[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[S. 1989 Introduced in Senate (IS)]

114th CONGRESS
  1st Session
                                S. 1989

              To improve access to primary care services.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             August 5, 2015

  Mr. Cassidy introduced the following bill; which was read twice and 
                  referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
              To improve access to primary care services.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Primary Care Enhancement Act of 
2015''.

SEC. 2. TREATMENT OF DIRECT PRIMARY CARE SERVICE ARRANGEMENTS.

    (a) In General.--Section 223(c) of the Internal Revenue Code of 
1986 is amended by adding at the end the following new paragraph:
            ``(6) Treatment of direct primary care service 
        arrangements.--An arrangement under which an individual is 
        provided ongoing primary care services in exchange for a fixed 
        periodic fee which is not billed to any third party on a fee 
        for service basis--
                    ``(A) shall not be treated as a health plan for 
                purposes of paragraph (1)(A)(ii), and
                    ``(B) shall not be treated as insurance for 
                purposes of subsection (d)(2)(B).''.
    (b) Effective Date.--The amendment made by this section shall apply 
to taxable years beginning after the date of the enactment of this Act.

SEC. 3. CERTAIN PROVIDER FEES TO BE TREATED AS MEDICAL CARE.

    (a) In General.--Subsection (d) of section 213 of the Internal 
Revenue Code of 1986 is amended by adding at the end the following new 
paragraph:
            ``(12) Periodic provider fees.--The term `medical care' 
        shall include periodic fees paid to a primary care physician 
        for a defined set of medical services on an as-needed basis.''.
    (b) Effective Date.--The amendment made by this section shall apply 
to taxable years beginning after the date of the enactment of this Act.

SEC. 4. MEDICARE PRIMARY CARE MEDICAL HOME DEMONSTRATION PROGRAM.

