[Senate Hearing 115-233]
[From the U.S. Government Publishing Office]


                                                       S. Hrg. 115-233

                       NOMINATION OF SEEMA VERMA

=======================================================================

                                HEARING

                               BEFORE THE
                               
                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                                 ON THE

                             NOMINATION OF

  SEEMA VERMA, TO BE ADMINISTRATOR, CENTERS FOR MEDICARE AND MEDICAID 
           SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES

                               __________

                           FEBRUARY 16, 2017

                               __________
                               
                               
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            Printed for the use of the Committee on Finance
            
            
                                __________
                               

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                          COMMITTEE ON FINANCE

                     ORRIN G. HATCH, Utah, Chairman

CHUCK GRASSLEY, Iowa                 RON WYDEN, Oregon
MIKE CRAPO, Idaho                    DEBBIE STABENOW, Michigan
PAT ROBERTS, Kansas                  MARIA CANTWELL, Washington
MICHAEL B. ENZI, Wyoming             BILL NELSON, Florida
JOHN CORNYN, Texas                   ROBERT MENENDEZ, New Jersey
JOHN THUNE, South Dakota             THOMAS R. CARPER, Delaware
RICHARD BURR, North Carolina         BENJAMIN L. CARDIN, Maryland
JOHNNY ISAKSON, Georgia              SHERROD BROWN, Ohio
ROB PORTMAN, Ohio                    MICHAEL F. BENNET, Colorado
PATRICK J. TOOMEY, Pennsylvania      ROBERT P. CASEY, Jr., Pennsylvania
DEAN HELLER, Nevada                  MARK R. WARNER, Virginia
TIM SCOTT, South Carolina            CLAIRE McCASKILL, Missouri
BILL CASSIDY, Louisiana

                     Chris Campbell, Staff Director

              Joshua Sheinkman, Democratic Staff Director

                                  (ii)


                            C O N T E N T S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page
Hatch, Hon. Orrin G., a U.S. Senator from Utah, chairman, 
  Committee on Finance...........................................     1
Wyden, Hon. Ron, a U.S. Senator from Oregon......................     4

                        CONGRESSIONAL WITNESSES

Donnelly, Hon. Joe, a U.S. Senator from Indiana..................     6
Young, Hon. Todd, a U.S. Senator from Indiana....................     7

                         ADMINISTRATION NOMINEE

Verma, Seema, nominated to be Administrator, Centers for Medicare 
  and Medicaid Services, Department of Health and Human Services, 
  Washington, DC.................................................     8

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Donnelly, Hon. Joe:
    Testimony....................................................     6
Enzi, Hon. Michael B.:
    Prepared statement...........................................    55
Hatch, Hon. Orrin G.:
    Opening statement............................................     1
    Prepared statement with attachments..........................    55
Heller, Hon. Dean:
    Letter from the Nevada Legislature to Senator Heller, January 
      10, 2017...................................................    62
Verma, Seema:
    Testimony....................................................     8
    Prepared statement...........................................    63
    Biographical information.....................................    65
    Responses to questions from committee members................    75
Wyden, Hon. Ron:
    Opening statement............................................     4
    Prepared statement...........................................   131
Young, Hon. Todd:
    Testimony....................................................     7

                                 (iii)

 
                    NOMINATION OF SEEMA VERMA, TO BE.
                  ADMINISTRATOR, CENTERS FOR MEDICARE
                  AND MEDICAID SERVICES, DEPARTMENT OF
                       HEALTH AND HUMAN SERVICES

                              ----------                              


                      THURSDAY, FEBRUARY 16, 2017

                                       U.S. Senate,
                                      Committee on Finance,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10:02 
a.m., in room SD-215, Dirksen Senate Office Building, Hon. 
Orrin G. Hatch (chairman of the committee) presiding.
    Present: Senators Grassley, Crapo, Roberts, Enzi, Cornyn, 
Thune, Burr, Isakson, Portman, Toomey, Heller, Scott, Cassidy, 
Wyden, Stabenow, Cantwell, Nelson, Menendez, Cardin, Brown, 
Bennet, Casey, Warner, and McCaskill.
    Also present: Republican Staff: Chris Campbell, Staff 
Director; Kimberly Brandt, Chief Health-care Investigative 
Counsel; Brett Baker, Health Policy Advisor; and Erin Dempsey, 
Health-care Policy Advisor. Democratic Staff: Joshua Sheinkman, 
Staff Director; Michael Evans, General Counsel; Elizabeth 
Jurinka, Chief Health Advisor; David Berick, Chief 
Investigator; Beth Vrabel, Senior Health Counsel; Ann Dwyer, 
Health-care Counsel; Matt Kazan, Health Policy Advisor; and Ian 
Nicholson, Investigator.

