(A)(i), feedback under this
subparagraph shall, to the extent an eligible
professional chooses to participate in a data
registry for purposes of this subsection
(including registries under subsections (k) and
(m)), be provided based on performance on
quality measures reported through the use of
such registries. With respect to any other
performance category described in paragraph
(2)(A), the Secretary shall encourage provision
of feedback through qualified clinical data
registries as described in subsection
(m)(3)(E)).
``(iii) Use of data.--For purposes of
clause (i), the Secretary may use data, with
respect to a MIPS eligible professional, from
periods prior to the current performance period
and may use rolling periods in order to make
illustrative calculations about the performance
of such professional.
``(iv) Disclosure exemption.--Feedback made
available under this subparagraph shall be
exempt from disclosure under section 552 of
title 5, United States Code.
``(v) Receipt of information.--The
Secretary may use the mechanisms established
under clause (ii) to receive information from
professionals, such as information with respect
to this subsection.
``(B) Additional information.--
``(i) In general.--Beginning July 1, 2018,
the Secretary shall make available to MIPS
eligible professionals information, with
respect to individuals who are patients of such
MIPS eligible professionals, about items and
services for which payment is made under this
title that are furnished to such individuals by
other suppliers and providers of services,
which may include information described in
clause (ii). Such information may be made
available under the previous sentence to such
MIPS eligible professionals by mechanisms
determined appropriate by the Secretary, which
may include use of a web-based portal. Such
information may be made available in accordance
with the same or similar terms as data are made
available to accountable care organizations
participating in the shared savings program
under section 1899.
``(ii) Type of information.--For purposes
of clause (i), the information described in
this clause, is the following:
``(I) With respect to selected
items and services (as determined
appropriate by the Secretary) for which
payment is made under this title and
that are furnished to individuals, who
are patients of a MIPS eligible
professional, by another supplier or
provider of services during the most
recent period for which data are
available (such as the most recent
three-month period), such as the name
of such providers furnishing such items
and services to such patients during
such period, the types of such items
and services so furnished, and the
dates such items and services were so
furnished.
``(II) Historical data, such as
averages and other measures of the
distribution if appropriate, of the
total, and components of, allowed
charges (and other figures as
determined appropriate by the
Secretary).
``(13) Review.--
``(A) Targeted review.--The Secretary shall
establish a process under which a MIPS eligible
professional may seek an informal review of the
calculation of the MIPS adjustment factor (or factors)
applicable to such eligible professional under this
subsection for a year. The results of a review
conducted pursuant to the previous sentence shall not
be taken into account for purposes of paragraph (6)
with respect to a year (other than with respect to the
calculation of such eligible professional's MIPS
adjustment factor for such year or additional MIPS
adjustment factor for such year) after the factors
determined in subparagraph (A) and subparagraph (C) of
such paragraph have been determined for such year.
``(B) Limitation.--Except as provided for in
subparagraph (A), there shall be no administrative or
judicial review under section 1869, section 1878, or
otherwise of the following:
``(i) The methodology used to determine the
amount of the MIPS adjustment factor under
paragraph (6)(A) and the amount of the
additional MIPS adjustment factor under
paragraph (6)(C) and the determination of such
amounts.
``(ii) The establishment of the performance
standards under paragraph (3) and the
performance period under paragraph (4).
``(iii) The identification of measures and
activities specified under paragraph (2)(B) and
information made public or posted on the
Physician Compare Internet website of the
Centers for Medicare & Medicaid Services under
paragraph (9).
``(iv) The methodology developed under
paragraph (5) that is used to calculate
performance scores and the calculation of such
scores, including the weighting of measures and
activities under such methodology.''.
(2) GAO reports.--
(A) Evaluation of eligible professional mips.--Not
later than October 1, 2021, the Comptroller General of
the United States shall submit to Congress a report
evaluating the eligible professional Merit-based
Incentive Payment System under subsection (q) of
section 1848 of the Social Security Act (42 U.S.C.
1395w-4), as added by paragraph (1). Such report
shall--
(i) examine the distribution of the
composite performance scores and MIPS
adjustment factors (and additional MIPS
adjustment factors) for MIPS eligible
professionals (as defined in subsection
(q)(1)(c) of such section) under such program,
and patterns relating to such scores and
adjustment factors, including based on type of
provider, practice size, geographic location,
and patient mix;
(ii) provide recommendations for improving
such program;
(iii) evaluate the impact of technical
assistance funding under section 1848(q)(11) of
the Social Security Act, as added by paragraph
(1), on the ability of professionals to improve
within such program or successfully transition
to an alternative payment model (as defined in
section 1833(z)(3) of the Social Security Act,
as added by subsection (e)), with priority for
such evaluation given to practices located in
rural areas, health professional shortage areas
(as designated in section 332(a)(1)(A) of the
Public Health Service Act), and medically
underserved areas; and
(iv) provide recommendations for optimizing
the use of such technical assistance funds.
(B) Study to examine alignment of quality measures
used in public and private programs.--
(i) In general.--Not later than 18 months
after the date of the enactment of this Act,
the Comptroller General of the United States
shall submit to Congress a report that--
(I) compares the similarities and
differences in the use of quality
measures under the original Medicare
fee-for-service program under parts A
and B of title XVIII of the Social
Security Act, the Medicare Advantage
program under part C of such title,
selected State Medicaid programs under
title XIX of such Act, and private
payer arrangements; and
(II) makes recommendations on how
to reduce the administrative burden
involved in applying such quality
measures.
(ii) Requirements.--The report under clause
(i) shall--
(I) consider those measures
applicable to individuals entitled to,
or enrolled for, benefits under such
part A, or enrolled under such part B
and individuals under the age of 65;
and
(II) focus on those measures that
comprise the most significant component
of the quality performance category of
the eligible professional MIPS
incentive program under subsection (q)
of section 1848 of the Social Security
Act (42 U.S.C. 1395w-4), as added by
paragraph (1).
(C) Study on role of independent risk managers.--
Not later than January 1, 2017, the Comptroller General
of the United States shall submit to Congress a report
examining whether entities that pool financial risk for
physician practices, such as independent risk managers,
can play a role in supporting physician practices,
particularly small physician practices, in assuming
financial risk for the treatment of patients. Such
report shall examine barriers that small physician
practices currently face in assuming financial risk for
treating patients, the types of risk management
entities that could assist physician practices in
participating in two-sided risk payment models, and how
such entities could assist with risk management and
with quality improvement activities. Such report shall
also include an analysis of any existing legal barriers
to such arrangements.
(D) Study to examine rural and health professional
shortage area alternative payment models.--Not later
than October 1, 2021, the Comptroller General of the
United States shall submit to Congress a report that
examines the transition of professionals in rural
areas, health professional shortage areas (as
designated in section 332(a)(1)(A) of the Public Health
Service Act), or medically underserved areas to an
alternative payment model (as defined in section
1833(z)(3) of the Social Security Act, as added by
subsection (e)). Such report shall make recommendations
for removing administrative barriers to practices,
including small practices consisting of 15 or fewer
professionals, in rural areas, health professional
shortage areas, and medically underserved areas to
participation in such models.
(3) 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 transfer of $80,000,000 from the Supplementary
Medical Insurance Trust Fund established under section 1841 of
the Social Security Act (42 U.S.C. 1395t) to the Centers for
Medicare & Medicaid Program Management Account for each of the
fiscal years 2015 through 2019. Amounts transferred under this
paragraph shall be available until expended.
(d) Improving Quality Reporting for Composite Scores.--
(1) Changes for group reporting option.--
(A) In general.--Section 1848(m)(3)(C)(ii) of the
Social Security Act (42 U.S.C. 1395w-4(m)(3)(C)(ii)) is
amended by inserting ``and, for 2016 and subsequent
years, may provide'' after ``shall provide''.
(B) Clarification of qualified clinical data
registry reporting to group practices.--Section
1848(m)(3)(D) of the Social Security Act (42 U.S.C.
1395w-4(m)(3)(D)) is amended by inserting ``and, for
2016 and subsequent years, subparagraph (A) or (C)''
after ``subparagraph (A)''.
(2) Changes for multiple reporting periods and alternative
criteria for satisfactory reporting.--Section 1848(m)(5)(F) of
the Social Security Act (42 U.S.C. 1395w-4(m)(5)(F)) is
amended--
(A) by striking ``and subsequent years'' and
inserting ``through reporting periods occurring in
2015''; and
(B) by inserting ``and, for reporting periods
occurring in 2016 and subsequent years, the Secretary
may establish'' after ``shall establish''.
(3) Physician feedback program reports succeeded by reports
under mips.--Section 1848(n) of the Social Security Act (42
U.S.C. 1395w-4(n)) is amended by adding at the end the
following new paragraph:
``(11) Reports ending with 2017.--Reports under the Program
shall not be provided after December 31, 2017. See subsection
(q)(12) for reports under the eligible professionals Merit-
based Incentive Payment System.''.
(4) Coordination with satisfying meaningful ehr use
clinical quality measure reporting requirement.--Section
1848(o)(2)(A)(iii) of the Social Security Act (42 U.S.C. 1395w-
4(o)(2)(A)(iii)) is amended by inserting ``and subsection
(q)(5)(B)(ii)(II)'' after ``Subject to subparagraph (B)(ii)''.
(e) Promoting Alternative Payment Models.--
(1) Increasing transparency of physician-focused payment
models.--Section 1868 of the Social Security Act (42 U.S.C.
1395ee) is amended by adding at the end the following new
subsection:
``(c) Physician-Focused Payment Models.--
``(1) Technical advisory committee.--
``(A) Establishment.--There is established an ad
hoc committee to be known as the `Physician-Focused
Payment Model Technical Advisory Committee' (referred
to in this subsection as the `Committee').
``(B) Membership.--
``(i) Number and appointment.--The
Committee shall be composed of 11 members
appointed by the Comptroller General of the
United States.
``(ii) Qualifications.--The membership of
the Committee shall include individuals with
national recognition for their expertise in
physician-focused payment models and related
delivery of care. No more than 5 members of the
Committee shall be providers of services or
suppliers, or representatives of providers of
services or suppliers.
``(iii) Prohibition on federal
employment.--A member of the Committee shall
not be an employee of the Federal Government.
``(iv) Ethics disclosure.--The Comptroller
General shall establish a system for public
disclosure by members of the Committee of
financial and other potential conflicts of
interest relating to such members. Members of
the Committee shall be treated as employees of
Congress for purposes of applying title I of
the Ethics in Government Act of 1978 (Public
Law 95-521).
``(v) Date of initial appointments.--The
initial appointments of members of the
Committee shall be made by not later than 180
days after the date of enactment of this
subsection.
``(C) Term; vacancies.--
``(i) Term.--The terms of members of the
Committee shall be for 3 years except that the
Comptroller General shall designate staggered
terms for the members first appointed.
``(ii) Vacancies.--Any member appointed to
fill a vacancy occurring before the expiration
of the term for which the member's predecessor
was appointed shall be appointed only for the
remainder of that term. A member may serve
after the expiration of that member's term
until a successor has taken office. A vacancy
in the Committee shall be filled in the manner
in which the original appointment was made.
``(D) Duties.--The Committee shall meet, as needed,
to provide comments and recommendations to the
Secretary, as described in paragraph (2)(C), on
physician-focused payment models.
``(E) Compensation of members.--
``(i) In general.--Except as provided in
clause (ii), a member of the Committee shall
serve without compensation.
``(ii) Travel expenses.--A member of the
Committee shall be allowed travel expenses,
including per diem in lieu of subsistence, at
rates authorized for an employee of an agency
under subchapter I of chapter 57 of title 5,
United States Code, while away from the home or
regular place of business of the member in the
performance of the duties of the Committee.
``(F) Operational and technical support.--
``(i) In general.--The Assistant Secretary
for Planning and Evaluation shall provide
technical and operational support for the
Committee, which may be by use of a contractor.
The Office of the Actuary of the Centers for
Medicare & Medicaid Services shall provide to
the Committee actuarial assistance as needed.
``(ii) Funding.--The Secretary shall
provide for the transfer, from the Federal
Supplementary Medical Insurance Trust Fund
under section 1841, such amounts as are
necessary to carry out this paragraph (not to
exceed $5,000,000) for fiscal year 2015 and
each subsequent fiscal year. Any amounts
transferred under the preceding sentence for a
fiscal year shall remain available until
expended.
``(G) Application.--Section 14 of the Federal
Advisory Committee Act (5 U.S.C. App.) shall not apply
to the Committee.
``(2) Criteria and process for submission and review of
physician-focused payment models.--
``(A) Criteria for assessing physician-focused
payment models.--
``(i) Rulemaking.--Not later than November
1, 2016, the Secretary shall, through notice
and comment rulemaking, following a request for
information, establish criteria for physician-
focused payment models, including models for
specialist physicians, that could be used by
the Committee for making comments and
recommendations pursuant to paragraph (1)(D).
``(ii) MedPAC submission of comments.--
During the comment period for the proposed rule
described in clause (i), the Medicare Payment
Advisory Commission may submit comments to the
Secretary on the proposed criteria under such
clause.
``(iii) Updating.--The Secretary may update
the criteria established under this
subparagraph through rulemaking.
``(B) Stakeholder submission of physician-focused
payment models.--On an ongoing basis, individuals and
stakeholder entities may submit to the Committee
proposals for physician-focused payment models that
such individuals and entities believe meet the criteria
described in subparagraph (A).
``(C) Committee review of models submitted.--The
Committee shall, on a periodic basis, review models
submitted under subparagraph (B), prepare comments and
recommendations regarding whether such models meet the
criteria described in subparagraph (A), and submit such
comments and recommendations to the Secretary.
``(D) Secretary review and response.--The Secretary
shall review the comments and recommendations submitted
by the Committee under subparagraph (C) and post a
detailed response to such comments and recommendations
on the Internet website of the Centers for Medicare &
Medicaid Services.
``(3) Rule of construction.--Nothing in this subsection
shall be construed to impact the development or testing of
models under this title or titles XI, XIX, or XXI.''.
(2) Incentive payments for participation in eligible
alternative payment models.--Section 1833 of the Social
Security Act (42 U.S.C. 1395l) is amended by adding at the end
the following new subsection:
``(z) Incentive Payments for Participation in Eligible Alternative
Payment Models.--
``(1) Payment incentive.--
``(A) In general.--In the case of covered
professional services furnished by an eligible
professional during a year that is in the period
beginning with 2019 and ending with 2024 and for which
the professional is a qualifying APM participant with
respect to such year, in addition to the amount of
payment that would otherwise be made for such covered
professional services under this part for such year,
there also shall be paid to such professional an amount
equal to 5 percent of the estimated aggregate payment
amounts for such covered professional services under
this part for the preceding year. For purposes of the
previous sentence, the payment amount for the preceding
year may be an estimation for the full preceding year
based on a period of such preceding year that is less
than the full year. The Secretary shall establish
policies to implement this subparagraph in cases in
which payment for covered professional services
furnished by a qualifying APM participant in an
alternative payment model--
``(i) is made to an eligible alternative
payment entity rather than directly to the
qualifying APM participant; or
``(ii) is made on a basis other than a fee-
for-service basis (such as payment on a
capitated basis).
``(B) Form of payment.--Payments under this
subsection shall be made in a lump sum, on an annual
basis, as soon as practicable.
``(C) Treatment of payment incentive.--Payments
under this subsection shall not be taken into account
for purposes of determining actual expenditures under
an alternative payment model and for purposes of
determining or rebasing any benchmarks used under the
alternative payment model.
``(D) Coordination.--The amount of the additional
payment under this subsection or subsection (m) shall
be determined without regard to any additional payment
under subsection (m) and this subsection, respectively.
The amount of the additional payment under this
subsection or subsection (x) shall be determined
without regard to any additional payment under
subsection (x) and this subsection, respectively. The
amount of the additional payment under this subsection
or subsection (y) shall be determined without regard to
any additional payment under subsection (y) and this
subsection, respectively.
``(2) Qualifying apm participant.--For purposes of this
subsection, the term `qualifying APM participant' means the
following:
``(A) 2019 and 2020.--With respect to 2019 and
2020, an eligible professional for whom the Secretary
determines that at least 25 percent of payments under
this part for covered professional services furnished
by such professional during the most recent period for
which data are available (which may be less than a
year) were attributable to such services furnished
under this part through an eligible alternative payment
entity.
``(B) 2021 and 2022.--With respect to 2021 and
2022, an eligible professional described in either of
the following clauses:
``(i) Medicare payment threshold option.--
An eligible professional for whom the Secretary
determines that at least 50 percent of payments
under this part for covered professional
services furnished by such professional during
the most recent period for which data are
available (which may be less than a year) were
attributable to such services furnished under
this part through an eligible alternative
payment entity.
``(ii) Combination all-payer and medicare
payment threshold option.--An eligible
professional--
``(I) for whom the Secretary
determines, with respect to items and
services furnished by such professional
during the most recent period for which
data are available (which may be less
than a year), that at least 50 percent
of the sum of--
``(aa) payments described
in clause (i); and
``(bb) all other payments,
regardless of payer (other than
payments made by the Secretary
of Defense or the Secretary of
Veterans Affairs and other than
payments made under title XIX
in a State in which no medical
home or alternative payment
model is available under the
State program under that
title),
meet the requirement described in
clause (iii)(I) with respect to
payments described in item (aa) and
meet the requirement described in
clause (iii)(II) with respect to
payments described in item (bb);
``(II) for whom the Secretary
determines at least 25 percent of
payments under this part for covered
professional services furnished by such
professional during the most recent
period for which data are available
(which may be less than a year) were
attributable to such services furnished
under this part through an eligible
alternative payment entity; and
``(III) who provides to the
Secretary such information as is
necessary for the Secretary to make a
determination under subclause (I), with
respect to such professional.