    Section 1115A of title XI of the Social Security Act (42 U.S.C. 
1315a) is amended--
            (1) in subsection (b)(2)(A), in the last sentence, by 
        inserting ``, and shall include the model described in 
        subsection (h)'' before the period at the end; and
            (2) by adding at the end the following new subsection:
    ``(h) Primary Care Medical Home Model.--
            ``(1) Model.--
                    ``(A) In general.--The model described in this 
                subsection is a model under which qualified direct 
                primary care medical home practices are reimbursed a 
                periodic fee for furnishing services to an individual 
                enrolled under part B of title XVIII.
                    ``(B) Qualified direct primary care medical home 
                practice.--In this subsection, the term `qualified 
                direct primary care medical home practice' means a 
                qualified direct primary care medical home practice 
                described in section 1301(a)(3) of the Patient 
                Protection and Affordable Care Act (as amended by 
                section 10104(a) of such Act).
            ``(2) Periodic fee.--
                    ``(A) In general.--Subject to the succeeding 
                provisions of this paragraph, the Secretary shall 
                establish the periodic fee to be paid to qualified 
                direct primary care medical home practices 
                participating in the model under this subsection for 
                each individual enrolled in the practice.
                    ``(B) Affordable primary care.--In no case may a 
                monthly equivalent of the periodic fee established by 
                the Secretary under subparagraph (A) exceed an amount 
                equal to twenty percent of the average per capita 
                monthly amount that the Secretary estimates will be 
                payable from the Federal Hospital Insurance Trust Fund 
                under section 1817 and from the Federal Supplementary 
                Medical Insurance Trust Fund for services and related 
                administrative costs for an individual under parts A 
                and B of title XVIII.
                    ``(C) Adjustment to periodic fee.--
                            ``(i) Performance benchmark.--The Secretary 
                        shall establish a performance benchmark for a 
                        year using the ACO quality measures in the 
                        Medicare shared savings program under section 
                        1899.
                            ``(ii) Adjustment.--Beginning with the 
                        second year the model under this subsection is 
                        conducted, in the case of a qualified direct 
                        primary care medical home practice 
                        participating in the model under this 
                        subsection--
                                    ``(I) that meets or exceeds the 
                                performance benchmark for the year 
                                under clause (i), the periodic fee paid 
                                to the practice for each individual 
                                enrolled in the practice shall be 
                                increased by 5 percent; and
                                    ``(II) that does not meet the 
                                performance benchmark for the year 
                                under clause (i), the periodic fee paid 
                                to the practice for each individual 
                                enrolled in the practice shall be 
                                reduced by 5 percent.
            ``(3) Termination if performance benchmark not net for 2 
        consecutive years.--The Secretary shall terminate the 
        participation of a qualified direct primary care medical home 
        practice in the model under this subsection if the practice 
        would otherwise be subject to the adjustment under paragraph 
        (2)(C)(ii)(II) for 2 consecutive years.
            ``(4) Scope of services.--Each qualified direct primary 
        care medical home practice shall employ the following 
        activities and functions associated with direct primary care 
        medical homes:
                    ``(A) Preventive care.
                    ``(B) Wellness counseling.
                    ``(C) Primary care.
                    ``(D) Coordination of primary care with specialty 
                and hospital care.
                    ``(E) Availability of ongoing care appointments 7 
                days per week.
                    ``(F) Secure e-mail and telephone consultation.
                    ``(G) Availability of telephone access for ongoing 
                care consultation on a 7-day-per-week, 24-hour-per-day 
                basis.
                    ``(H) Use of a primary care provider panel size 
                that promotes the ability of participating providers to 
                appropriately provide the scope of services described 
                in this paragraph.
            ``(5) Priority.--
                    ``(A) In general.--In selecting qualified direct 
                primary care medical home practices to participate 
                under this subsection, the Secretary shall provide 
                priority to practices that seek to enroll individuals 
                who are dual eligible individuals.
                    ``(B) Dual eligible individual.--In subparagraph 
                (A), the term `dual eligible individual' means an 
                individual who is--
                            ``(i) enrolled under part B of title XVIII; 
                        and
                            ``(ii) described in subparagraph (A)(ii) of 
                        section 1935(c)(6) of the Social Security Act 
                        (42 U.S.C. 1396u-5(c)(6)), taking into account 
                        the application of subparagraph (B) of such 
                        section.
            ``(6) Not insurance.--Care provided in a qualified direct 
        primary care medical home practice participating in the model 
        under this subsection shall not be considered an insurance 
        product and shall not be subject to regulation as an insurance 
        product or health maintenance organization by State insurance 
        commissioners.
            ``(7) Reporting to secretary.--A qualified direct primary 
        care medical home practice participating in the model under 
        this subsection shall submit to the Secretary an annual report 
        on--
                    ``(A) the progress, of individuals enrolled in the 
                practice with one or more chronic conditions, on the 
                following:
                            ``(i) Emergency room visits.
                            ``(ii) Hospitalizations.
                            ``(iii) Surgeries (including type of 
                        surgery).
                            ``(iv) Specialist visits.
                            ``(v) Use of advanced radiology (other than 
                        mammograms and DEXA scans); and
                    ``(B) such other areas determined appropriate by 
                the Secretary.
            ``(8) Provision of data to practices.--The Secretary shall 
        provide qualified direct primary care medical home practices 
        participating in the model under this subsection with all 
        necessary and relevant patient data, including any prior claims 
        data, needed for clinical purposes and for the purpose of 
        providing an evaluation of such the model under this 
        subsection.
            ``(9) Providers currently opted out of medicare.--
        Notwithstanding section 1802(b), a physician or practitioner 
        who has currently opted out of the Medicare program under such 
        section may participate in a qualified direct primary care 
        medical home practice participating in the model under this 
        subsection and payment may be made under this title with 
        respect to items and services furnished by such physician or 
        practitioner under such model to Medicare beneficiaries with 
        whom the physician or practitioner has in effect a private 
        contract under such section.
            ``(10) Fraud.--A physician or practitioner who has been 
        excluded from participation in a Federal health care program 
        (as defined in section 1128C(f)) shall not be permitted to 
        participate in a qualified direct primary care medical home 
        practice under the model under this subsection.
            ``(11) Duration.--Subject to subsection (b)(3), the 
        Secretary shall conduct the model under this subsection for a 
        period of not less than 3 years.
            ``(12) Expansion.--Notwithstanding subsection (c), if the 
        Secretary determines, after the third year that the model under 
        this subsection is conducted, that--
                    ``(A) a qualified direct primary care medical home 
                practice participating in the model under this 
                subsection meets the requirements under paragraphs (1), 
                (2), and (3) of such subsection, such practice shall 
                continue permanently as long as it continues to meet 
                such requirements and the other requirements of this 
                subsection; and
                    ``(B) a majority of qualified direct primary care 
                medical home practice participating in the model under 
                this subsection meet the requirements under paragraphs 
                (1), (2), and (3) of such subsection, the Secretary 
                shall expand the model on a nationwide basis.''.

SEC. 5. USE OF DIRECT PRIMARY CARE MEDICAL HOMES UNDER THE MEDICARE 
              ADVANTAGE PROGRAM.

    (a) In General.--Nothing in title XVIII of the Social Security Act 
or any other provision of law shall be construed to prohibit a Medicare 
Advantage organization offering a Medicare Advantage plan under part C 
of such title from--
            (1) contracting with a qualified direct primary care 
        medical home practice to offer primary care services under such 
        plan; or
            (2) including in such contract provisions for shared 
        savings agreed upon between the Medicare Advantage organization 
        and the the qualified direct primary care medical home 
        practice.
    (b) Qualified Direct Primary Care Medical Home Practice.--In this 
section, the term ``qualified direct primary care medical home 
practice'' means a qualified direct primary care medical home practice 
described in section 1301(a)(3) of the Patient Protection and 
Affordable Care Act (as amended by section 10104(a) of such Act).
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