 OPENING STATEMENT OF HON. ORRIN G. HATCH, A U.S. SENATOR FROM 
              UTAH, CHAIRMAN, COMMITTEE ON FINANCE

    The Chairman. The committee will come to order. I would 
like to welcome everyone to this morning's hearing. Today we 
are going to consider the nomination of Seema Verma to serve as 
Administrator of the Centers for Medicare and Medicaid 
Services.
    Welcome, Ms. Verma. We are so happy to have you here and 
your family as well. I appreciate your willingness to lead this 
key agency at this critical time. And I see that your family 
has joined you here today to lend support, so I extend a warm 
welcome to them as well.
    CMS is the world's largest health insurer, covering over 
one-third of the U.S. population through Medicare and Medicaid 
alone. It has a budget of over $1 trillion, and it processes 
over 1.2 billion claims a year for services provided to some of 
our Nation's most vulnerable citizens.
    Ms. Verma, having dealt with CMS extensively in your 
capacity as a consultant to numerous State Medicaid programs, 
you know full well the challenges the agency deals with on a 
daily basis. And I suspect you also know that the job you have 
been nominated for is a thankless one, fraught with numerous 
challenges.
    The good news is that there are opportunities in those 
challenges, and I believe you are the right person for the job 
and that you will make the most of those opportunities to 
improve our health-care system.
    The failings of Obamacare are urgent and must be addressed 
in short order. Over the past 6 years, we have watched as the 
system created under Obamacare has led to increased costs, 
higher taxes, fewer choices, reduced competition, and more 
strains on our economy. Under Obamacare, health insurance 
premiums are up by an average of 25 percent this year alone.
    Under Obamacare, Americans, including millions of middle-
class Americans, have been hit with a trillion dollars in new 
taxes. And under Obamacare, major insurers are no longer 
offering coverage on exchanges. And earlier this week, we 
learned that another major carrier will exit the market in 
2018.
    As Congress works to change course with regard to our 
ailing health-care system, CMS will play a major role in 
determining our success. I applaud the step the agency took 
yesterday under the leadership of HHS Secretary Price with its 
proposed rule to help stabilize the individual insurance 
markets. But there is much more work to be done, and I am 
confident that if you are confirmed, and I expect you to be, 
you will be a valuable voice in driving change.
    Now, I would like to talk specifically about Medicaid for a 
moment. The Medicaid program was destined to be a safety net 
for the most vulnerable Americans. As such, I understand and 
value the moral and social responsibilities the Federal 
Government has in ensuring health-care coverage for our most 
needy citizens.
    I am committed to working with the States and other 
stakeholders, as I think everyone on this committee is, and, of 
course, the American public, to improve the quality and ensure 
the longevity of the Medicaid program. But we must also 
acknowledge that the Medicaid program is three times larger, 
both in terms of enrollment and expenditures, than it was just 
20 years ago.
    Additionally, the Medicaid expansion under Obamacare 
exacerbated pressures on the program at a time when many States 
were already facing difficult choices about which benefits and 
populations to serve. And as a result, we have a responsibility 
to consider alternative funding arrangements that could help to 
preserve this important program. We also need to consider 
various reform proposals that can improve the way Medicaid 
operates.
    Ms. Verma, we will need your assistance in both of these 
efforts. And your experience in this particular area should 
serve you well.
    On the subject of Ms. Verma's experience, I want to note 
for the committee that she has been credited as the creative 
force behind the Healthy Indiana Plan, the State's Medicaid 
alternative. This program provides access and quality health 
care to its enrollees while ensuring that they are engaged in 
their care decisions.
    The program continues to evolve while hitting key metrics, 
and, overall, enrollees are very satisfied with their 
experience, as I understand it. And while we may hear 
criticisms of this program from the other side of the dais here 
today, we should note that HHS and CMS leaders under the Obama 
administration repeatedly approved the waiver necessary to make 
this program a reality.
    Ms. Verma has assisted a number of other State Medicaid 
programs as well. Her efforts all have the same focus: getting 
needed, high-quality health care to patients and to engage 
patients in a fiscally responsible way. This is exactly the 
mind-set we need in a CMS Administrator.
    Now, Ms. Verma, as if the challenges associated with 
Medicaid are not enough to keep you busy as CMS Administrator, 
you will also be tasked with helping to ensure the longevity 
and solvency of the Medicare trust fund, which is projected to 
go bankrupt in 2028. That has already come down from 2032, I 
believe.
    All told, between now and 2030, 76 million baby boomers 
will become eligible for Medicare. Even factoring in deaths 
over that period, the program will grow from approximately 47 
million beneficiaries today to roughly 80 million in 2030.
    Maintaining the solvency of the Medicare program while 
continuing to provide care to an ever-expanding beneficiary 
base is going to require creative solutions. It will not be 
easy, but we cannot put it off forever. And the longer we wait, 
the worse it will get.
    Now that I have had a chance to discuss the challenges 
facing CMS and some of Ms. Verma's qualifications, I would like 
to speak more generally about recent events.
    We have gone through a pretty rough patch recently on this 
committee, particularly as we have dealt with President Trump's 
nominations. I do not want to rehash the details of the past 
few weeks, but I will say that I hope that recent developments 
do not become the new normal for our committee.
    As I said before, I am going to do all I can to restore and 
maintain the customs and traditions of this committee, which 
has always operated with assumptions of bipartisanship, comity, 
and good faith.
    With regard to considering nominations, that means a robust 
and fair vetting process, a rigorous discussion among committee 
members, and, of course, a vote in an executive session. On 
that note, maybe the icy treatment of nominees is starting to 
thaw today; at least I hope it is.
    One tradition that has been absent before this session has 
been the introduction on many occasions of nominees by Senators 
of both parties from the nominees' home State, especially in 
cases when the nominee and the home State Senator have a 
relationship.
    I am pleased to say that the senior Senator from Indiana is 
reaffirming that tradition by appearing here today, and so is 
our other Senator from Indiana. I thank these Senators for 
taking time to appear today and to introduce their constituent. 
I will give them a chance to do so in just a few minutes.
    With that, I look forward to Ms. Verma sharing her vision 
and views here today. I also look forward to what I hope will 
be a full and fair committee process that allows us to process 
this nomination and report it to the full Senate in short 
order.
    [The prepared statement of Chairman Hatch appears in the 
appendix.]
    The Chairman. I will now at this time recognize my co-chair 
on this committee, Senator Wyden, for his opening statement.