``(iii) Requirement.--For purposes of
clause (ii)(I)--
``(I) the requirement described in
this subclause, with respect to
payments described in item (aa) of such
clause, is that such payments are made
to an eligible alternative payment
entity; and
``(II) the requirement described in
this subclause, with respect to
payments described in item (bb) of such
clause, is that such payments are made
under arrangements in which--
``(aa) quality measures
comparable to measures under
the performance category
described in section
1848(q)(2)(B)(i) apply;
``(bb) certified EHR
technology is used; and
``(cc) the eligible
professional participates in an
entity that--
``(AA) bears more
than nominal financial
risk if actual
aggregate expenditures
exceeds expected
aggregate expenditures;
or
``(BB) with respect
to beneficiaries under
title XIX, is a medical
home that meets
criteria comparable to
medical homes expanded
under section 1115A(c).
``(C) Beginning in 2023.--With respect to 2023 and
each subsequent year, an eligible professional
described in either of the following clauses:
``(i) Medicare payment threshold option.--
An eligible professional for whom the Secretary
determines that at least 75 percent of payments
under this part for covered professional
services furnished by such professional during
the most recent period for which data are
available (which may be less than a year) were
attributable to such services furnished under
this part through an eligible alternative
payment entity.
``(ii) Combination all-payer and medicare
payment threshold option.--An eligible
professional--
``(I) for whom the Secretary
determines, with respect to items and
services furnished by such professional
during the most recent period for which
data are available (which may be less
than a year), that at least 75 percent
of the sum of--
``(aa) payments described
in clause (i); and
``(bb) all other payments,
regardless of payer (other than
payments made by the Secretary
of Defense or the Secretary of
Veterans Affairs and other than
payments made under title XIX
in a State in which no medical
home or alternative payment
model is available under the
State program under that
title),
meet the requirement described in
clause (iii)(I) with respect to
payments described in item (aa) and
meet the requirement described in
clause (iii)(II) with respect to
payments described in item (bb);
``(II) for whom the Secretary
determines at least 25 percent of
payments under this part for covered
professional services furnished by such
professional during the most recent
period for which data are available
(which may be less than a year) were
attributable to such services furnished
under this part through an eligible
alternative payment entity; and
``(III) who provides to the
Secretary such information as is
necessary for the Secretary to make a
determination under subclause (I), with
respect to such professional.
``(iii) Requirement.--For purposes of
clause (ii)(I)--
``(I) the requirement described in
this subclause, with respect to
payments described in item (aa) of such
clause, is that such payments are made
to an eligible alternative payment
entity; and
``(II) the requirement described in
this subclause, with respect to
payments described in item (bb) of such
clause, is that such payments are made
under arrangements in which--
``(aa) quality measures
comparable to measures under
the performance category
described in section
1848(q)(2)(B)(i) apply;
``(bb) certified EHR
technology is used; and
``(cc) the eligible
professional participates in an
entity that--
``(AA) bears more
than nominal financial
risk if actual
aggregate expenditures
exceeds expected
aggregate expenditures;
or
``(BB) with respect
to beneficiaries under
title XIX, is a medical
home that meets
criteria comparable to
medical homes expanded
under section 1115A(c).
``(D) Use of patient approach.--The Secretary may
base the determination of whether an eligible
professional is a qualifying APM participant under this
subsection and the determination of whether an eligible
professional is a partial qualifying APM participant
under section 1848(q)(1)(C)(iii) by using counts of
patients in lieu of using payments and using the same
or similar percentage criteria (as specified in this
subsection and such section, respectively), as the
Secretary determines appropriate.
``(3) Additional definitions.--In this subsection:
``(A) Covered professional services.--The term
`covered professional services' has the meaning given
that term in section 1848(k)(3)(A).
``(B) Eligible professional.--The term `eligible
professional' has the meaning given that term in
section 1848(k)(3)(B) and includes a group that
includes such professionals.
``(C) Alternative payment model (apm).--The term
`alternative payment model' means, other than for
purposes of subparagraphs (B)(ii)(I)(bb) and
(C)(ii)(I)(bb) of paragraph (2), any of the following:
``(i) A model under section 1115A (other
than a health care innovation award).
``(ii) The shared savings program under
section 1899.
``(iii) A demonstration under section
1866C.
``(iv) A demonstration required by Federal
law.
``(D) Eligible alternative payment entity.--The
term `eligible alternative payment entity' means, with
respect to a year, an entity that--
``(i) participates in an alternative
payment model that--
``(I) requires participants in such
model to use certified EHR technology
(as defined in subsection (o)(4)); and
``(II) provides for payment for
covered professional services based on
quality measures comparable to measures
under the performance category
described in section 1848(q)(2)(B)(i);
and
``(ii)(I) bears financial risk for monetary
losses under such alternative payment model
that are in excess of a nominal amount; or
``(II) is a medical home expanded under
section 1115A(c).
``(4) Limitation.--There shall be no administrative or
judicial review under section 1869, 1878, or otherwise, of the
following:
``(A) The determination that an eligible
professional is a qualifying APM participant under
paragraph (2) and the determination that an entity is
an eligible alternative payment entity under paragraph
(3)(D).
``(B) The determination of the amount of the 5
percent payment incentive under paragraph (1)(A),
including any estimation as part of such
determination.''.
(3) Coordination conforming amendments.--Section 1833 of
the Social Security Act (42 U.S.C. 1395l) is further amended--
(A) in subsection (x)(3), by adding at the end the
following new sentence: ``The amount of the additional
payment for a service under this subsection and
subsection (z) shall be determined without regard to
any additional payment for the service under subsection
(z) and this subsection, respectively.''; and
(B) in subsection (y)(3), by adding at the end the
following new sentence: ``The amount of the additional
payment for a service under this subsection and
subsection (z) shall be determined without regard to
any additional payment for the service under subsection
(z) and this subsection, respectively.''.
(4) Encouraging development and testing of certain
models.--Section 1115A(b)(2) of the Social Security Act (42
U.S.C. 1315a(b)(2)) is amended--
(A) in subparagraph (B), by adding at the end the
following new clauses:
``(xxi) Focusing primarily on physicians'
services (as defined in section 1848(j)(3))
furnished by physicians who are not primary
care practitioners.
``(xxii) Focusing on practices of 15 or
fewer professionals.
``(xxiii) Focusing on risk-based models for
small physician practices which may involve
two-sided risk and prospective patient
assignment, and which examine risk-adjusted
decreases in mortality rates, hospital
readmissions rates, and other relevant and
appropriate clinical measures.
``(xxiv) Focusing primarily on title XIX,
working in conjunction with the Center for
Medicaid and CHIP Services.''; and
(B) in subparagraph (C)(viii), by striking ``other
public sector or private sector payers'' and inserting
``other public sector payers, private sector payers, or
statewide payment models''.
(5) Construction regarding telehealth services.--Nothing in
the provisions of, or amendments made by, this title shall be
construed as precluding an alternative payment model or a
qualifying APM participant (as those terms are defined in
section 1833(z) of the Social Security Act, as added by
paragraph (1)) from furnishing a telehealth service for which
payment is not made under section 1834(m) of the Social
Security Act (42 U.S.C. 1395m(m)).
(6) Integrating medicare advantage alternative payment
models.--Not later than July 1, 2016, the Secretary of Health
and Human Services shall submit to Congress a study that
examines the feasibility of integrating alternative payment
models in the Medicare Advantage payment system. The study
shall include the feasibility of including a value-based
modifier and whether such modifier should be budget neutral.
(7) Study and report on fraud related to alternative
payment models under the medicare program.--
(A) Study.--The Secretary of Health and Human
Services, in consultation with the Inspector General of
the Department of Health and Human Services, shall
conduct a study that--
(i) examines the applicability of the
Federal fraud prevention laws to items and
services furnished under title XVIII of the
Social Security Act for which payment is made
under an alternative payment model (as defined
in section 1833(z)(3)(C) of such Act (42 U.S.C.
1395l(z)(3)(C)));
(ii) identifies aspects of such alternative
payment models that are vulnerable to
fraudulent activity; and
(iii) examines the implications of waivers
to such laws granted in support of such
alternative payment models, including under any
potential expansion of such models.
(B) Report.--Not later than 2 years after the date
of the enactment of this Act, the Secretary shall
submit to Congress a report containing the results of
the study conducted under subparagraph (A). Such report
shall include recommendations for actions to be taken
to reduce the vulnerability of such alternative payment
models to fraudulent activity. Such report also shall
include, as appropriate, recommendations of the
Inspector General for changes in Federal fraud
prevention laws to reduce such vulnerability.
(f) Collaborating With the Physician, Practitioner, and Other
Stakeholder Communities To Improve Resource Use Measurement.--Section
1848 of the Social Security Act (42 U.S.C. 1395w-4), as amended by
subsection (c), is further amended by adding at the end the following
new subsection:
``(r) Collaborating With the Physician, Practitioner, and Other
Stakeholder Communities To Improve Resource Use Measurement.--
``(1) In general.--In order to involve the physician,
practitioner, and other stakeholder communities in enhancing
the infrastructure for resource use measurement, including for
purposes of the Merit-based Incentive Payment System under
subsection (q) and alternative payment models under section
1833(z), the Secretary shall undertake the steps described in
the succeeding provisions of this subsection.
``(2) Development of care episode and patient condition
groups and classification codes.--
``(A) In general.--In order to classify similar
patients into care episode groups and patient condition
groups, the Secretary shall undertake the steps
described in the succeeding provisions of this
paragraph.
``(B) Public availability of existing efforts to
design an episode grouper.--Not later than 180 days
after the date of the enactment of this subsection, the
Secretary shall post on the Internet website of the
Centers for Medicare & Medicaid Services a list of the
episode groups developed pursuant to subsection
(n)(9)(A) and related descriptive information.
``(C) Stakeholder input.--The Secretary shall
accept, through the date that is 120 days after the day
the Secretary posts the list pursuant to subparagraph
(B), suggestions from physician specialty societies,
applicable practitioner organizations, and other
stakeholders for episode groups in addition to those
posted pursuant to such subparagraph, and specific
clinical criteria and patient characteristics to
classify patients into--
``(i) care episode groups; and
``(ii) patient condition groups.
``(D) Development of proposed classification
codes.--
``(i) In general.--Taking into account the
information described in subparagraph (B) and
the information received under subparagraph
(C), the Secretary shall--
``(I) establish care episode groups
and patient condition groups, which
account for a target of an estimated
\1/2\ of expenditures under parts A and
B (with such target increasing over
time as appropriate); and
``(II) assign codes to such groups.
``(ii) Care episode groups.--In
establishing the care episode groups under
clause (i), the Secretary shall take into
account--
``(I) the patient's clinical
problems at the time items and services
are furnished during an episode of
care, such as the clinical conditions
or diagnoses, whether or not inpatient
hospitalization occurs, and the
principal procedures or services
furnished; and
``(II) other factors determined
appropriate by the Secretary.
``(iii) Patient condition groups.--In
establishing the patient condition groups under
clause (i), the Secretary shall take into
account--
``(I) the patient's clinical
history at the time of a medical visit,
such as the patient's combination of
chronic conditions, current health
status, and recent significant history
(such as hospitalization and major
surgery during a previous period, such
as 3 months); and
``(II) other factors determined
appropriate by the Secretary, such as
eligibility status under this title
(including eligibility under section
226(a), 226(b), or 226A, and dual
eligibility under this title and title
XIX).
``(E) Draft care episode and patient condition
groups and classification codes.--Not later than 270
days after the end of the comment period described in
subparagraph (C), the Secretary shall post on the
Internet website of the Centers for Medicare & Medicaid
Services a draft list of the care episode and patient
condition codes established under subparagraph (D) (and
the criteria and characteristics assigned to such
code).
``(F) Solicitation of input.--The Secretary shall
seek, through the date that is 120 days after the
Secretary posts the list pursuant to subparagraph (E),
comments from physician specialty societies, applicable
practitioner organizations, and other stakeholders,
including representatives of individuals entitled to
benefits under part A or enrolled under this part,
regarding the care episode and patient condition groups
(and codes) posted under subparagraph (E). In seeking
such comments, the Secretary shall use one or more
mechanisms (other than notice and comment rulemaking)
that may include use of open door forums, town hall
meetings, or other appropriate mechanisms.
``(G) Operational list of care episode and patient
condition groups and codes.--Not later than 270 days
after the end of the comment period described in
subparagraph (F), taking into account the comments
received under such subparagraph, the Secretary shall
post on the Internet website of the Centers for
Medicare & Medicaid Services an operational list of
care episode and patient condition codes (and the
criteria and characteristics assigned to such code).
``(H) Subsequent revisions.--Not later than
November 1 of each year (beginning with 2018), the
Secretary shall, through rulemaking, make revisions to
the operational lists of care episode and patient
condition codes as the Secretary determines may be
appropriate. Such revisions may be based on experience,
new information developed pursuant to subsection
(n)(9)(A), and input from the physician specialty
societies, applicable practitioner organizations, and
other stakeholders, including representatives of
individuals entitled to benefits under part A or
enrolled under this part.
``(3) Attribution of patients to physicians or
practitioners.--
``(A) In general.--In order to facilitate the
attribution of patients and episodes (in whole or in
part) to one or more physicians or applicable
practitioners furnishing items and services, the
Secretary shall undertake the steps described in the
succeeding provisions of this paragraph.
``(B) Development of patient relationship
categories and codes.--The Secretary shall develop
patient relationship categories and codes that define
and distinguish the relationship and responsibility of
a physician or applicable practitioner with a patient
at the time of furnishing an item or service. Such
patient relationship categories shall include different
relationships of the physician or applicable
practitioner to the patient (and the codes may reflect
combinations of such categories), such as a physician
or applicable practitioner who--
``(i) considers themself to have the
primary responsibility for the general and
ongoing care for the patient over extended
periods of time;
``(ii) considers themself to be the lead
physician or practitioner and who furnishes
items and services and coordinates care
furnished by other physicians or practitioners
for the patient during an acute episode;
``(iii) furnishes items and services to the
patient on a continuing basis during an acute
episode of care, but in a supportive rather
than a lead role;
``(iv) furnishes items and services to the
patient on an occasional basis, usually at the
request of another physician or practitioner;
or
``(v) furnishes items and services only as
ordered by another physician or practitioner.
``(C) Draft list of patient relationship categories
and codes.--Not later than one year after the date of
the enactment of this subsection, the Secretary shall
post on the Internet website of the Centers for
Medicare & Medicaid Services a draft list of the
patient relationship categories and codes developed
under subparagraph (B).
``(D) Stakeholder input.--The Secretary shall seek,
through the date that is 120 days after the Secretary
posts the list pursuant to subparagraph (C), comments
from physician specialty societies, applicable
practitioner organizations, and other stakeholders,
including representatives of individuals entitled to
benefits under part A or enrolled under this part,
regarding the patient relationship categories and codes
posted under subparagraph (C). In seeking such
comments, the Secretary shall use one or more
mechanisms (other than notice and comment rulemaking)
that may include open door forums, town hall meetings,
web-based forums, or other appropriate mechanisms.
``(E) Operational list of patient relationship
categories and codes.--Not later than 240 days after
the end of the comment period described in subparagraph
(D), taking into account the comments received under
such subparagraph, the Secretary shall post on the
Internet website of the Centers for Medicare & Medicaid
Services an operational list of patient relationship
categories and codes.
``(F) Subsequent revisions.--Not later than
November 1 of each year (beginning with 2018), the
Secretary shall, through rulemaking, make revisions to
the operational list of patient relationship categories
and codes as the Secretary determines appropriate. Such
revisions may be based on experience, new information
developed pursuant to subsection (n)(9)(A), and input
from the physician specialty societies, applicable
practitioner organizations, and other stakeholders,
including representatives of individuals entitled to
benefits under part A or enrolled under this part.
``(4) Reporting of information for resource use
measurement.--Claims submitted for items and services furnished
by a physician or applicable practitioner on or after January
1, 2018, shall, as determined appropriate by the Secretary,
include--
``(A) applicable codes established under paragraphs
(2) and (3); and
``(B) the national provider identifier of the
ordering physician or applicable practitioner (if
different from the billing physician or applicable
practitioner).
``(5) Methodology for resource use analysis.--
``(A) In general.--In order to evaluate the
resources used to treat patients (with respect to care
episode and patient condition groups), the Secretary
shall, as the Secretary determines appropriate--
``(i) use the patient relationship codes
reported on claims pursuant to paragraph (4) to
attribute patients (in whole or in part) to one
or more physicians and applicable
practitioners;
``(ii) use the care episode and patient
condition codes reported on claims pursuant to
paragraph (4) as a basis to compare similar
patients and care episodes and patient
condition groups; and
``(iii) conduct an analysis of resource use
(with respect to care episodes and patient
condition groups of such patients).
