[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2 Enrolled Bill (ENR)]
H.R.2
One Hundred Fourteenth Congress
of the
United States of America
AT THE FIRST SESSION
Begun and held at the City of Washington on Tuesday,
the sixth day of January, two thousand and fifteen
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).
Speaker of the House of Representatives.
Vice President of the United States and
President of the Senate.