             OPENING STATEMENT OF HON. RON WYDEN, 
                   A U.S. SENATOR FROM OREGON

    Senator Wyden. Thank you very much, Mr. Chairman.
    And welcome to you, Ms. Verma, and to our colleagues from 
Indiana.
    I just thought it was worth noting that with the Hoosier 
basketball tradition, Ms. Verma, it looks like you have brought 
close to two squads of basketball players. [Laughter.]
    And we welcome you and your family today.
    It is obvious that the health-care post that we are going 
to discuss today is not exactly dinner table conversation in 
much of America. But the fact is, it is one of the most 
consequential positions in government.
    The agency is responsible for the health care of over 100 
million Americans who count on Medicare and Medicaid. It plays 
a key role in implementing the Affordable Care Act. And that is 
why CMS needs experienced and qualified people for the job, 
people who know the ins and outs of the whole system: Medicare, 
Medicaid, and private insurance.
    The agency needs a strong and experienced authority. And 
this is particularly true now when it does appear that some of 
my colleagues on Capitol Hill, many in the administration, are 
looking to make radical changes to American health care. In my 
view, many of these proposals would take the country back to 
the days when health care was mostly for the healthy and the 
wealthy.
    So we are going to start with the promise of Medicare, 
which has always been a promise of guaranteed benefits. That 
makes up more than half of the agency's spending, about $2-
billion-plus a day. With more seniors entering the program each 
year, there is an awful lot to do to protect and, in my view, 
update the Medicare guarantee for this century. That means 
addressing the high cost of prescription drugs. It means making 
the program work better for those with chronic illnesses, like 
heart disease and cancer, which is the majority of the Medicare 
spending today. It is going to take bipartisan support.
    Privatizing Medicare is the wrong direction in my view. It 
is important to hear today, Ms. Verma, how your views differ 
from some of the policymakers who are advocating those kinds of 
approaches, who would literally be interested in turning the 
program into a voucher system.
    Additionally, if confirmed, you are going to play a key 
role in implementing the Medicare physician payment reforms. It 
is essential that they be implemented as intended by the 
Congress, because we want to start moving health care from 
paying for volume to paying for value.
    Also, the agency implements rules of the road in the 
private insurance market. And today, many of those rules amount 
to bedrock values for health insurance in the country. It means 
not discriminating against those with a preexisting condition 
no matter what. It means setting the bar for what type of 
medical care insurance companies have to cover. And it means 
letting young people stay on their parent's policy until 26.
    Unfortunately, just yesterday the agency released a 
proposed rule that, in my view, goes in the opposite direction. 
From where I sit, the message from yesterday's rule is, 
insurance companies are back in charge and patients are going 
to take a back seat.
    The open enrollment period, for example, was cut in half 
from 3 months to 6 weeks. If somebody dropped coverage during 
the year for any reason, insurance companies could collect back 
premiums before an individual can get health insurance again. 
And insurance companies would have free reign to offer less 
generous coverage at the same or higher cost.
    This, again, sounds to me like it is going back to yester-
year when the health-care system really did work for the 
healthy and wealthy.
    Now the administration has been saying, of course, that the 
best is yet to come. The evidence, it seems to me, suggests 
otherwise. The President could have taken steps to create more 
stability on a bipartisan basis, but instead issued an 
executive order on the day he was sworn in that is obviously 
now creating market uncertainty and anxiety. And you do not 