``(B) Analysis of patients of physicians and
practitioners.--In conducting the analysis described in
subparagraph (A)(iii) with respect to patients
attributed to physicians and applicable practitioners,
the Secretary shall, as feasible--
``(i) use the claims data experience of
such patients by patient condition codes during
a common period, such as 12 months; and
``(ii) use the claims data experience of
such patients by care episode codes--
``(I) in the case of episodes
without a hospitalization, during
periods of time (such as the number of
days) determined appropriate by the
Secretary; and
``(II) in the case of episodes with
a hospitalization, during periods of
time (such as the number of days)
before, during, and after the
hospitalization.
``(C) Measurement of resource use.--In measuring
such resource use, the Secretary--
``(i) shall use per patient total allowed
charges for all services under part A and this
part (and, if the Secretary determines
appropriate, part D) for the analysis of
patient resource use, by care episode codes and
by patient condition codes; and
``(ii) may, as determined appropriate, use
other measures of allowed charges (such as
subtotals for categories of items and services)
and measures of utilization of items and
services (such as frequency of specific items
and services and the ratio of specific items
and services among attributed patients or
episodes).
``(D) Stakeholder input.--The Secretary shall seek
comments from the physician specialty societies,
applicable practitioner organizations, and other
stakeholders, including representatives of individuals
entitled to benefits under part A or enrolled under
this part, regarding the resource use methodology
established pursuant to this paragraph. In seeking
comments the Secretary shall use one or more mechanisms
(other than notice and comment rulemaking) that may
include open door forums, town hall meetings, web-based
forums, or other appropriate mechanisms.
``(6) Implementation.--To the extent that the Secretary
contracts with an entity to carry out any part of the
provisions of this subsection, the Secretary may not contract
with an entity or an entity with a subcontract if the entity or
subcontracting entity currently makes recommendations to the
Secretary on relative values for services under the fee
schedule for physicians' services under this section.
``(7) Limitation.--There shall be no administrative or
judicial review under section 1869, section 1878, or otherwise
of--
``(A) care episode and patient condition groups and
codes established under paragraph (2);
``(B) patient relationship categories and codes
established under paragraph (3); and
``(C) measurement of, and analyses of resource use
with respect to, care episode and patient condition
codes and patient relationship codes pursuant to
paragraph (5).
``(8) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to this section.
``(9) Definitions.--In this subsection:
``(A) Physician.--The term `physician' has the
meaning given such term in section 1861(r)(1).
``(B) Applicable practitioner.--The term
`applicable practitioner' means--
``(i) a physician assistant, nurse
practitioner, and clinical nurse specialist (as
such terms are defined in section 1861(aa)(5)),
and a certified registered nurse anesthetist
(as defined in section 1861(bb)(2)); and
``(ii) beginning January 1, 2019, such
other eligible professionals (as defined in
subsection (k)(3)(B)) as specified by the
Secretary.
``(10) Clarification.--The provisions of sections
1890(b)(7) and 1890A shall not apply to this subsection.''.
SEC. 102. PRIORITIES AND FUNDING FOR MEASURE DEVELOPMENT.
Section 1848 of the Social Security Act (42 U.S.C. 1395w-4), as
amended by subsections (c) and (f) of section 101, is further amended
by inserting at the end the following new subsection:
``(s) Priorities and Funding for Measure Development.--
``(1) Plan identifying measure development priorities and
timelines.--
``(A) Draft measure development plan.--Not later
than January 1, 2016, the Secretary shall develop, and
post on the Internet website of the Centers for
Medicare & Medicaid Services, a draft plan for the
development of quality measures for application under
the applicable provisions (as defined in paragraph
(5)). Under such plan the Secretary shall--
``(i) address how measures used by private
payers and integrated delivery systems could be
incorporated under title XVIII;
``(ii) describe how coordination, to the
extent possible, will occur across
organizations developing such measures; and
``(iii) take into account how clinical best
practices and clinical practice guidelines
should be used in the development of quality
measures.
``(B) Quality domains.--For purposes of this
subsection, the term `quality domains' means at least
the following domains:
``(i) Clinical care.
``(ii) Safety.
``(iii) Care coordination.
``(iv) Patient and caregiver experience.
``(v) Population health and prevention.
``(C) Consideration.--In developing the draft plan
under this paragraph, the Secretary shall consider--
``(i) gap analyses conducted by the entity
with a contract under section 1890(a) or other
contractors or entities;
``(ii) whether measures are applicable
across health care settings;
``(iii) clinical practice improvement
activities submitted under subsection
(q)(2)(C)(iv) for identifying possible areas
for future measure development and identifying
existing gaps with respect to such measures;
and
``(iv) the quality domains applied under
this subsection.
``(D) Priorities.--In developing the draft plan
under this paragraph, the Secretary shall give priority
to the following types of measures:
``(i) Outcome measures, including patient
reported outcome and functional status
measures.
``(ii) Patient experience measures.
``(iii) Care coordination measures.
``(iv) Measures of appropriate use of
services, including measures of over use.
``(E) Stakeholder input.--The Secretary shall
accept through March 1, 2016, comments on the draft
plan posted under paragraph (1)(A) from the public,
including health care providers, payers, consumers, and
other stakeholders.
``(F) Final measure development plan.--Not later
than May 1, 2016, taking into account the comments
received under this subparagraph, the Secretary shall
finalize the plan and post on the Internet website of
the Centers for Medicare & Medicaid Services an
operational plan for the development of quality
measures for use under the applicable provisions. Such
plan shall be updated as appropriate.
``(2) Contracts and other arrangements for quality measure
development.--
``(A) In general.--The Secretary shall enter into
contracts or other arrangements with entities for the
purpose of developing, improving, updating, or
expanding in accordance with the plan under paragraph
(1) quality measures for application under the
applicable provisions. Such entities shall include
organizations with quality measure development
expertise.
``(B) Prioritization.--
``(i) In general.--In entering into
contracts or other arrangements under
subparagraph (A), the Secretary shall give
priority to the development of the types of
measures described in paragraph (1)(D).
``(ii) Consideration.--In selecting
measures for development under this subsection,
the Secretary shall consider--
``(I) whether such measures would
be electronically specified; and
``(II) clinical practice guidelines
to the extent that such guidelines
exist.
``(3) Annual report by the secretary.--
``(A) In general.--Not later than May 1, 2017, and
annually thereafter, the Secretary shall post on the
Internet website of the Centers for Medicare & Medicaid
Services a report on the progress made in developing
quality measures for application under the applicable
provisions.
``(B) Requirements.--Each report submitted pursuant
to subparagraph (A) shall include the following:
``(i) A description of the Secretary's
efforts to implement this paragraph.
``(ii) With respect to the measures
developed during the previous year--
``(I) a description of the total
number of quality measures developed
and the types of such measures, such as
an outcome or patient experience
measure;
``(II) the name of each measure
developed;
``(III) the name of the developer
and steward of each measure;
``(IV) with respect to each type of
measure, an estimate of the total
amount expended under this title to
develop all measures of such type; and
``(V) whether the measure would be
electronically specified.
``(iii) With respect to measures in
development at the time of the report--
``(I) the information described in
clause (ii), if available; and
``(II) a timeline for completion of
the development of such measures.
``(iv) A description of any updates to the
plan under paragraph (1) (including newly
identified gaps and the status of previously
identified gaps) and the inventory of measures
applicable under the applicable provisions.
``(v) Other information the Secretary
determines to be appropriate.
``(4) Stakeholder input.--With respect to paragraph (1),
the Secretary shall seek stakeholder input with respect to--
``(A) the identification of gaps where no quality
measures exist, particularly with respect to the types
of measures described in paragraph (1)(D);
``(B) prioritizing quality measure development to
address such gaps; and
``(C) other areas related to quality measure
development determined appropriate by the Secretary.
``(5) Definition of applicable provisions.--In this
subsection, the term `applicable provisions' means the
following provisions:
``(A) Subsection (q)(2)(B)(i).
``(B) Section 1833(z)(2)(C).
``(6) Funding.--For purposes of carrying out this
subsection, the Secretary shall provide for the transfer, from
the Federal Supplementary Medical Insurance Trust Fund under
section 1841, of $15,000,000 to the Centers for Medicare &
Medicaid Services Program Management Account for each of fiscal
years 2015 through 2019. Amounts transferred under this
paragraph shall remain available through the end of fiscal year
2022.
``(7) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to the collection of information
for the development of quality measures.''.
SEC. 103. ENCOURAGING CARE MANAGEMENT FOR INDIVIDUALS WITH CHRONIC CARE
NEEDS.
(a) In General.--Section 1848(b) of the Social Security Act (42
U.S.C. 1395w-4(b)) is amended by adding at the end the following new
paragraph:
``(8) Encouraging care management for individuals with
chronic care needs.--
``(A) In general.--In order to encourage the
management of care for individuals with chronic care
needs the Secretary shall, subject to subparagraph (B),
make payment (as the Secretary determines to be
appropriate) under this section for chronic care
management services furnished on or after January 1,
2015, by a physician (as defined in section
1861(r)(1)), physician assistant or nurse practitioner
(as defined in section 1861(aa)(5)(A)), clinical nurse
specialist (as defined in section 1861(aa)(5)(B)), or
certified nurse midwife (as defined in section
1861(gg)(2)).
``(B) Policies relating to payment.--In carrying
out this paragraph, with respect to chronic care
management services, the Secretary shall--
``(i) make payment to only one applicable
provider for such services furnished to an
individual during a period;
``(ii) not make payment under subparagraph
(A) if such payment would be duplicative of
payment that is otherwise made under this title
for such services; and
``(iii) not require that an annual wellness
visit (as defined in section 1861(hhh)) or an
initial preventive physical examination (as
defined in section 1861(ww)) be furnished as a
condition of payment for such management
services.''.
(b) Education and Outreach.--
(1) Campaign.--
(A) In general.--The Secretary of Health and Human
Services (in this subsection referred to as the
``Secretary'') shall conduct an education and outreach
campaign to inform professionals who furnish items and
services under part B of title XVIII of the Social
Security Act and individuals enrolled under such part
of the benefits of chronic care management services
described in section 1848(b)(8) of the Social Security
Act, as added by subsection (a), and encourage such
individuals with chronic care needs to receive such
services.
(B) Requirements.--Such campaign shall--
(i) be directed by the Office of Rural
Health Policy of the Department of Health and
Human Services and the Office of Minority
Health of the Centers for Medicare & Medicaid
Services; and
(ii) focus on encouraging participation by
underserved rural populations and racial and
ethnic minority populations.
(2) Report.--Not later than December 31, 2017, the
Secretary shall submit to Congress a report on the use of
chronic care management services described in such section
1848(b)(8) by individuals living in rural areas and by racial
and ethnic minority populations. Such report shall--
(A) identify barriers to receiving chronic care
management services; and
(B) make recommendations for increasing the
appropriate use of chronic care management services.
SEC. 104. EMPOWERING BENEFICIARY CHOICES THROUGH CONTINUED ACCESS TO
INFORMATION ON PHYSICIANS' SERVICES.
(a) In General.--On an annual basis (beginning with 2015), the
Secretary shall make publicly available, in an easily understandable
format, information with respect to physicians and, as appropriate,
other eligible professionals on items and services furnished to
Medicare beneficiaries under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.).
(b) Type and Manner of Information.--The information made available
under this section shall be similar to the type of information in the
Medicare Provider Utilization and Payment Data: Physician and Other
Supplier Public Use File released by the Secretary with respect to 2012
and shall be made available in a manner similar to the manner in which
the information in such file is made available.
(c) Requirements.--The information made available under this
section shall include, at a minimum, the following:
(1) Information on the number of services furnished by the
physician or other eligible professional under part B of title
XVIII of the Social Security Act (42 U.S.C. 1395j et seq.),
which may include information on the most frequent services
furnished or groupings of services.
(2) Information on submitted charges and payments for
services under such part.
(3) A unique identifier for the physician or other eligible
professional that is available to the public, such as a
national provider identifier.
(d) Searchability.--The information made available under this
section shall be searchable by at least the following:
(1) The specialty or type of the physician or other
eligible professional.
(2) Characteristics of the services furnished, such as
volume or groupings of services.
(3) The location of the physician or other eligible
professional.
(e) Integration on Physician Compare.--Beginning with 2016, the
Secretary shall integrate the information made available under this
section on Physician Compare.
(f) Definitions.--In this section:
(1) Eligible professional; physician; secretary.--The terms
``eligible professional'', ``physician'', and ``Secretary''
have the meaning given such terms in section 10331(i) of Public
Law 111-148.
(2) Physician compare.--The term ``Physician Compare''
means the Physician Compare Internet website of the Centers for
Medicare & Medicaid Services (or a successor website).
SEC. 105. EXPANDING AVAILABILITY OF MEDICARE DATA.
(a) Expanding Uses of Medicare Data by Qualified Entities.--
(1) Additional analyses.--
(A) In general.--Subject to subparagraph (B), to
the extent consistent with applicable information,
privacy, security, and disclosure laws (including
paragraph (3)), notwithstanding paragraph (4)(B) of
section 1874(e) of the Social Security Act (42 U.S.C.
1395kk(e)) and the second sentence of paragraph (4)(D)
of such section, beginning July 1, 2016, a qualified
entity may use the combined data described in paragraph
(4)(B)(iii) of such section received by such entity
under such section, and information derived from the
evaluation described in such paragraph (4)(D), to
conduct additional non-public analyses (as determined
appropriate by the Secretary) and provide or sell such
analyses to authorized users for non-public use
(including for the purposes of assisting providers of
services and suppliers to develop and participate in
quality and patient care improvement activities,
including developing new models of care).
(B) Limitations with respect to analyses.--
(i) Employers.--Any analyses provided or
sold under subparagraph (A) to an employer
described in paragraph (9)(A)(iii) may only be
used by such employer for purposes of providing
health insurance to employees and retirees of
the employer.
(ii) Health insurance issuers.--A qualified
entity may not provide or sell an analysis to a
health insurance issuer described in paragraph
(9)(A)(iv) unless the issuer is providing the
qualified entity with data under section
1874(e)(4)(B)(iii) of the Social Security Act
(42 U.S.C. 1395kk(e)(4)(B)(iii)).
(2) Access to certain data.--
(A) Access.--To the extent consistent with
applicable information, privacy, security, and
disclosure laws (including paragraph (3)),
notwithstanding paragraph (4)(B) of section 1874(e) of
the Social Security Act (42 U.S.C. 1395kk(e)) and the
second sentence of paragraph (4)(D) of such section,
beginning July 1, 2016, a qualified entity may--
(i) provide or sell the combined data
described in paragraph (4)(B)(iii) of such
section to authorized users described in
clauses (i), (ii), and (v) of paragraph (9)(A)
for non-public use, including for the purposes
described in subparagraph (B); or
(ii) subject to subparagraph (C), provide
Medicare claims data to authorized users
described in clauses (i), (ii), and (v), of
paragraph (9)(A) for non-public use, including
for the purposes described in subparagraph (B).
(B) Purposes described.--The purposes described in
this subparagraph are assisting providers of services
and suppliers in developing and participating in
quality and patient care improvement activities,
including developing new models of care.
(C) Medicare claims data must be provided at no
cost.--A qualified entity may not charge a fee for
providing the data under subparagraph (A)(ii).
(3) Protection of information.--
(A) In general.--Except as provided in subparagraph
(B), an analysis or data that is provided or sold under
paragraph (1) or (2) shall not contain information that
individually identifies a patient.
(B) Information on patients of the provider of
services or supplier.--To the extent consistent with
applicable information, privacy, security, and
disclosure laws, an analysis or data that is provided
or sold to a provider of services or supplier under
paragraph (1) or (2) may contain information that
individually identifies a patient of such provider or
supplier, including with respect to items and services
furnished to the patient by other providers of services
or suppliers.
(C) Prohibition on using analyses or data for
marketing purposes.--An authorized user shall not use
an analysis or data provided or sold under paragraph
(1) or (2) for marketing purposes.
(4) Data use agreement.--A qualified entity and an
authorized user described in clauses (i), (ii), and (v) of
paragraph (9)(A) shall enter into an agreement regarding the
use of any data that the qualified entity is providing or
selling to the authorized user under paragraph (2). Such
agreement shall describe the requirements for privacy and
security of the data and, as determined appropriate by the
Secretary, any prohibitions on using such data to link to other
individually identifiable sources of information. If the
authorized user is not a covered entity under the rules
promulgated pursuant to the Health Insurance Portability and
Accountability Act of 1996, the agreement shall identify the
relevant regulations, as determined by the Secretary, that the
user shall comply with as if it were acting in the capacity of
such a covered entity.
(5) No redisclosure of analyses or data.--
(A) In general.--Except as provided in subparagraph
(B), an authorized user that is provided or sold an
analysis or data under paragraph (1) or (2) shall not
redisclose or make public such analysis or data or any
analysis using such data.
(B) Permitted redisclosure.--A provider of services
or supplier that is provided or sold an analysis or
data under paragraph (1) or (2) may, as determined by
the Secretary, redisclose such analysis or data for the
purposes of performance improvement and care
coordination activities but shall not make public such
analysis or data or any analysis using such data.