have to look much further than Humana's decision here in the 
last day or so.
    So we want to hear from you, Ms. Verma, this morning about 
how you are going to implement this program that millions of 
Americans count on and how you are going to do it even though 
we have Republicans here who want to unravel the law.
    In short, I want to see us get beyond what has come to be 
known as ``repeal and run.'' And repeal and run goes beyond 
disrupting the individual market. It would also end the 
Medicaid expansion that brought millions of low-income, 
vulnerable Americans into the health-care system. And this is 
an area, obviously, where you have extensive experience.
    I want to discuss some of the tradeoffs associated with 
those efforts. And I am particularly concerned about the 
possibility, as I have been informed, that somebody making 
barely $12,000 a year would get locked out of health coverage 
for no less than 6 months because they could not pay for health 
care due to an upcoming rent check, for example, or an 
emergency car repair.
    There has been an independent evaluation indicating that 
2,500 people were bumped from coverage due to situations like 
this.
    I have also seen in that same report that more than 20,000 
persons were pushed into a more expensive, less comprehensive 
Medicaid plan because they could not navigate this system that 
you all put in place.
    Now, I want to wrap up with just two last points, Mr. 
Chairman.
    One, with respect to taking these ideas on a nationwide 
tour, I am not there yet. And I say that respectfully. We will 
hear more about the program.
    And here is the point with respect to the States--and we 
touched on it in the office. We authored section 1332 of the 
Affordable Care Act, saying that States can do better. If 
States have an idea--better coverage, lower costs--God bless 
them, we are all for it, but we cannot use 1332 or any other 
provision for the States to do worse.
    One last issue that I want to touch on deals with Ms. 
Verma's work.
    As I understand it, you had a consulting firm. You all were 
awarded more than $8.3 million in contracts directly by the 
State of Indiana to advise the State. And that was while you 
all were managing the programs. In effect, you were the 
architect.
    At the same time, as has been told to me, you contracted 
with at least five other companies that provided hundreds of 
millions of dollars of services and products to these programs: 
HP Enterprises, Milliman, Maximus, Health Management 
Associates, Roche Diagnostics.
    And with at least two of these firms, HP and HMA, the terms 
of the State contracts appear to have had you, in effect, 
overseeing work that the firms performed.
    Now, George W. Bush had an ethics lawyer, a fellow named 
Richard Painter. He was not exactly a liberal guy, and he said 
yesterday that this arrangement, and I will quote him, 
``clearly should not happen and is definitely improper.'' He, 
in effect, said that you were on both sides of the deal helping 
to manage State health programs while being paid by vendors to 
the same programs.
    He said that was a conflict of interest. I want to hear you 
respond to his assertions.
    So we are going to want to know more about your work for 
companies that did business with the State. And one of the 
questions will be, if you are the CMS Administrator, if you are 
confirmed, would you recuse yourself from decisions that affect 
the companies that were your clients?
    We will look forward to your testimony with the two Indiana 
Senators. You are running with the right crowd.
    And thank you, Mr. Chairman.
    The Chairman. Well, thank you, Senator.
    [The prepared statement of Senator Wyden appears in the 
appendix.]
    The Chairman. I am pleased to hand over my normal witness 
introduction duties today to a pair of our distinguished 
colleagues. That both Senators from the Hoosier State will 
introduce Ms. Verma is a statement and a testament to her work 
and to her as a person.
    I ask that the senior Senator from Indiana, Mr. Donnelly, 
start the introduction, and then turn it over to Senator Young.
    Senator Donnelly, you go ahead and proceed.