(6) Opportunity for providers of services and suppliers to
review.--Prior to a qualified entity providing or selling an
analysis to an authorized user under paragraph (1), to the
extent that such analysis would individually identify a
provider of services or supplier who is not being provided or
sold such analysis, such qualified entity shall provide such
provider or supplier with the opportunity to appeal and correct
errors in the manner described in section 1874(e)(4)(C)(ii) of
the Social Security Act (42 U.S.C. 1395kk(e)(4)(C)(ii)).
(7) Assessment for a breach.--
(A) In general.--In the case of a breach of a data
use agreement under this section or section 1874(e) of
the Social Security Act (42 U.S.C. 1395kk(e)), the
Secretary shall impose an assessment on the qualified
entity both in the case of--
(i) an agreement between the Secretary and
a qualified entity; and
(ii) an agreement between a qualified
entity and an authorized user.
(B) Assessment.--The assessment under subparagraph
(A) shall be an amount up to $100 for each individual
entitled to, or enrolled for, benefits under part A of
title XVIII of the Social Security Act or enrolled for
benefits under part B of such title--
(i) in the case of an agreement described
in subparagraph (A)(i), for whom the Secretary
provided data on to the qualified entity under
paragraph (2); and
(ii) in the case of an agreement described
in subparagraph (A)(ii), for whom the qualified
entity provided data on to the authorized user
under paragraph (2).
(C) Deposit of amounts collected.--Any amounts
collected pursuant to this paragraph shall be deposited
in Federal Supplementary Medical Insurance Trust Fund
under section 1841 of the Social Security Act (42
U.S.C. 1395t).
(8) Annual reports.--Any qualified entity that provides or
sells an analysis or data under paragraph (1) or (2) shall
annually submit to the Secretary a report that includes--
(A) a summary of the analyses provided or sold,
including the number of such analyses, the number of
purchasers of such analyses, and the total amount of
fees received for such analyses;
(B) a description of the topics and purposes of
such analyses;
(C) information on the entities who received the
data under paragraph (2), the uses of the data, and the
total amount of fees received for providing, selling,
or sharing the data; and
(D) other information determined appropriate by the
Secretary.
(9) Definitions.--In this subsection and subsection (b):
(A) Authorized user.--The term ``authorized user''
means the following:
(i) A provider of services.
(ii) A supplier.
(iii) An employer (as defined in section
3(5) of the Employee Retirement Insurance
Security Act of 1974).
(iv) A health insurance issuer (as defined
in section 2791 of the Public Health Service
Act).
(v) A medical society or hospital
association.
(vi) Any entity not described in clauses
(i) through (v) that is approved by the
Secretary (other than an employer or health
insurance issuer not described in clauses (iii)
and (iv), respectively, as determined by the
Secretary).
(B) Provider of services.--The term ``provider of
services'' has the meaning given such term in section
1861(u) of the Social Security Act (42 U.S.C.
1395x(u)).
(C) Qualified entity.--The term ``qualified
entity'' has the meaning given such term in section
1874(e)(2) of the Social Security Act (42 U.S.C.
1395kk(e)).
(D) Secretary.--The term ``Secretary'' means the
Secretary of Health and Human Services.
(E) Supplier.--The term ``supplier'' has the
meaning given such term in section 1861(d) of the
Social Security Act (42 U.S.C. 1395x(d)).
(b) Access to Medicare Data by Qualified Clinical Data Registries
To Facilitate Quality Improvement.--
(1) Access.--
(A) In general.--To the extent consistent with
applicable information, privacy, security, and
disclosure laws, beginning July 1, 2016, the Secretary
shall, at the request of a qualified clinical data
registry under section 1848(m)(3)(E) of the Social
Security Act (42 U.S.C. 1395w-4(m)(3)(E)), provide the
data described in subparagraph (B) (in a form and
manner determined to be appropriate) to such qualified
clinical data registry for purposes of linking such
data with clinical outcomes data and performing risk-
adjusted, scientifically valid analyses and research to
support quality improvement or patient safety, provided
that any public reporting of such analyses or research
that identifies a provider of services or supplier
shall only be conducted with the opportunity of such
provider or supplier to appeal and correct errors in
the manner described in subsection (a)(6).
(B) Data described.--The data described in this
subparagraph is--
(i) claims data under the Medicare program
under title XVIII of the Social Security Act;
and
(ii) if the Secretary determines
appropriate, claims data under the Medicaid
program under title XIX of such Act and the
State Children's Health Insurance Program under
title XXI of such Act.
(2) Fee.--Data described in paragraph (1)(B) shall be
provided to a qualified clinical data registry under paragraph
(1) at a fee equal to the cost of providing such data. Any fee
collected pursuant to the preceding sentence shall be deposited
in the Centers for Medicare & Medicaid Services Program
Management Account.
(c) Expansion of Data Available to Qualified Entities.--Section
1874(e) of the Social Security Act (42 U.S.C. 1395kk(e)) is amended--
(1) in the subsection heading, by striking ``Medicare'';
and
(2) in paragraph (3)--
(A) by inserting after the first sentence the
following new sentence: ``Beginning July 1, 2016, if
the Secretary determines appropriate, the data
described in this paragraph may also include
standardized extracts (as determined by the Secretary)
of claims data under titles XIX and XXI for assistance
provided under such titles for one or more specified
geographic areas and time periods requested by a
qualified entity.''; and
(B) in the last sentence, by inserting ``or under
titles XIX or XXI'' before the period at the end.
(d) Revision of Placement of Fees.--Section 1874(e)(4)(A) of the
Social Security Act (42 U.S.C. 1395kk(e)(4)(A)) is amended, in the
second sentence--
(1) by inserting ``, for periods prior to July 1, 2016,''
after ``deposited''; and
(2) by inserting the following before the period at the
end: ``, and, beginning July 1, 2016, into the Centers for
Medicare & Medicaid Services Program Management Account''.
SEC. 106. REDUCING ADMINISTRATIVE BURDEN AND OTHER PROVISIONS.
(a) Medicare Physician and Practitioner Opt-Out to Private
Contract.--
(1) Indefinite, continuing automatic extension of opt out
election.--
(A) In general.--Section 1802(b)(3) of the Social
Security Act (42 U.S.C. 1395a(b)(3)) is amended--
(i) in subparagraph (B)(ii), by striking
``during the 2-year period beginning on the
date the affidavit is signed'' and inserting
``during the applicable 2-year period (as
defined in subparagraph (D))'';
(ii) in subparagraph (C), by striking
``during the 2-year period described in
subparagraph (B)(ii)'' and inserting ``during
the applicable 2-year period''; and
(iii) by adding at the end the following
new subparagraph:
``(D) Applicable 2-year periods for effectiveness
of affidavits.--In this subsection, the term
`applicable 2-year period' means, with respect to an
affidavit of a physician or practitioner under
subparagraph (B), the 2-year period beginning on the
date the affidavit is signed and includes each
subsequent 2-year period unless the physician or
practitioner involved provides notice to the Secretary
(in a form and manner specified by the Secretary), not
later than 30 days before the end of the previous 2-
year period, that the physician or practitioner does
not want to extend the application of the affidavit for
such subsequent 2-year period.''.
(B) Effective date.--The amendments made by
subparagraph (A) shall apply to affidavits entered into
on or after the date that is 60 days after the date of
the enactment of this Act.
(2) Public availability of information on opt-out
physicians and practitioners.--Section 1802(b) of the Social
Security Act (42 U.S.C. 1395a(b)) is amended--
(A) in paragraph (5), by adding at the end the
following new subparagraph:
``(D) Opt-out physician or practitioner.--The term `opt-out
physician or practitioner' means a physician or practitioner
who has in effect an affidavit under paragraph (3)(B).'';
(B) by redesignating paragraph (5) as paragraph
(6); and
(C) by inserting after paragraph (4) the following
new paragraph:
``(5) Posting of information on opt-out physicians and
practitioners.--
``(A) In general.--Beginning not later than
February 1, 2016, the Secretary shall make publicly
available through an appropriate publicly accessible
website of the Department of Health and Human Services
information on the number and characteristics of opt-
out physicians and practitioners and shall update such
information on such website not less often than
annually.
``(B) Information to be included.--The information
to be made available under subparagraph (A) shall
include at least the following with respect to opt-out
physicians and practitioners:
``(i) Their number.
``(ii) Their physician or professional
specialty or other designation.
``(iii) Their geographic distribution.
``(iv) The timing of their becoming opt-out
physicians and practitioners, relative, to the
extent feasible, to when they first enrolled in
the program under this title and with respect
to applicable 2-year periods.
``(v) The proportion of such physicians and
practitioners who billed for emergency or
urgent care services.''.
(b) Promoting Interoperability of Electronic Health Record
Systems.--
(1) Recommendations for achieving widespread ehr
interoperability.--
(A) Objective.--As a consequence of a significant
Federal investment in the implementation of health
information technology through the Medicare and
Medicaid EHR incentive programs, Congress declares it a
national objective to achieve widespread exchange of
health information through interoperable certified EHR
technology nationwide by December 31, 2018.
(B) Definitions.--In this paragraph:
(i) Widespread interoperability.--The term
``widespread interoperability'' means
interoperability between certified EHR
technology systems employed by meaningful EHR
users under the Medicare and Medicaid EHR
incentive programs and other clinicians and
health care providers on a nationwide basis.
(ii) Interoperability.--The term
``interoperability'' means the ability of two
or more health information systems or
components to exchange clinical and other
information and to use the information that has
been exchanged using common standards as to
provide access to longitudinal information for
health care providers in order to facilitate
coordinated care and improved patient outcomes.
(C) Establishment of metrics.--Not later than July
1, 2016, and in consultation with stakeholders, the
Secretary shall establish metrics to be used to
determine if and to the extent that the objective
described in subparagraph (A) has been achieved.
(D) Recommendations if objective not achieved.--If
the Secretary of Health and Human Services determines
that the objective described in subparagraph (A) has
not been achieved by December 31, 2018, then the
Secretary shall submit to Congress a report, by not
later than December 31, 2019, that identifies barriers
to such objective and recommends actions that the
Federal Government can take to achieve such objective.
Such recommended actions may include recommendations--
(i) to adjust payments for not being
meaningful EHR users under the Medicare EHR
incentive programs; and
(ii) for criteria for decertifying
certified EHR technology products.
(2) Preventing blocking the sharing of information.--
(A) For meaningful use ehr professionals.--Section
1848(o)(2)(A)(ii) of the Social Security Act (42 U.S.C.
1395w-4(o)(2)(A)(ii)) is amended by inserting before
the period at the end the following: ``, and the
professional demonstrates (through a process specified
by the Secretary, such as the use of an attestation)
that the professional has not knowingly and willfully
taken action (such as to disable functionality) to
limit or restrict the compatibility or interoperability
of the certified EHR technology''.
(B) For meaningful use ehr hospitals.--Section
1886(n)(3)(A)(ii) of the Social Security Act (42 U.S.C.
1395ww(n)(3)(A)(ii)) is amended by inserting before the
period at the end the following: ``, and the hospital
demonstrates (through a process specified by the
Secretary, such as the use of an attestation) that the
hospital has not knowingly and willfully taken action
(such as to disable functionality) to limit or restrict
the compatibility or interoperability of the certified
EHR technology''.
(C) Effective date.--The amendments made by this
subsection shall apply to meaningful EHR users as of
the date that is one year after the date of the
enactment of this Act.
(3) Study and report on the feasibility of establishing a
mechanism to compare certified ehr technology products.--
(A) Study.--The Secretary shall conduct a study to
examine the feasibility of establishing one or more
mechanisms to assist providers in comparing and
selecting certified EHR technology products. Such
mechanisms may include--
(i) a website with aggregated results of
surveys of meaningful EHR users on the
functionality of certified EHR technology
products to enable such users to directly
compare the functionality and other features of
such products; and
(ii) information from vendors of certified
products that is made publicly available in a
standardized format.
The aggregated results of the surveys described in
clause (i) may be made available through contracts with
physicians, hospitals, or other organizations that
maintain such comparative information described in such
clause.
(B) Report.--Not later than 1 year after the date
of the enactment of this Act, the Secretary shall
submit to Congress a report on mechanisms that would
assist providers in comparing and selecting certified
EHR technology products. The report shall include
information on the benefits of, and resources needed to
develop and maintain, such mechanisms.
(4) Definitions.--In this subsection:
(A) The term ``certified EHR technology'' has the
meaning given such term in section 1848(o)(4) of the
Social Security Act (42 U.S.C. 1395w-4(o)(4)).
(B) The term ``meaningful EHR user'' has the
meaning given such term under the Medicare EHR
incentive programs.
(C) The term ``Medicare and Medicaid EHR incentive
programs'' means--
(i) in the case of the Medicare program
under title XVIII of the Social Security Act,
the incentive programs under section
1814(l)(3), section 1848(o), subsections (l)
and (m) of section 1853, and section 1886(n) of
the Social Security Act (42 U.S.C. 1395f(l)(3),
1395w-4(o), 1395w-23, 1395ww(n)); and
(ii) in the case of the Medicaid program
under title XIX of such Act, the incentive
program under subsections (a)(3)(F) and (t) of
section 1903 of such Act (42 U.S.C. 1396b).
(D) The term ``Secretary'' means the Secretary of
Health and Human Services.
(c) GAO Studies and Reports on the Use of Telehealth Under Federal
Programs and on Remote Patient Monitoring Services.--
(1) Study on telehealth services.--The Comptroller General
of the United States shall conduct a study on the following:
(A) How the definition of telehealth across various
Federal programs and Federal efforts can inform the use
of telehealth in the Medicare program under title XVIII
of the Social Security Act (42 U.S.C. 1395 et seq.).
(B) Issues that can facilitate or inhibit the use
of telehealth under the Medicare program under such
title, including oversight and professional licensure,
changing technology, privacy and security,
infrastructure requirements, and varying needs across
urban and rural areas.
(C) Potential implications of greater use of
telehealth with respect to payment and delivery system
transformations under the Medicare program under such
title XVIII and the Medicaid program under title XIX of
such Act (42 U.S.C. 1396 et seq.).
(D) How the Centers for Medicare & Medicaid
Services monitors payments made under the Medicare
program under such title XVIII to providers for
telehealth services.
(2) Study on remote patient monitoring services.--
(A) In general.--The Comptroller General of the
United States shall conduct a study--
(i) of the dissemination of remote patient
monitoring technology in the private health
insurance market;
(ii) of the financial incentives in the
private health insurance market relating to
adoption of such technology;
(iii) of the barriers to adoption of such
services under the Medicare program under title
XVIII of the Social Security Act;
(iv) that evaluates the patients,
conditions, and clinical circumstances that
could most benefit from remote patient
monitoring services; and
(v) that evaluates the challenges related
to establishing appropriate valuation for
remote patient monitoring services under the
Medicare physician fee schedule under section
1848 of the Social Security Act (42 U.S.C.
1395w-4) in order to accurately reflect the
resources involved in furnishing such services.
(B) Definitions.--For purposes of this paragraph:
(i) Remote patient monitoring services.--
The term ``remote patient monitoring services''
means services furnished through remote patient
monitoring technology.
(ii) Remote patient monitoring
technology.--The term ``remote patient
monitoring technology'' means a coordinated
system that uses one or more home-based or
mobile monitoring devices that automatically
transmit vital sign data or information on
activities of daily living and may include
responses to assessment questions collected on
the devices wirelessly or through a
telecommunications connection to a server that
complies with 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, as
part of an established plan of care for that
patient that includes the review and
interpretation of that data by a health care
professional.
(3) Reports.--Not later than 24 months after the date of
the enactment of this Act, the Comptroller General shall submit
to Congress--
(A) a report containing the results of the study
conducted under paragraph (1); and
(B) a report containing the results of the study
conducted under paragraph (2).
A report required under this paragraph shall be submitted
together with recommendations for such legislation and
administrative action as the Comptroller General determines
appropriate. The Comptroller General may submit one report
containing the results described in subparagraphs (A) and (B)
and the recommendations described in the previous sentence.
(d) Rule of Construction Regarding Health Care Providers.--
(1) In general.--Subject to paragraph (3), the development,
recognition, or implementation of any guideline or other
standard under any Federal health care provision shall not be
construed to establish the standard of care or duty of care
owed by a health care provider to a patient in any medical
malpractice or medical product liability action or claim.
(2) Definitions.--For purposes of this subsection:
(A) Federal health care provision.--The term
``Federal health care provision'' means any provision
of the Patient Protection and Affordable Care Act
(Public Law 111-148), title I or subtitle B of title II
of the Health Care and Education Reconciliation Act of
2010 (Public Law 111-152), or title XVIII or XIX of the
Social Security Act (42 U.S.C. 1395 et seq., 42 U.S.C.
1396 et seq.).
(B) Health care provider.--The term ``health care
provider'' means any individual, group practice,
corporation of health care professionals, or hospital--
(i) licensed, registered, or certified
under Federal or State laws or regulations to
provide health care services; or
(ii) required to be so licensed,
registered, or certified but that is exempted
by other statute or regulation.
(C) Medical malpractice or medical product
liability action or claim.--The term ``medical
malpractice or medical product liability action or
claim'' means a medical malpractice action or claim (as
defined in section 431(7) of the Health Care Quality
Improvement Act of 1986 (42 U.S.C. 11151(7))) and
includes a liability action or claim relating to a
health care provider's prescription or provision of a
drug, device, or biological product (as such terms are
defined in section 201 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 321) or section 351 of the
Public Health Service Act (42 U.S.C. 262)).
(D) State.--The term ``State'' includes the
District of Columbia, Puerto Rico, and any other
commonwealth, possession, or territory of the United
States.
(3) No preemption.--Nothing in paragraph (1) or any
provision of the Patient Protection and Affordable Care Act
(Public Law 111-148), title I or subtitle B of title II of the
Health Care and Education Reconciliation Act of 2010 (Public
Law 111-152), or title XVIII or XIX of the Social Security Act
(42 U.S.C. 1395 et seq., 42 U.S.C. 1396 et seq.) shall be
construed to preempt any State or common law governing medical
professional or medical product liability actions or claims.
TITLE II--MEDICARE AND OTHER HEALTH EXTENDERS
Subtitle A--Medicare Extenders
SEC. 201. EXTENSION OF WORK GPCI FLOOR.
Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)(E)) is amended by striking ``April 1, 2015'' and inserting
``January 1, 2018''.
SEC. 202. EXTENSION OF THERAPY CAP EXCEPTIONS PROCESS.
(a) In General.--Section 1833(g) of the Social Security Act (42
U.S.C. 1395l(g)) is amended--
(1) in paragraph (5)(A), in the first sentence, by striking
``March 31, 2015'' and inserting ``December 31, 2017''; and
(2) in paragraph (6)(A)--
(A) by striking ``March 31, 2015'' and inserting
``December 31, 2017''; and
(B) by striking ``2012, 2013, 2014, or the first
three months of 2015'' and inserting ``2012 through
2017''.
(b) Targeted Reviews Under Manual Medical Review Process for
Outpatient Therapy Services.--
(1) In general.--Section 1833(g)(5) of the Social Security
Act (42 U.S.C. 1395l(g)(5)) is amended--
(A) in subparagraph (C)(i), by inserting ``,
subject to subparagraph (E),'' after ``manual medical
review process that''; and
(B) by adding at the end the following new
subparagraph:
``(E)(i) In place of the manual medical review process under
subparagraph (C)(i), the Secretary shall implement a process for
medical review under this subparagraph under which the Secretary shall
identify and conduct medical review for services described in
subparagraph (C)(i) furnished by a provider of services or supplier (in
this subparagraph referred to as a `therapy provider') using such
factors as the Secretary determines to be appropriate.
``(ii) Such factors may include the following:
``(I) The therapy provider has had a high claims denial
percentage for therapy services under this part or is less
compliant with applicable requirements under this title.
``(II) The therapy provider has a pattern of billing for
therapy services under this part that is aberrant compared to
peers or otherwise has questionable billing practices for such
services, such as billing medically unlikely units of services
in a day.
``(III) The therapy provider is newly enrolled under this
title or has not previously furnished therapy services under
this part.
``(IV) The services are furnished to treat a type of
medical condition.
``(V) The therapy provider is part of group that includes
another therapy provider identified using the factors
determined under this subparagraph.
``(iii) For purposes of carrying out this subparagraph, the
Secretary shall provide for the transfer, from the Federal
Supplementary Medical Insurance Trust Fund under section 1841, of
$5,000,000 to the Centers for Medicare & Medicaid Services Program
Management Account for fiscal years 2015 and 2016, to remain available
until expended. Such funds may not be used by a contractor under
section 1893(h) for medical reviews under this subparagraph.
``(iv) The targeted review process under this subparagraph shall
not apply to services for which expenses are incurred beyond the period
for which the exceptions process under subparagraph (A) is
implemented.''.
(2) Effective date.--The amendments made by this subsection
shall apply with respect to requests described in section
1833(g)(5)(C)(i) of the Social Security Act (42 U.S.C.
1395l(g)(5)(C)(i)) with respect to which the Secretary of
Health and Human Services has not conducted medical review
under such section by a date (not later than 90 days after the
date of the enactment of this Act) specified by the Secretary.
SEC. 203. EXTENSION OF AMBULANCE ADD-ONS.
(a) Ground Ambulance.--Section 1834(l)(13)(A) of the Social
Security Act (42 U.S.C. 1395m(l)(13)(A)) is amended by striking ``April
1, 2015'' and inserting ``January 1, 2018'' each place it appears.
(b) Super Rural Ground Ambulance.--Section 1834(l)(12)(A) of the
Social Security Act (42 U.S.C. 1395m(l)(12)(A)) is amended, in the
first sentence, by striking ``April 1, 2015'' and inserting ``January
1, 2018''.
SEC. 204. EXTENSION OF INCREASED INPATIENT HOSPITAL PAYMENT ADJUSTMENT
FOR CERTAIN LOW-VOLUME HOSPITALS.
Section 1886(d)(12) of the Social Security Act (42 U.S.C.
1395ww(d)(12)) is amended--
(1) in subparagraph (B), in the matter preceding clause
(i), by striking ``in fiscal year 2015 (beginning on April 1,
2015), fiscal year 2016, and subsequent fiscal years'' and
inserting ``in fiscal year 2018 and subsequent fiscal years'';
(2) in subparagraph (C)(i), by striking ``fiscal years 2011
through 2014 and fiscal year 2015 (before April 1, 2015),'' and
inserting ``fiscal years 2011 through 2017,'' each place it
appears; and
(3) in subparagraph (D), by striking ``fiscal years 2011
through 2014 and fiscal year 2015 (before April 1, 2015),'' and
inserting ``fiscal years 2011 through 2017,''.
SEC. 205. EXTENSION OF THE MEDICARE-DEPENDENT HOSPITAL (MDH) PROGRAM.
(a) In General.--Section 1886(d)(5)(G) of the Social Security Act
(42 U.S.C. 1395ww(d)(5)(G)) is amended--
(1) in clause (i), by striking ``April 1, 2015'' and
inserting ``October 1, 2017''; and
(2) in clause (ii)(II), by striking ``April 1, 2015'' and
inserting ``October 1, 2017''.
(b) Conforming Amendments.--
(1) Extension of target amount.--Section 1886(b)(3)(D) of
the Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is
amended--
(A) in the matter preceding clause (i), by striking
``April 1, 2015'' and inserting ``October 1, 2017'';
and
(B) in clause (iv), by striking ``through fiscal
year 2014 and the portion of fiscal year 2015 before
April 1, 2015'' and inserting ``through fiscal year
2017''.
(2) Permitting hospitals to decline reclassification.--
Section 13501(e)(2) of the Omnibus Budget Reconciliation Act of
1993 (42 U.S.C. 1395ww note) is amended by striking ``through
the first 2 quarters of fiscal year 2015'' and inserting
``through fiscal year 2017''.
SEC. 206. EXTENSION FOR SPECIALIZED MEDICARE ADVANTAGE PLANS FOR
SPECIAL NEEDS INDIVIDUALS.
Section 1859(f)(1) of the Social Security Act (42 U.S.C. 1395w-
28(f)(1)) is amended by striking ``2017'' and inserting ``2019''.
SEC. 207. EXTENSION OF FUNDING FOR QUALITY MEASURE ENDORSEMENT, INPUT,
AND SELECTION.
Section 1890(d)(2) of the Social Security Act (42 U.S.C.
1395aaa(d)(2)) is amended by striking ``and $15,000,000 for the first 6
months of fiscal year 2015'' and inserting ``and $30,000,000 for each
of fiscal years 2015 through 2017''.
SEC. 208. EXTENSION OF FUNDING OUTREACH AND ASSISTANCE FOR LOW-INCOME
PROGRAMS.
(a) Additional Funding for State Health Insurance Programs.--
Subsection (a)(1)(B) of section 119 of the Medicare Improvements for
Patients and Providers Act of 2008 (42 U.S.C. 1395b-3 note), as amended
by section 3306 of the Patient Protection and Affordable Care Act
(Public Law 111-148), section 610 of the American Taxpayer Relief Act
of 2012 (Public Law 112-240), section 1110 of the Pathway for SGR
Reform Act of 2013 (Public Law 113-67), and section 110 of the
Protecting Access to Medicare Act of 2014 (Public Law 113-93), is
amended--
(1) in clause (iv), by striking ``and'' at the end;
(2) by striking clause (v); and
(3) by adding at the end the following new clauses:
``(v) for fiscal year 2015, of $7,500,000;
``(vi) for fiscal year 2016, of
$13,000,000; and
``(vii) for fiscal year 2017, of
$13,000,000.''.
(b) Additional Funding for Area Agencies on Aging.--Subsection
(b)(1)(B) of such section 119, as so amended, is amended--
(1) in clause (iv), by striking ``and'' at the end;
(2) by striking clause (v); and
(3) by inserting after clause (iv) the following new
clauses:
``(v) for fiscal year 2015, of $7,500,000;
``(vi) for fiscal year 2016, of $7,500,000;
and
``(vii) for fiscal year 2017, of
$7,500,000.''.
(c) Additional Funding for Aging and Disability Resource Centers.--
Subsection (c)(1)(B) of such section 119, as so amended, is amended--
(1) in clause (iv), by striking ``and'' at the end;
(2) by striking clause (v); and
(3) by inserting after clause (iv) the following new
clauses:
``(v) for fiscal year 2015, of $5,000,000;
``(vi) for fiscal year 2016, of $5,000,000;
and
``(vii) for fiscal year 2017, of
$5,000,000.''.
(d) Additional Funding for Contract With the National Center for
Benefits and Outreach Enrollment.--Subsection (d)(2) of such section
119, as so amended, is amended--
(1) in clause (iv), by striking ``and'' at the end;
(2) by striking clause (v); and
(3) by inserting after clause (iv) the following new
clauses:
``(v) for fiscal year 2015, of $5,000,000;
``(vi) for fiscal year 2016, of
$12,000,000; and
``(vii) for fiscal year 2017, of
$12,000,000.''.
SEC. 209. EXTENSION AND TRANSITION OF REASONABLE COST REIMBURSEMENT
CONTRACTS.
(a) One-Year Transition and Notice Regarding Transition.--Section
1876(h)(5)(C) of the Social Security Act (42 U.S.C. 1395mm(h)(5)(C)) is
amended--
(1) in clause (ii), in the matter preceding subclause (I),
by striking ``For any'' and inserting ``Subject to clause (iv),
for any'';
(2) in clause (iii)(I), by inserting ``cost plan service''
after ``With respect to any portion of the'';
(3) in clause (iii)(II), by inserting ``cost plan service''
after ``With respect to any other portion of such''; and
(4) by adding at the end the following new clauses:
``(iv) In the case of an eligible organization that is offering a
reasonable cost reimbursement contract that may no longer be extended
or renewed because of the application of clause (ii), or where such
contract has been extended or renewed but the eligible organization has
informed the Secretary in writing not later than a date determined
appropriate by the Secretary that such organization voluntarily plans
not to seek renewal of the reasonable cost reimbursement contract, the
following shall apply:
``(I) Notwithstanding such clause, such contract may be
extended or renewed for the two years subsequent to 2016. The
final year in which such contract is extended or renewed is
referred to in this subsection as the `last reasonable cost
reimbursement contract year for the contract'.
``(II) The organization may not enroll a new enrollee under
such contract during the last reasonable cost reimbursement
contract year for the contract (but may continue to enroll new
enrollees through the end of the year immediately preceding
such year) unless such enrollee is any of the following:
``(aa) An individual who chooses enrollment in the
reasonable cost contract during the annual election
period with respect to such last year.
``(bb) An individual whose spouse, at the time of
the individual's enrollment is an enrollee under the
reasonable cost reimbursement contract.
``(cc) An individual who is covered under an
employer group health plan that offers coverage through
the reasonable cost reimbursement contract.
``(dd) An individual who becomes entitled to
benefits under part A, or enrolled under part B, and
was enrolled in a plan offered by the eligible
organization immediately prior to the individual's
enrollment under the reasonable cost reimbursement
contract.
``(III) Not later than a date determined appropriate by the
Secretary prior to the beginning of the last reasonable cost
reimbursement contract year for the contract, the organization
shall provide notice to the Secretary as to whether the
organization will apply to have the contract converted over, in
whole or in part, and offered as a Medicare Advantage plan
under part C for the year following the last reasonable cost
reimbursement contract year for the contract.
``(IV) If the organization provides the notice described in
subclause (III) that the contract will be converted, in whole
or in part, the organization shall, not later than a date
determined appropriate by the Secretary, provide the Secretary
with such information as the Secretary determines appropriate
in order to carry out section 1851(c)(4) and to carry out
section 1854(a)(5), including subparagraph (C)(ii) of such
section.
``(V) In the case that the organization enrolls a new
enrollee under such contract during the last reasonable cost
reimbursement contract year for the contract, the organization
shall provide the individual with a notification that such year
is the last year for such contract.
``(v) If an eligible organization that is offering a reasonable
cost reimbursement contract that is extended or renewed pursuant to
clause (iv) provides the notice described in clause (iv)(III) that the
contract will be converted, in whole or in part, the following shall
apply:
``(I) The deemed enrollment under section 1851(c)(4).
``(II) The special rule for quality increase under section
1853(o)(4)(C).
``(III) During the last reasonable cost reimbursement
contract year for the contract and the year immediately
preceding such year, the eligible organization, or the
corporate parent organization of the eligible organization,
shall be permitted to offer an MA plan in the area that such
contract is being offered and enroll Medicare Advantage
eligible individuals in such MA plan and such cost plan.''.
(b) Deemed Enrollment From Reasonable Cost Reimbursement Contracts
Converted to Medicare Advantage Plans.--
(1) In general.--Section 1851(c) of the Social Security Act
(42 U.S.C. 1395w-21(c)) is amended--
(A) in paragraph (1), by striking ``Such
elections'' and inserting ``Subject to paragraph (4),
such elections''; and
(B) by adding at the end the following:
``(4) Deemed enrollment relating to converted reasonable
cost reimbursement contracts.--
``(A) In general.--On the first day of the annual,
coordinated election period under subsection (e)(3) for
plan years beginning on or after January 1, 2017, an MA
eligible individual described in clause (i) or (ii) of
subparagraph (B) is deemed, unless the individual
elects otherwise, to have elected to receive benefits
under this title through an applicable MA plan (and
shall be enrolled in such plan) beginning with such
plan year, if--
``(i) the individual is enrolled in a
reasonable cost reimbursement contract under
section 1876(h) in the previous plan year;
``(ii) such reasonable cost reimbursement
contract was extended or renewed for the last
reasonable cost reimbursement contract year of
the contract (as described in subclause (I) of
section 1876(h)(5)(C)(iv)) pursuant to such
section;
``(iii) the eligible organization that is
offering such reasonable cost reimbursement
contract provided the notice described in
subclause (III) of such section that the
contract was to be converted;
``(iv) the applicable MA plan--
``(I) is the plan that was
converted from the reasonable cost
reimbursement contract described in
clause (iii);
``(II) is offered by the same
entity (or an organization affiliated
with such entity that has a common
ownership interest of control) that
entered into such contract; and
``(III) is offered in the service
area where the individual resides;
``(v) in the case of reasonable cost
reimbursement contracts that provide coverage
under parts A and B (and, to the extent the
Secretary determines it to be feasible,
contracts that provide only part B coverage),
the difference between the estimated individual
costs (as determined applicable by the
Secretary) for the applicable MA plan and such
costs for the predecessor cost plan does not
exceed a threshold established by the
Secretary; and
``(vi) the applicable MA plan--
``(I) provides coverage for
enrollees transitioning from the
converted reasonable cost reimbursement
contract to such plan to maintain
current providers of services and
suppliers and course of treatment at
the time of enrollment for a period of
at least 90 days after enrollment; and
``(II) during such period, pays
such providers of services and
suppliers for items and services
furnished to the enrollee an amount
that is not less than the amount of
payment applicable for such items and
services under the original Medicare
fee-for-service program under parts A
and B.
``(B) MA eligible individuals described.--
``(i) Without prescription drug coverage.--
An MA eligible individual described in this
clause, with respect to a plan year, is an MA
eligible individual who is enrolled in a
reasonable cost reimbursement contract under
section 1876(h) in the previous plan year and
who is not, for such previous plan year,
enrolled in a prescription drug plan under part
D, including coverage under section 1860D-22.
``(ii) With prescription drug coverage.--An
MA eligible individual described in this
clause, with respect to a plan year, is an MA
eligible individual who is enrolled in a
reasonable cost reimbursement contract under
section 1876(h) in the previous plan year and
who, for such previous plan year, is enrolled
in a prescription drug plan under part D--
``(I) through such contract; or
``(II) through a prescription drug
plan, if the sponsor of such plan is
the same entity (or an organization
affiliated with such entity) that
entered into such contract.
``(C) Applicable ma plan defined.--In this
paragraph, the term `applicable MA plan' means, in the
case of an individual described in--
``(i) subparagraph (B)(i), an MA plan that
is not an MA-PD plan; and
``(ii) subparagraph (B)(ii), an MA-PD plan.
``(D) Identification and notification of deemed
individuals.--Not later than 45 days before the first
day of the annual, coordinated election period under
subsection (e)(3) for plan years beginning on or after
January 1, 2017, the Secretary shall identify and
notify the individuals who will be subject to deemed
elections under subparagraph (A) on the first day of
such period.''.