                STATEMENT OF HON. JOE DONNELLY, 
                  A U.S. SENATOR FROM INDIANA

    Senator Donnelly. Thank you, Mr. Chairman.
    Chairman Hatch, Ranking Member Wyden, members of the 
committee, thank you for inviting me here today. It is a 
pleasure to be here with my friend and colleague Senator Todd 
Young to recognize this important accomplishment of a fellow 
Hoosier.
    As you know, any time the President nominates an individual 
for a leadership position in our government, it is an honor and 
a reflection of the tremendous trust and respect he has in that 
person.
    For this reason, I am pleased to be here today to help 
recognize Ms. Seema Verma for her nomination to be the next 
Administrator for the Centers for Medicare and Medicaid 
Services, CMS, and introduce her to this committee for your 
consideration.
    I have always held a personal belief that we accomplish 
more when we work together. In Indiana, we call that Hoosier 
common sense. And working collaboratively to help Hoosiers get 
access to quality health care is something Ms. Verma and I have 
had the opportunity to do together.
    As many of you are already aware, Ms. Verma has played a 
central role in crafting Medicaid policy in many States, 
including our own.
    In Indiana, she worked with Governor Daniels and then 
Governor Pence, as well as other State and Federal partners, to 
take advantage of opportunities made possible by the Affordable 
Care Act to expand Medicaid through the Healthy Indiana Plan, 
also known as HIP.
    Today, HIP 2.0 has helped to lower our State's uninsured 
rate, improve health-care outcomes, and has played a critical 
role in combating the opioid abuse and heroin use epidemics.
    Hundreds of thousands of Hoosiers currently have health 
insurance through HIP 2.0. And the program is an example of 
what is possible when we work together.
    As I have shared with Ms. Verma and I will share with you, 
I am deeply concerned about the future of health care in our 
country as well as the rhetoric surrounding the current debate. 
I firmly believe that maintaining access to critical programs 
like Medicaid and Medicare and building upon the progress of 
the ACA is fundamental to both the physical and financial well-
being of thousands of Americans across our country.
    It is my sincere hope that this administration, working 
with this committee and others, will approach Medicare and 
Medicaid with the thoughtful and pragmatic consideration these 
critical programs deserve.
    I have watched Ms. Verma take this common-sense Hoosier 
approach, and I hope she uses this opportunity today to share 
with you her vision for how she can work together with all of 
the members of this committee and Congress as a whole to expand 
access to quality health care and protect and build on the 
progress we have made over the last several years.
    With that, Chairman Hatch, Ranking Member Wyden, members of 
the committee, thank you for allowing me to introduce Ms. 
Verma.
    To Ms. Verma and her family, congratulations on this 
tremendous honor. I look forward to Ms. Verma's testimony.
    And I thank the committee for your hard work and your 
consideration of Ms. Verma for this very important position.
    The Chairman. Well, thank you very much.
    Senator Young, you now can proceed.

                 STATEMENT OF HON. TODD YOUNG, 
                  A U.S. SENATOR FROM INDIANA

    Senator Young. Well, thank you, Chairman Hatch, Ranking 
Member Wyden, and members of the committee. It truly is an 
honor to be with you to introduce a fellow Hoosier, Seema 
Verma, to be Administrator of the Centers for Medicare and 
Medicaid Services.
    You know, President Trump simply could not have made a 
better choice in selecting Seema to lead what is arguably the 
most important office within HHS, an office that covers the 
health-care needs of over 100 million Americans, with a budget 
of almost $1 trillion.
    In her 20-year career as an innovator in the health-care 
sector, she has worked extensively with a variety of 
stakeholders from both sides of the aisle to deliver better 
access to health care.
    As president, CEO, and founder of SVC, she helped several 
States to redesign their archaic Medicaid systems, including in 
my home State of Indiana. Seema revolutionized the Medicaid 
program as architect of the Healthy Indiana Plan, which we know 
as HIP. It is the Nation's first consumer-directed Medicaid 
program. She transformed a complex, rigid Medicaid system into 
one where Hoosiers are back in control of their health-care 
needs.
    Since 2007, HIP has achieved impressive results. Hoosiers 
are more likely to seek preventative care, take their 
prescription medications, and seek primary care services at 
their physician's office, not the emergency room.
    Seema's innovative idea is working and is now an important 
proof of the concept that Medicaid can be more efficient than a 
one-size-fits-all approach. And she accomplished this with the 
support and buy-in from people, again, on both sides of the 
aisle and at all levels of the process.
    By putting the mission above politics, she demonstrated a 
willingness to work with anyone--anyone--who was willing to do 
the same. She worked with Democrats in the Indiana Statehouse. 
She worked with the Obama administration to find common ground 
on how to best provide quality health care to hundreds of 
thousands of low-income Hoosiers. And it worked.
    As CMS Administrator, Seema will have the ability to use 
her extensive experience to help other States achieve what we 
have in Indiana: better health outcomes for our most 
vulnerable. I look forward to working with her.
    I thank you, sir.
    The Chairman. Well, thanks to both of you, Senators. It is 
a real honor for the committee to have both of you come. And I 
know Ms. Verma really appreciates it.
    Senator Young. Thank you.
    The Chairman. We know you are busy, so we will let you go.
    Ms. Verma, we are now going to turn to you for your 
comments and your feelings on this nomination, and then we will 
turn to questions from the Senators up here.