(2) Beneficiary option to discontinue or change ma plan or
ma-pd plan after deemed enrollment.--
(A) In general.--Section 1851(e)(2) of the Social
Security Act (42 U.S.C. 1395w-21(e)(4)) is amended by
adding at the end the following:
``(F) Special period for certain deemed
elections.--
``(i) In general.--At any time during the
period beginning after the last day of the
annual, coordinated election period under
paragraph (3) in which an individual is deemed
to have elected to enroll in an MA plan or MA-
PD plan under subsection (c)(4) and ending on
the last day of February of the first plan year
for which the individual is enrolled in such
plan, such individual may change the election
under subsection (a)(1) (including changing the
MA plan or MA-PD plan in which the individual
is enrolled).
``(ii) Limitation of one change.--An
individual may exercise the right under clause
(i) only once during the applicable period
described in such clause. The limitation under
this clause shall not apply to changes in
elections effected during an annual,
coordinated election period under paragraph (3)
or during a special enrollment period under
paragraph (4).''.
(B) Conforming amendments.--
(i) Plan requirement for open enrollment.--
Section 1851(e)(6)(A) of the Social Security
Act (42 U.S.C. 1395w-21(e)(6)(A)) is amended by
striking ``paragraph (1),'' and inserting
``paragraph (1), during the period described in
paragraph (2)(F),''.
(ii) Part d.--Section 1860D-1(b)(1)(B) of
such Act (42 U.S.C. 1395w-101(b)(1)(B)) is
amended--
(I) in clause (ii), by adding ``and
paragraph (4)'' after ``paragraph
(3)(A)''; and
(II) in clause (iii) by striking
``and (E)'' and inserting ``(E), and
(F)''.
(3) Treatment of esrd for deemed enrollment.--Section
1851(a)(3)(B) of the Social Security Act (42 U.S.C. 1395w-
21(a)(3)(B)) is amended by adding at the end the following
flush sentence: ``An individual who develops end-stage renal
disease while enrolled in a reasonable cost reimbursement
contract under section 1876(h) shall be treated as an MA
eligible individual for purposes of applying the deemed
enrollment under subsection (c)(4).''.
(c) Information Requirements.--Section 1851(d)(2)(B) of the Social
Security Act (42 U.S.C. 1395w-21(d)(2)(B)) is amended--
(1) in the heading, by striking ``Notification to newly
eligible medicare advantage eligible individuals'' and
inserting the following: ``Notifications required.--
``(i) Notification to newly eligible
medicare advantage eligible individuals.--'';
and
(2) by adding at the end the following new clause:
``(ii) Notification related to certain
deemed elections.--The Secretary shall require
a Medicare Advantage organization that is
offering a Medicare Advantage plan that has
been converted from a reasonable cost
reimbursement contract pursuant to section
1876(h)(5)(C)(iv) to mail, not later than 30
days prior to the first day of the annual,
coordinated election period under subsection
(e)(3) of a year, to any individual enrolled
under such contract and identified by the
Secretary under subsection (c)(4)(D) for such
year--
``(I) a notification that such
individual will, on such day, be deemed
to have made an election with respect
to such plan to receive benefits under
this title through an MA plan or MA-PD
plan (and shall be enrolled in such
plan) for the next plan year under
subsection (c)(4)(A), but that the
individual may make a different
election during the annual, coordinated
election period for such year;
``(II) the information described in
subparagraph (A);
``(III) a description of the
differences between such MA plan or MA-
PD plan and the reasonable cost
reimbursement contract in which the
individual was most recently enrolled
with respect to benefits covered under
such plans, including cost-sharing,
premiums, drug coverage, and provider
networks;
``(IV) information about the
special period for elections under
subsection (e)(2)(F); and
``(V) other information the
Secretary may specify.''.
(d) Treatment of Transition Plan for Quality Rating for Payment
Purposes.--Section 1853(o)(4) of the Social Security Act (42 U.S.C.
1395w-23(o)(4)) is amended by adding at the end the following new
subparagraph:
``(C) Special rule for first 3 plan years for plans
that were converted from a reasonable cost
reimbursement contract.--For purposes of applying
paragraph (1) and section 1854(b)(1)(C) for the first 3
plan years under this part in the case of an MA plan to
which deemed enrollment applies under section
1851(c)(4)--
``(i) such plan shall not be treated as a
new MA plan (as defined in paragraph
(3)(A)(iii)(II)); and
``(ii) in determining the star rating of
the plan under subparagraph (A), to the extent
that Medicare Advantage data for such plan is
not available for a measure used to determine
such star rating, the Secretary shall use data
from the period in which such plan was a
reasonable cost reimbursement contract.''.
SEC. 210. EXTENSION OF HOME HEALTH RURAL ADD-ON.
Section 421(a) of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2283; 42
U.S.C. 1395fff note), as amended by section 5201(b) of the Deficit
Reduction Act of 2005 (Public Law 109-171; 120 Stat. 46) and by section
3131(c) of the Patient Protection and Affordable Care Act (Public Law
111-148; 124 Stat. 428), is amended by striking ``January 1, 2016'' and
inserting ``January 1, 2018'' each place it appears.
Subtitle B--Other Health Extenders
SEC. 211. PERMANENT EXTENSION OF THE QUALIFYING INDIVIDUAL (QI)
PROGRAM.
(a) Permanent Extension.--Section 1902(a)(10)(E)(iv) of the Social
Security Act (42 U.S.C. 1396a(a)(10)(E)(iv)) is amended by striking
``(but only for premiums payable with respect to months during the
period beginning with January 1998, and ending with March 2015)''.
(b) Allocations.--Section 1933(g) of the Social Security Act (42
U.S.C. 1396u-3(g)) is amended--
(1) in paragraph (2)--
(A) by striking subparagraphs (A) through (H);
(B) in subparagraph (V), by striking ``and'' at the
end;
(C) in subparagraph (W), by striking the period at
the end and inserting a semicolon;
(D) by redesignating subparagraphs (I) through (W)
as subparagraphs (A) through (O), respectively; and
(E) by adding at the end the following new
subparagraphs:
``(P) for the period that begins on April 1, 2015,
and ends on December 31, 2015, the total allocation
amount is $535,000,000; and
``(Q) for 2016 and, subject to paragraph (4), for
each subsequent year, the total allocation amount is
$980,000,000.'';
(2) in paragraph (3), by striking ``(P), (R), (T), or (V)''
and inserting ``or (P)''; and
(3) by adding at the end the following new paragraph:
``(4) Adjustment to allocations.--The Secretary may
increase the allocation amount under paragraph (2)(Q) for a
year (beginning with 2017) up to an amount that does not exceed
the product of the following:
``(A) Maximum allocation amount for previous
year.--In the case of 2017, the allocation amount for
2016, or in the case of a subsequent year, the maximum
allocation amount allowed under this paragraph for the
previous year.
``(B) Increase in part b premium.--The monthly
premium rate determined under section 1839 for the year
divided by the monthly premium rate determined under
such section for the previous year.
``(C) Increase in part b enrollment.--The average
number of individuals (as estimated by the Chief
Actuary of the Centers for Medicare & Medicaid Services
in September of the previous year) to be enrolled under
part B of title XVIII for months in the year divided by
the average number of such individuals (as so
estimated) under this subparagraph with respect to
enrollments in months in the previous year.''.
SEC. 212. PERMANENT EXTENSION OF TRANSITIONAL MEDICAL ASSISTANCE (TMA).
(a) In General.--Section 1925 of the Social Security Act (42 U.S.C.
1396r-6) is amended--
(1) by striking subsection (f); and
(2) by redesignating subsection (g) as subsection (f).
(b) Conforming Amendment.--Section 1902(e)(1) of the Social
Security Act (42 U.S.C. 1396a(e)(1)) is amended to read as follows:
``(1) Beginning April 1, 1990, for provisions relating to the
extension of eligibility for medical assistance for certain families
who have received aid pursuant to a State plan approved under part A of
title IV and have earned income, see section 1925.''.
SEC. 213. EXTENSION OF SPECIAL DIABETES PROGRAM FOR TYPE I DIABETES AND
FOR INDIANS.
(a) Special Diabetes Programs for Type I Diabetes.--Section
330B(b)(2)(C) of the Public Health Service Act (42 U.S.C. 254c-
2(b)(2)(C)) is amended by striking ``2015'' and inserting ``2017''.
(b) Special Diabetes Programs for Indians.--Section 330C(c)(2)(C)
of the Public Health Service Act (42 U.S.C. 254c-3(c)(2)(C)) is amended
by striking ``2015'' and inserting ``2017''.
SEC. 214. EXTENSION OF ABSTINENCE EDUCATION.
(a) In General.--Section 510 of the Social Security Act (42 U.S.C.
710) is amended--
(1) in subsection (a), striking ``2015'' and inserting
``2017''; and
(2) in subsection (d), by inserting ``and an additional
$75,000,000 for each of fiscal years 2016 and 2017'' after
``2015''.
(b) Budget Scoring.--Notwithstanding section 257(b)(2) of the
Balanced Budget and Emergency Deficit Control Act of 1985, the baseline
shall be calculated assuming that no grant shall be made under section
510 of the Social Security Act (42 U.S.C. 710) after fiscal year 2017.
(c) Reallocation of Unused Funding.--The remaining unobligated
balances of the amount appropriated for fiscal years 2016 and 2017 by
section 510(d) of the Social Security Act (42 U.S.C. 710(d)) for which
no application has been received by the Funding Opportunity
Announcement deadline, shall be made available to States that require
the implementation of each element described in subparagraphs (A)
through (H) of the definition of abstinence education in section
510(b)(2). The remaining unobligated balances shall be reallocated to
such States that submit a valid application consistent with the
original formula for this funding.
SEC. 215. EXTENSION OF PERSONAL RESPONSIBILITY EDUCATION PROGRAM
(PREP).
Section 513 of the Social Security Act (42 U.S.C. 713) is amended--
(1) in paragraphs (1)(A) and (4)(A) of subsection (a), by
striking ``2015'' and inserting ``2017'' each place it appears;
(2) in subsection (a)(4)(B)(i), by striking ``, 2013, 2014,
and 2015'' and inserting ``through 2017''; and
(3) in subsection (f), by striking ``2015'' and inserting
``2017''.
SEC. 216. EXTENSION OF FUNDING FOR FAMILY-TO-FAMILY HEALTH INFORMATION
CENTERS.
Section 501(c)(1)(A) of the Social Security Act (42 U.S.C.
701(c)(1)(A)) is amended--
(1) by striking clause (vi); and
(2) by adding after clause (v) the following new clause:
``(vi) $5,000,000 for each of fiscal years 2015 through
2017.''.
SEC. 217. EXTENSION OF HEALTH WORKFORCE DEMONSTRATION PROJECT FOR LOW-
INCOME INDIVIDUALS.
Section 2008(c)(1) of the Social Security Act (42 U.S.C.
1397g(c)(1)) is amended by striking ``2015'' and inserting ``2017''.
SEC. 218. EXTENSION OF MATERNAL, INFANT, AND EARLY CHILDHOOD HOME
VISITING PROGRAMS.
Section 511(j)(1) of the Social Security Act (42 U.S.C. 711(j)) is
amended--
(1) by striking ``and'' at the end of subparagraph (E);
(2) in subparagraph (F)--
(A) by striking ``for the period beginning on
October 1, 2014, and ending on March 31, 2015'' and
inserting ``for fiscal year 2015'';
(B) by striking ``an amount equal to the amount
provided in subparagraph (E)'' and inserting
``$400,000,000''; and
(C) by striking the period at the end and inserting
a semicolon; and
(3) by adding at the end the following new subparagraphs:
``(G) for fiscal year 2016, $400,000,000; and
``(H) for fiscal year 2017, $400,000,000.''.
SEC. 219. TENNESSEE DSH ALLOTMENT FOR FISCAL YEARS 2015 THROUGH 2025.
Section 1923(f)(6)(A) of the Social Security Act (42 U.S.C. 1396r-
4(f)(6)(A)) is amended by adding at the end the following:
``(vi) Allotment for fiscal years 2015
through 2025.--Notwithstanding any other
provision of this subsection, any other
provision of law, or the terms of the TennCare
Demonstration Project in effect for the State,
the DSH allotment for Tennessee for fiscal year
2015, and for each fiscal year thereafter
through fiscal year 2025, shall be $53,100,000
for each such fiscal year.''.
SEC. 220. DELAY IN EFFECTIVE DATE FOR MEDICAID AMENDMENTS RELATING TO
BENEFICIARY LIABILITY SETTLEMENTS.
Section 202(c) of the Bipartisan Budget Act of 2013 (division A of
Public Law 113-67; 42 U.S.C. 1396a note), as amended by section 211 of
the Protecting Access to Medicare Act of 2014 (Public Law 113-93; 128
Stat. 1047) is amended by striking ``October 1, 2016'' and inserting
``October 1, 2017''.
SEC. 221. EXTENSION OF FUNDING FOR COMMUNITY HEALTH CENTERS, THE
NATIONAL HEALTH SERVICE CORPS, AND TEACHING HEALTH
CENTERS.
(a) Funding for Community Health Centers and the National Health
Service Corps.--
(1) Community health centers.--Section 10503(b)(1)(E) of
the Patient Protection and Affordable Care Act (42 U.S.C. 254b-
2(b)(1)(E)) is amended by striking ``for fiscal year 2015'' and
inserting ``for each of fiscal years 2015 through 2017''.
(2) National health service corps.--Section 10503(b)(2)(E)
of the Patient Protection and Affordable Care Act (42 U.S.C.
254b-2(b)(2)(E)) is amended by striking ``for fiscal year
2015'' and inserting ``for each of fiscal years 2015 through
2017''.
(b) Extension of Teaching Health Centers Program.--Section 340H(g)
of the Public Health Service Act (42 U.S.C. 256h(g)) is amended by
inserting ``and $60,000,000 for each of fiscal years 2016 and 2017''
before the period at the end.
(c) Application.--Amounts appropriated pursuant to this section for
fiscal year 2016 and fiscal year 2017 are subject to the requirements
contained in Public Law 113-235 for funds for programs authorized under
sections 330 through 340 of the Public Health Service Act (42 U.S.C.
254b-256).
TITLE III--CHIP
SEC. 301. 2-YEAR EXTENSION OF THE CHILDREN'S HEALTH INSURANCE PROGRAM.
(a) Funding.--Section 2104(a) of the Social Security Act (42 U.S.C.
1397dd(a)) is amended--
(1) in paragraph (17), by striking ``and'' at the end;
(2) in paragraph (18)(B), by striking the period at the end
and inserting a semicolon; and
(3) by adding at the end the following new paragraphs:
``(19) for fiscal year 2016, $19,300,000,000; and
``(20) for fiscal year 2017, for purposes of making 2 semi-
annual allotments--
``(A) $2,850,000,000 for the period beginning on
October 1, 2016, and ending on March 31, 2017; and
``(B) $2,850,000,000 for the period beginning on
April 1, 2017, and ending on September 30, 2017.''.
(b) Allotments.--
(1) In general.--Section 2104(m) of the Social Security Act
(42 U.S.C. 1397dd(m)) is amended--
(A) in the subsection heading, by striking
``Through 2015'' and inserting ``and Thereafter'';
(B) in paragraph (2)--
(i) in the paragraph heading, by striking
``2014'' and inserting ``2016''; and
(ii) by striking subparagraph (B) and
inserting the following new subparagraph:
``(B) Fiscal year 2013 and each succeeding fiscal
year.--Subject to paragraphs (5) and (7), from the
amount made available under paragraphs (16) through
(19) of subsection (a) for fiscal year 2013 and each
succeeding fiscal year, respectively, the Secretary
shall compute a State allotment for each State
(including the District of Columbia and each
commonwealth and territory) for each such fiscal year
as follows:
``(i) Rebasing in fiscal year 2013 and each
succeeding odd-numbered fiscal year.--For
fiscal year 2013 and each succeeding odd-
numbered fiscal year (other than fiscal years
2015 and 2017), the allotment of the State is
equal to the Federal payments to the State that
are attributable to (and countable toward) the
total amount of allotments available under this
section to the State in the preceding fiscal
year (including payments made to the State
under subsection (n) for such preceding fiscal
year as well as amounts redistributed to the
State in such preceding fiscal year),
multiplied by the allotment increase factor
under paragraph (6) for such odd-numbered
fiscal year.
``(ii) Growth factor update for fiscal year
2014 and each succeeding even-numbered fiscal
year.--Except as provided in clauses (iii) and
(iv), for fiscal year 2014 and each succeeding
even-numbered fiscal year, the allotment of the
State is equal to the sum of--
``(I) the amount of the State
allotment under clause (i) for the
preceding fiscal year; and
``(II) the amount of any payments
made to the State under subsection (n)
for such preceding fiscal year,
multiplied by the allotment increase factor
under paragraph (6) for such even-numbered
fiscal year.
``(iii) Special rule for 2016.--For fiscal
year 2016, the allotment of the State is equal
to the Federal payments to the State that are
attributable to (and countable toward) the
total amount of allotments available under this
section to the State in the preceding fiscal
year (including payments made to the State
under subsection (n) for such preceding fiscal
year as well as amounts redistributed to the
State in such preceding fiscal year), but
determined as if the last two sentences of
section 2105(b) were in effect in such
preceding fiscal year and then multiplying the
result by the allotment increase factor under
paragraph (6) for fiscal year 2016.
``(iv) Reduction in 2018.--For fiscal year
2018, with respect to the allotment of the
State for fiscal year 2017, any amounts of such
allotment that remain available for expenditure
by the State in fiscal year 2018 shall be
reduced by one-third.'';
(C) in paragraph (4), by inserting ``or 2017''
after ``2015'';
(D) in paragraph (6)--
(i) in subparagraph (A), by striking
``2015'' and inserting ``2017''; and
(ii) in the second sentence, by striking
``or fiscal year 2014'' and inserting ``fiscal
year 2014, or fiscal year 2016'';
(E) in paragraph (8)--
(i) in the paragraph heading, by striking
``fiscal year 2015'' and inserting ``fiscal
years 2015 and 2017''; and
(ii) by inserting ``or fiscal year 2017''
after ``2015'';
(F) by redesignating paragraphs (4) through (8) as
paragraphs (5) through (9), respectively; and
(G) by inserting after paragraph (3) the following
new paragraph:
``(4) For fiscal year 2017.--
``(A) First half.--Subject to paragraphs (5) and
(7), from the amount made available under subparagraph
(A) of paragraph (20) of subsection (a) for the semi-
annual period described in such paragraph, increased by
the amount of the appropriation for such period under
section 301(b)(3) of the Medicare Access and CHIP
Reauthorization Act of 2015, the Secretary shall
compute a State allotment for each State (including the
District of Columbia and each commonwealth and
territory) for such semi-annual period in an amount
equal to the first half ratio (described in
subparagraph (D)) of the amount described in
subparagraph (C).
``(B) Second half.--Subject to paragraphs (5) and
(7), from the amount made available under subparagraph
(B) of paragraph (20) of subsection (a) for the semi-
annual period described in such paragraph, the
Secretary shall compute a State allotment for each
State (including the District of Columbia and each
commonwealth and territory) for such semi-annual period
in an amount equal to the amount made available under
such subparagraph, multiplied by the ratio of--
``(i) the amount of the allotment to such
State under subparagraph (A); to
``(ii) the total of the amount of all of
the allotments made available under such
subparagraph.
``(C) Full year amount based on rebased amount.--
The amount described in this subparagraph for a State
is equal to the Federal payments to the State that are
attributable to (and countable towards) the total
amount of allotments available under this section to
the State in fiscal year 2016 (including payments made
to the State under subsection (n) for fiscal year 2016
as well as amounts redistributed to the State in fiscal
year 2016), multiplied by the allotment increase factor
under paragraph (6) for fiscal year 2017.
``(D) First half ratio.--The first half ratio
described in this subparagraph is the ratio of--
``(i) the sum of--
``(I) the amount made available
under subsection (a)(20)(A); and
``(II) the amount of the
appropriation for such period under
section 301(b)(3) of the Medicare
Access and CHIP Reauthorization Act of
2015; to
``(ii) the sum of the--
``(I) amount described in clause
(i); and
``(II) the amount made available
under subsection (a)(20)(B).''.
(2) Conforming amendments.--
(A) Section 2104(c)(1) of the Social Security Act
(42 U.S.C. 1397dd(c)(1)) is amended by striking
``(m)(4)'' and inserting ``(m)(5)''.
(B) Section 2104(m) of such Act (42 U.S.C.
1397dd(m)), as amended by paragraph (1), is further
amended--
(i) in paragraph (1)--
(I) by striking ``paragraph (4)''
each place it appears in subparagraphs
(A) and (B) and inserting ``paragraph
(5)''; and
(II) by striking ``the allotment
increase factor determined under
paragraph (5)'' each place it appears
and inserting ``the allotment increase
factor determined under paragraph
(6)'';
(ii) in paragraph (2)(A), by striking ``the
allotment increase factor under paragraph (5)''
and inserting ``the allotment increase factor
under paragraph (6)'';
(iii) in paragraph (3)--
(I) by striking ``paragraphs (4)
and (6)'' and inserting ``paragraphs
(5) and (7)'' each place it appears;
and
(II) by striking ``the allotment
increase factor under paragraph (5)''
and inserting ``the allotment increase
factor under paragraph (6)'';
(iv) in paragraph (5) (as redesignated by
paragraph (1)(F)), by striking ``paragraph (1),
(2), or (3)'' and inserting ``paragraph (1),
(2), (3), or (4)'';
(v) in paragraph (7) (as redesignated by
paragraph (1)(F)), by striking ``subject to
paragraph (4)'' and inserting ``subject to
paragraph (5)''; and
(vi) in paragraph (9), (as redesignated by
paragraph (1)(F)), by striking ``paragraph
(3)'' and inserting ``paragraph (3) or (4)''.
(C) Section 2104(n)(3)(B)(ii) of such Act (42
U.S.C. 1397dd(n)(3)(B)(ii)) is amended by striking
``subsection (m)(5)(B)'' and inserting ``subsection
(m)(6)(B)''.
(D) Section 2111(b)(2)(B)(i) of such Act (42 U.S.C.
1397kk(b)(2)(B)(i)) is amended by striking ``section
2104(m)(4)'' and inserting ``section 2104(m)(5)''.
(3) One-time appropriation for fiscal year 2017.--There is
appropriated to the Secretary of Health and Human Services, out
of any money in the Treasury not otherwise appropriated,
$14,700,000,000 to accompany the allotment made for the period
beginning on October 1, 2016, and ending on March 31, 2017,
under paragraph (20)(A) of section 2104(a) of the Social
Security Act (42 U.S.C. 1397dd(a)) (as added by subsection
(a)(1)), to remain available until expended. Such amount shall
be used to provide allotments to States under paragraph (4) of
section 2104(m) of such Act (42 U.S.C. 1397dd(m)) (as amended
by paragraph(1)(G)) for the first 6 months of fiscal year 2017
in the same manner as allotments are provided under subsection
(a)(20)(A) of such section 2104 and subject to the same terms
and conditions as apply to the allotments provided from such
subsection (a)(20)(A).
(c) Extension of Qualifying States Option.--Section 2105(g)(4) of
the Social Security Act (42 U.S.C. 1397ee(g)(4)) is amended--
(1) in the paragraph heading, by striking ``2015'' and
inserting ``2017''; and
(2) in subparagraph (A), by striking ``2015'' and inserting
``2017''.
(d) Extension of the Child Enrollment Contingency Fund.--
(1) In general.--Section 2104(n) of the Social Security Act
(42 U.S.C. 1397dd(n)) is amended--
(A) in paragraph (2)--
(i) in subparagraph (A)(ii)--
(I) by striking ``2010 through
2014'' and inserting ``2010, 2011,
2012, 2013, 2014, and 2016''; and
(II) by inserting ``and fiscal year
2017'' after ``2015''; and
(ii) in subparagraph (B)--
(I) by striking ``2010 through
2014'' and inserting ``2010, 2011,
2012, 2013, 2014, and 2016''; and
(II) by inserting ``and fiscal year
2017'' after ``2015''; and
(B) in paragraph (3)(A), in the matter preceding
clause (i), by striking ``fiscal year 2009, fiscal year
2010, fiscal year 2011, fiscal year 2012, fiscal year
2013, fiscal year 2014, or a semi-annual allotment
period for fiscal year 2015'' and inserting ``any of
fiscal years 2009 through 2014, fiscal year 2016, or a
semi-annual allotment period for fiscal year 2015 or
2017''.
SEC. 302. EXTENSION OF EXPRESS LANE ELIGIBILITY.
Section 1902(e)(13)(I) of the Social Security Act (42 U.S.C.
1396a(e)(13)(I)) is amended by striking ``2015'' and inserting
``2017''.
SEC. 303. EXTENSION OF OUTREACH AND ENROLLMENT PROGRAM.
Section 2113 of the Social Security Act (42 U.S.C. 1397mm) is
amended--
(1) in subsection (a)(1), by striking ``2015'' and
inserting ``2017''; and
(2) in subsection (g), by inserting ``and $40,000,000 for
the period of fiscal years 2016 and 2017'' after ``2015''.
SEC. 304. EXTENSION OF CERTAIN PROGRAMS AND DEMONSTRATION PROJECTS.
(a) Childhood Obesity Demonstration Project.--Section 1139A(e)(8)
of the Social Security Act (42 U.S.C. 1320b-9a(e)(8)) is amended by
inserting ``, and $10,000,000 for the period of fiscal years 2016 and
2017'' after ``2014''.
(b) Pediatric Quality Measures Program.--Section 1139A(i) of the
Social Security Act (42 U.S.C. 1320b-9a(i)) is amended in the first
sentence by inserting before the period at the end the following: ``,
and there is appropriated for the period of fiscal years 2016 and 2017,
$20,000,000 for the purpose of carrying out this section (other than
subsections (e), (f), and (g))''.
SEC. 305. REPORT OF INSPECTOR GENERAL OF HHS ON USE OF EXPRESS LANE
OPTION UNDER MEDICAID AND CHIP.
Not later than 18 months after the date of the enactment of this
Act, the Inspector General of the Department of Health and Human
Services shall submit to the Committee on Energy and Commerce of the
House of Representatives and the Committee on Finance of the Senate a
report that--
(1) provides data on the number of individuals enrolled in
the Medicaid program under title XIX of the Social Security Act
(referred to in this section as ``Medicaid'') and the
Children's Health Insurance Program under title XXI of such Act
(referred to in this section as ``CHIP'') through the use of
the Express Lane option under section 1902(e)(13) of the Social
Security Act (42 U.S.C. 1396a(e)(13));
(2) assesses the extent to which individuals so enrolled
meet the eligibility requirements under Medicaid or CHIP (as
applicable); and
(3) provides data on Federal and State expenditures under
Medicaid and CHIP for individuals so enrolled and disaggregates
such data between expenditures made for individuals who meet
the eligibility requirements under Medicaid or CHIP (as
applicable) and expenditures made for individuals who do not
meet such requirements.
TITLE IV--OFFSETS
Subtitle A--Medicare Beneficiary Reforms
SEC. 401. LIMITATION ON CERTAIN MEDIGAP POLICIES FOR NEWLY ELIGIBLE
MEDICARE BENEFICIARIES.
Section 1882 of the Social Security Act (42 U.S.C. 1395ss) is
amended by adding at the end the following new subsection:
``(z) Limitation on Certain Medigap Policies for Newly Eligible
Medicare Beneficiaries.--
``(1) In general.--Notwithstanding any other provision of
this section, on or after January 1, 2020, a medicare
supplemental policy that provides coverage of the part B
deductible, including any such policy (or rider to such a
policy) issued under a waiver granted under subsection (p)(6),
may not be sold or issued to a newly eligible Medicare
beneficiary.
``(2) Newly eligible medicare beneficiary defined.--In this
subsection, the term `newly eligible Medicare beneficiary'
means an individual who is neither of the following:
``(A) An individual who has attained age 65 before
January 1, 2020.
``(B) An individual who was entitled to benefits
under part A pursuant to section 226(b) or 226A, or
deemed to be eligible for benefits under section
226(a), before January 1, 2020.
``(3) Treatment of waivered states.--In the case of a State
described in subsection (p)(6), nothing in this section shall
be construed as preventing the State from modifying its
alternative simplification program under such subsection so as
to eliminate the coverage of the part B deductible for any
medical supplemental policy sold or issued under such program
to a newly eligible Medicare beneficiary on or after January 1,
2020.
``(4) Treatment of references to certain policies.--In the
case of a newly eligible Medicare beneficiary, except as the
Secretary may otherwise provide, any reference in this section
to a medicare supplemental policy which has a benefit package
classified as `C' or `F' shall be deemed, as of January 1,
2020, to be a reference to a medicare supplemental policy which
has a benefit package classified as `D' or `G', respectively.
``(5) Enforcement.--The penalties described in clause (ii)
of subsection (d)(3)(A) shall apply with respect to a violation
of paragraph (1) in the same manner as it applies to a
violation of clause (i) of such subsection.''.
SEC. 402. INCOME-RELATED PREMIUM ADJUSTMENT FOR PARTS B AND D.
(a) In General.--Section 1839(i)(3)(C)(i) of the Social Security
Act (42 U.S.C. 1395r(i)(3)(C)(i)) is amended--
(1) by inserting after ``In general.--'' the following:
``(I) Subject to paragraphs (5) and
(6), for years before 2018:''; and
(2) by adding at the end the following:
``(II) Subject to paragraph (5),
for years beginning with 2018:
``If the modified adjusted gross income is: The applicable
percentage is:
More than $85,000 but not more than $107,000..... 35 percent
More than $107,000 but not more than $133,500.... 50 percent
More than $133,500 but not more than $160,000.... 65 percent
More than $160,000............................... 80 percent.''.
(b) Conforming Amendments.--Section 1839(i) of the Social Security
Act (42 U.S.C. 1395r(i)) is amended--
(1) in paragraph (2)(A), by inserting ``(or, beginning with
2018, $85,000)'' after ``$80,000'';
(2) in paragraph (3)(A)(i), by inserting ``applicable''
before ``table'';
(3) in paragraph (5)(A)--
(A) in the matter before clause (i), by inserting
``(other than 2018 and 2019)'' after ``2007''; and
(B) in clause (ii), by inserting ``(or, in the case
of a calendar year beginning with 2020, August 2018)''
after ``August 2006''; and
(4) in paragraph (6), in the matter before subparagraph
(A), by striking ``2019'' and inserting ``2017''.
Subtitle B--Other Offsets
SEC. 411. MEDICARE PAYMENT UPDATES FOR POST-ACUTE PROVIDERS.
(a) SNFs.--Section 1888(e) of the Social Security Act (42 U.S.C.
1395yy(e))--
(1) in paragraph (5)(B)--
(A) in clause (i), by striking ``clause (ii)'' and
inserting ``clauses (ii) and (iii)'';
(B) in clause (ii), by inserting ``subject to
clause (iii),'' after ``each subsequent fiscal year,'';
and
(C) by adding at the end the following new clause:
``(iii) Special rule for fiscal year
2018.--For fiscal year 2018 (or other similar
annual period specified in clause (i)), the
skilled nursing facility market basket
percentage, after application of clause (ii),
is equal to 1 percent.''; and
(2) in paragraph (6)(A), by striking ``paragraph
(5)(B)(ii)'' and inserting ``clauses (ii) and (iii) of
paragraph (5)(B)'' each place it appears.
(b) IRFs.--Section 1886(j) of the Social Security Act (42 U.S.C.
1395ww(j)) is amended--
(1) in paragraph (3)(C)--
(A) in clause (i), by striking ``clause (ii)'' and
inserting ``clauses (ii) and (iii)'';
(B) in clause (ii), by striking ``After'' and
inserting ``Subject to clause (iii), after''; and
(C) by adding at the end the following new clause:
``(iii) Special rule for fiscal year
2018.--The increase factor to be applied under
this subparagraph for fiscal year 2018, after
the application of clause (ii), shall be 1
percent.''; and
(2) in paragraph (7)(A)(i), by striking ``paragraph
(3)(D)'' and inserting ``subparagraphs (C)(iii) and (D) of
paragraph (3)''.
(c) HHAs.--Section 1895(b)(3)(B) of the Social Security Act (42
U.S.C. 1395fff(b)(3)(B)) is amended--
(1) in clause (iii), by adding at the end the following:
``Notwithstanding the previous sentence, the home health market
basket percentage increase for 2018 shall be 1 percent.''; and
(2) in clause (vi)(I), by inserting ``(except 2018)'' after
``each subsequent year''.
(d) Hospice.--Section 1814(i) of the Social Security Act (42 U.S.C.
1395f(i)) is amended--
(1) in paragraph (1)(C)--
(A) in clause (ii)(VII), by striking ``clause
(iv),,'' and inserting ``clauses (iv) and (vi),'';
(B) in clause (iii), by striking ``clause (iv),''
and inserting ``clauses (iv) and (vi),'';
(C) in clause (iv), by striking ``After
determining'' and inserting ``Subject to clause (vi),
after determining''; and
(D) by adding at the end the following new clause:
``(vi) For fiscal year 2018, the market basket percentage increase
under clause (ii)(VII) or (iii), as applicable, after application of
clause (iv), shall be 1 percent.''; and
(2) in paragraph (5)(A)(i), by striking ``paragraph
(1)(C)(iv)'' and inserting ``clauses (iv) and (vi) of paragraph
(1)(C)''.
(e) LTCHs.--Section 1886(m)(3) of the Social Security Act (42
U.S.C. 1395ww(m)(3)) is amended--
(1) in subparagraph (A), in the matter preceding clause
(i), by striking ``In implementing'' and inserting ``Subject to
subparagraph (C), in implementing''; and
(2) by adding at the end the following new subparagraph:
``(C) Additional special rule.--For fiscal year
2018, the annual update under subparagraph (A) for the
fiscal year, after application of clauses (i) and (ii)
of subparagraph (A), shall be 1 percent.''.
SEC. 412. DELAY OF REDUCTION TO MEDICAID DSH ALLOTMENTS.
Section 1923(f) of the Social Security Act (42 U.S.C. 1396r-4(f))
is amended--
(1) in paragraph (7)(A)--
(A) in clause (i), by striking ``2017 through
2024'' and inserting ``2018 through 2025'';
(B) by striking clause (ii) and inserting the
following new clause:
``(ii) Aggregate reductions.--The aggregate
reductions in DSH allotments for all States
under clause (i)(I) shall be equal to--
``(I) $2,000,000,000 for fiscal
year 2018;
``(II) $3,000,000,000 for fiscal
year 2019;
``(III) $4,000,000,000 for fiscal
year 2020;
``(IV) $5,000,000,000 for fiscal
year 2021;
``(V) $6,000,000,000 for fiscal
year 2022;
``(VI) $7,000,000,000 for fiscal
year 2023;
``(VII) $8,000,000,000 for fiscal
year 2024; and
``(VIII) $8,000,000,000 for fiscal
year 2025.''; and
(C) by adding at the end the following new clause:
``(v) Distribution of aggregate
reductions.--The Secretary shall distribute the
aggregate reductions under clause (ii) among
States in accordance with subparagraph (B).'';
and
(2) in paragraph (8), by striking ``2024'' and inserting
``2025''.
SEC. 413. LEVY ON DELINQUENT PROVIDERS.
(a) In General.--Paragraph (3) of section 6331(h) of the Internal
Revenue Code of 1986 is amended by striking ``30 percent'' and
inserting ``100 percent''.
(b) Effective Date.--The amendment made by this section shall apply
to payments made after 180 days after the date of the enactment of this
Act.
SEC. 414. ADJUSTMENTS TO INPATIENT HOSPITAL PAYMENT RATES.
Section 7(b) of the TMA, Abstinence Education, and QI Programs
Extension Act of 2007 (Public Law 110-90), as amended by section 631(b)
of the American Taxpayer Relief Act of 2012 (Public Law 112-240), is
amended--
(1) in paragraph (1)--
(A) in the matter preceding subparagraph (A), by
striking ``, 2009, or 2010'' and inserting ``or 2009'';
and
(B) in subparagraph (B)--
(i) in clause (i), by striking ``and'' at
the end;
(ii) in clause (ii), by striking the period
at the end and inserting ``; and''; and
(iii) by adding at the end the following
new clause:
``(iii) make an additional adjustment to the
standardized amounts under such section 1886(d) of an
increase of 0.5 percentage points for discharges
occurring during each of fiscal years 2018 through 2023
and not make the adjustment (estimated to be an
increase of 3.2 percent) that would otherwise apply for
discharges occurring during fiscal year 2018 by reason
of the completion of the adjustments required under
clause (ii).'';
(2) in paragraph (3)--
(A) by striking ``shall be construed'' and all that
follows through ``providing authority'' and inserting
``shall be construed as providing authority''; and
(B) by inserting ``and each succeeding fiscal year
through fiscal year 2023'' after ``2017'';
(3) by redesignating paragraphs (3) and (4) as paragraphs
(4) and (5), respectively; and
(4) by inserting after paragraph (2) the following new
paragraph:
``(3) Prohibition.--The Secretary shall not make an
additional prospective adjustment (estimated to be a decrease
of 0.55 percent) to the standardized amounts under such section
1886(d) to offset the amount of the increase in aggregate
payments related to documentation and coding changes for
discharges occurring during fiscal year 2010.''.
TITLE V--MISCELLANEOUS
Subtitle A--Protecting the Integrity of Medicare
SEC. 501. 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. 502. 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 subsection (a),
that have been conducted since such date of enactment.
SEC. 503. 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 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. 504. 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. 505. REDUCING IMPROPER MEDICARE PAYMENTS.
(a) Medicare Administrative Contractor Improper Payment Outreach
and Education Program.--Section 1874A of the Social Security Act (42
U.S.C. 1395kk-1) is amended--
(1) in subsection (a)(4)--
(A) by redesignating subparagraph (G) as
subparagraph (H); and
(B) 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
(2) 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
514(b) of the Medicare Access and CHIP Reauthorization
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. 506. 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. 507. 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 subparagraph (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. 508. 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. 509. 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. 510. 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. 511. 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. 512. 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. 513. 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. 514. 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 paragraph (10) of section 1893(h) of the Social Security
Act (42 U.S.C. 1395ddd(h)), as added by section 505, 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. 515. 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
515(a) of the Medicare Access and CHIP Reauthorization
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. 516. 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. 517. 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 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 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. 518. 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. 519. RULE OF CONSTRUCTION.
Except as explicitly provided in this subtitle, nothing in this
subtitle, including the amendments made by this subtitle, 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
subtitle.
Subtitle B--Other Provisions
SEC. 521. EXTENSION OF TWO-MIDNIGHT PAMA RULES ON CERTAIN MEDICAL
REVIEW ACTIVITIES.
Section 111 of the Protecting Access to Medicare Act of 2014
(Public Law 113-93; 42 U.S.C. 1395ddd note) is amended--
(1) in subsection (a), by striking ``the first 6 months of
fiscal year 2015'' and inserting ``through the end of fiscal
year 2015'';
(2) in subsection (b), by striking ``March 31, 2015'' and
inserting ``September 30, 2015''; and
(3) by adding at the end the following new subsection:
``(c) Construction.--Except as provided in subsections (a) and (b),
nothing in this section shall be construed as limiting the Secretary's
authority to pursue fraud and abuse activities under such section
1893(h) or otherwise.''.
SEC. 522. REQUIRING BID SURETY BONDS AND STATE LICENSURE FOR ENTITIES
SUBMITTING BIDS UNDER THE MEDICARE DMEPOS COMPETITIVE
ACQUISITION PROGRAM.
(a) Bid Surety Bonds.--Section 1847(a)(1) of the Social Security
Act (42 U.S.C. 1395w-3(a)(1)) is amended by adding at the end the
following new subparagraphs:
``(G) Requiring bid bonds for bidding entities.--
With respect to rounds of competitions beginning under
this subsection for contracts beginning not earlier
than January 1, 2017, and not later than January 1,
2019, an entity may not submit a bid for a competitive
acquisition area unless, as of the deadline for bid
submission, the entity has obtained (and provided the
Secretary with proof of having obtained) a bid surety
bond (in this paragraph referred to as a `bid bond') in
a form specified by the Secretary consistent with
subparagraph (H) and in an amount that is not less than
$50,000 and not more than $100,000 for each competitive
acquisition area in which the entity submits the bid.
``(H) Treatment of bid bonds submitted.--
``(i) For bidders that submit bids at or
below the median and are offered but do not
accept the contract.--In the case of a bidding
entity that is offered a contract for any
product category for a competitive acquisition
area, if--
``(I) the entity's composite bid
for such product category and area was
at or below the median composite bid
rate for all bidding entities included
in the calculation of the single
payment amounts for such product
category and area; and
``(II) the entity does not accept
the contract offered for such product
category and area,
the bid bond submitted by such entity for such
area shall be forfeited by the entity and the
Secretary shall collect on it.
``(ii) Treatment of other bidders.--In the
case of a bidding entity for any product
category for a competitive acquisition area, if
the entity does not meet the bid forfeiture
conditions in subclauses (I) and (II) of clause
(i) for any product category for such area, the
bid bond submitted by such entity for such area
shall be returned within 90 days of the public
announcement of the contract suppliers for such
area.''.
(b) State Licensure.--
(1) In general.--Section 1847(b)(2)(A) of the Social
Security Act (42 U.S.C. 1395w-3(b)(2)(A)) is amended by adding
at the end the following new clause:
``(v) The entity meets applicable State
licensure requirements.''.
(2) Construction.--Nothing in the amendment made by
paragraph (1) shall be construed as affecting the authority of
the Secretary of Health and Human Services to require State
licensure of an entity under the Medicare competitive
acquisition program under section 1847 of the Social Security
Act (42 U.S.C. 1395w-3) before the date of the enactment of
this Act.
(c) GAO Report on Bid Bond Impact on Small Suppliers.--
(1) Study.--The Comptroller General of the United States
shall conduct a study that evaluates the effect of the bid
surety bond requirement under the amendment made by subsection
(a) on the participation of small suppliers in the Medicare
DMEPOS competitive acquisition program under section 1847 of
the Social Security Act (42 U.S.C. 1395w-3).
(2) Report.--Not later than 6 months after the date
contracts are first awarded subject to such bid surety bond
requirement, the Comptroller General shall submit to Congress a
report on the study conducted under paragraph (1). Such report
shall include recommendations for changes in such requirement
in order to ensure robust participation by legitimate small
suppliers in the Medicare DMEPOS competition acquisition
program.
SEC. 523. PAYMENT FOR GLOBAL SURGICAL PACKAGES.
(a) In General.--Section 1848(c) of the Social Security Act (42
U.S.C. 1395w-4(c)) is amended by adding at the end the following new
paragraph:
``(8) Global surgical packages.--
``(A) Prohibition of implementation of rule
regarding global surgical packages.--
``(i) In general.--The Secretary shall not
implement the policy established in the final
rule published on November 13, 2014 (79 Fed.
Reg. 67548 et seq.), that requires the
transition of all 10-day and 90-day global
surgery packages to 0-day global periods.
``(ii) Construction.--Nothing in clause (i)
shall be construed to prevent the Secretary
from revaluing misvalued codes for specific
surgical services or assigning values to new or
revised codes for surgical services.
``(B) Collection of data on services included in
global surgical packages.--
``(i) In general.--Subject to clause (ii),
the Secretary shall through rulemaking develop
and implement a process to gather, from a
representative sample of physicians, beginning
not later than January 1, 2017, information
needed to value surgical services. Such
information shall include the number and level
of medical visits furnished during the global
period and other items and services related to
the surgery and furnished during the global
period, as appropriate. Such information shall
be reported on claims at the end of the global
period or in another manner specified by the
Secretary. For purposes of carrying out this
paragraph (other than clause (iii)), the
Secretary shall transfer from the Federal
Supplemental Medical Insurance Trust Fund under
section 1841 $2,000,000 to the Center for
Medicare & Medicaid Services Program Management
Account for fiscal year 2015. Amounts
transferred under the previous sentence shall
remain available until expended.
``(ii) Reassessment and potential sunset.--
Every 4 years, the Secretary shall reassess the
value of the information collected pursuant to
clause (i). Based on such a reassessment and by
regulation, the Secretary may discontinue the
requirement for collection of information under
such clause if the Secretary determines that
the Secretary has adequate information from
other sources, such as qualified clinical data
registries, surgical logs, billing systems or
other practice or facility records, and
electronic health records, in order to
accurately value global surgical services under
this section.
``(iii) Inspector general audit.--The
Inspector General of the Department of Health
and Human Services shall audit a sample of the
information reported under clause (i) to verify
the accuracy of the information so reported.
``(C) Improving accuracy of pricing for surgical
services.--For years beginning with 2019, the Secretary
shall use the information reported under subparagraph
(B)(i) as appropriate and other available data for the
purpose of improving the accuracy of valuation of
surgical services under the physician fee schedule
under this section.''.
(b) Incentive for Reporting Information on Global Surgical
Services.--Section 1848(a) of the Social Security Act (42 U.S.C. 1395w-
4(a)) is amended by adding at the end the following new paragraph:
``(9) Information reporting on services included in global
surgical packages.--With respect to services for which a
physician is required to report information in accordance with
subsection (c)(8)(B)(i), the Secretary may through rulemaking
delay payment of 5 percent of the amount that would otherwise
be payable under the physician fee schedule under this section
for such services until the information so required is
reported.''.
SEC. 524. EXTENSION OF SECURE RURAL SCHOOLS AND COMMUNITY SELF-
DETERMINATION ACT OF 2000.
(a) Payments for Fiscal Years 2014 and 2015.--
(1) Payments required.--Section 101 of the Secure Rural
Schools and Community Self-Determination Act of 2000 (16 U.S.C.
7111) is amended by striking ``2013'' both places it appears
and inserting ``2015''.
(2) Prompt payment.--Payments for fiscal year 2014 under
title I of the Secure Rural Schools and Community Self-
Determination Act of 2000 (16 U.S.C. 7111 et seq.), as amended
by this section, shall be made not later than 45 days after the
date of the enactment of this Act.
(3) Reduction in fiscal year 2014 payments on account of
previous 25- and 50-percent payments.--Section 101 of the
Secure Rural Schools and Community Self-Determination Act of
2000 (16 U.S.C. 7111) is amended by adding at the end the
following new subsection:
``(c) Special Rule for Fiscal Year 2014 Payments.--
``(1) State payment.--If an eligible county in a State that
will receive a share of the State payment for fiscal year 2014
has already received, or will receive, a share of the 25-
percent payment for fiscal year 2014 distributed to the State
before the date of the enactment of this subsection, the amount
of the State payment shall be reduced by the amount of that
eligible county's share of the 25-percent payment.
``(2) County payment.--If an eligible county that will
receive a county payment for fiscal year 2014 has already
received a 50-percent payment for that fiscal year, the amount
of the county payment shall be reduced by the amount of the 50-
percent payment.''.
(4) Shares of california state payment.--Section 103(d)(2)
of the Secure Rural Schools and Community Self-Determination
Act of 2000 (16 U.S.C. 7113(d)(2)) is amended by striking
``2013'' and inserting ``2015''.
(b) Use of Fiscal Year 2013 Elections and Reservations for Fiscal
Years 2014 and 2015.--Section 102 of the Secure Rural Schools and
Community Self-Determination Act of 2000 (16 U.S.C. 7112) is amended--
(1) in subsection (b)(1), by adding at the end the
following new subparagraph:
``(C) Effect of late payment for fiscal years 2014
and 2015.--The election otherwise required by
subparagraph (A) shall not apply for fiscal year 2014
or 2015.'';
(2) in subsection (b)(2)--
(A) in subparagraph (A), by adding at the end the
following new sentence: ``If such two-fiscal year
period included fiscal year 2013, the county election
to receive a share of the 25-percent payment or 50-
percent payment, as applicable, also shall be effective
for fiscal years 2014 and 2015.''; and
(B) in subparagraph (B), by striking ``2013'' the
second place it appears and inserting ``2015''; and
(3) in subsection (d)--
(A) by adding at the end of paragraph (1) the
following new subparagraph:
``(E) Effect of late payment for fiscal year
2014.--The election made by an eligible county under
subparagraph (B), (C), or (D) for fiscal year 2013, or
deemed to be made by the county under paragraph (3)(B)
for that fiscal year, shall be effective for fiscal
years 2014 and 2015.''; and
(B) by adding at the end of paragraph (3) the
following new subparagraph:
``(C) Effect of late payment for fiscal year
2014.--This paragraph does not apply for fiscal years
2014 and 2015.''.
(c) Special Projects on Federal Land.--Title II of the Secure Rural
Schools and Community Self-Determination Act of 2000 (16 U.S.C. 7121 et
seq.) is amended--
(1) in section 203(a)(1) (16 U.S.C. 7123(a)(1)), by
striking ``September 30 for fiscal year 2008 (or as soon
thereafter as the Secretary concerned determines is
practicable), and each September 30 thereafter for each
succeeding fiscal year through fiscal year 2013'' and inserting
``September 30 of each fiscal year (or a later date specified
by the Secretary concerned for the fiscal year)'';
(2) in section 204(e)(3)(B)(iii) (16 U.S.C.
7124(e)(3)(B)(iii)), by striking ``each of fiscal years 2010
through 2013'' and inserting ``fiscal year 2010 and fiscal
years thereafter'';
(3) in section 207(a) (16 U.S.C. 7127(a)), by striking
``September 30, 2008 (or as soon thereafter as the Secretary
concerned determines is practicable), and each September 30
thereafter for each succeeding fiscal year through fiscal year
2013'' and inserting ``September 30 of each fiscal year (or a
later date specified by the Secretary concerned for the fiscal
year)''; and
(4) in section 208 (16 U.S.C. 7128)--
(A) in subsection (a), by striking ``2013'' and
inserting ``2017''; and
(B) in subsection (b), by striking ``2014'' and
inserting ``2018''.
(d) County Funds.--Section 304 of the Secure Rural Schools and
Community Self-Determination Act of 2000 (16 U.S.C. 7144) is amended--
(1) in subsection (a), by striking ``2013'' and inserting
``2017''; and
(2) in subsection (b), by striking ``2014'' and inserting
``2018''.
(e) Authorization of Appropriations.--Section 402 of the Secure
Rural Schools and Community Self-Determination Act of 2000 (16 U.S.C.
7152) is amended by striking ``for each of fiscal years 2008 through
2013''.
SEC. 525. EXCLUSION FROM PAYGO SCORECARDS.
(a) Statutory Pay-As-You-Go Scorecards.--The budgetary effects of
this Act shall not be entered on either PAYGO scorecard maintained
pursuant to section 4(d) of the Statutory Pay-As-You-Go Act of 2010.
(b) Senate PAYGO Scorecards.--The budgetary effects of this Act
shall not be entered on any PAYGO scorecard maintained for purposes of
section 201 of S. Con. Res. 21 (110th Congress).
Passed the House of Representatives March 26, 2015.
Attest:
Clerk.
114th CONGRESS
1st Session
H. R. 2
_______________________________________________________________________
AN ACT
To amend title XVIII of the Social Security Act to repeal the Medicare
sustainable growth rate and strengthen Medicare access by improving
physician payments and making other improvements, to reauthorize the
Children's Health Insurance Program, and for other purposes.