   STATEMENT OF SEEMA VERMA, NOMINATED TO BE ADMINISTRATOR, 
   CENTERS FOR MEDICARE AND MEDICAID SERVICES, DEPARTMENT OF 
           HEALTH AND HUMAN SERVICES, WASHINGTON, DC

    Ms. Verma. Good morning, Chairman Hatch and Ranking Member 
Wyden. I appreciate and am grateful for your consideration of 
my nomination by President Trump to be the Administrator for 
the Centers for Medicare and Medicaid Services. And I thank you 
for the time that many of you have spent with me in advance of 
the hearing. And I appreciate hearing about your priorities.
    Before I begin my statement, I would like to take a moment 
to introduce my family. With me today are my parents, Mr. and 
Mrs. Verma; my husband Sanjay; my two kids, Maya and Shaan; and 
the rest of my family and friends who are here with me. I 
really appreciate it; thank you.
    I have often been asked by my family and my friends, as 
well as many members of this committee, why I would be 
interested in this job. I was honored and humbled and accepted 
President Trump's call to service because I understand what is 
at stake.
    I have never stood on the sidelines of our Nation's health-
care debate, merely pointing out what is wrong with our health-
care system. More than 20 years ago when I graduated from 
college, I started my career working on national policy on 
behalf of people with HIV and AIDS, as well as for low-income 
mothers to improve birth outcomes.
    I fought for coverage, greater health-care access, and for 
improving the quality of care, and I have continued to fight 
for these issues for the past 20 years.
    But I am deeply concerned about the state of our health-
care system, as there is frustration all around. Many Americans 
are not getting the care that they need, and we have a long way 
to go in improving the health status of Americans.
    Doctors are increasingly frustrated by the number of costly 
and time-consuming burdens. Health care continues to grow more 
and more expensive, and the American people are tired of 
partisan politics. They just want their health-care system to 
be fixed. And I know this, not simply because I have worked in 
health care, but because of how intimately it has affected my 
own personal life.
    My mother is a breast cancer survivor, due to early 
diagnosis and treatment. And a few years back, my neighbor 
Aidan was diagnosed with a stage IV neuroblastoma. He was only 
4 years old. A large tumor had been growing for some time, 
maybe since he was born, and it was wrapped all around his 
kidney. Aiden went through excruciating, painful chemotherapy, 
radiation, stem cell treatment, and surgeries, all 
experimental.
    This May, Aidan will celebrate his 12th birthday. And both 
my mom and Aidan are testaments to the grace of God and the 
ingenuity of the American health-care system. This is why 
people travel from all across the world to get care in the 
United States.
    I want to be part of the solution, making sure that the 
health-care system works for all Americans so that families 
like my own and Aidan's have the care that they need. I want to 
be able to look my children in the eye and tell them that I did 
my part to serve my country and to be a voice for people who 
often do not have one.
    This is a formidable challenge, but I am no stranger to 
achieving success under difficult circumstances.
    My father left his entire family to immigrate to the United 
States during the 1960s and pursued four degrees while working 
to earn money. On my mother's side, my grandmother was married 
at the age of 17 with no more than a fifth-grade education, but 
my mother went on to be the first woman in her family to finish 
a master's degree.
    My parents made a lot of sacrifices along the way to 
provide me with the opportunities that they did not have and 
have taught me the value of hard work and determination.
    I am extremely humbled as a first-generation American to be 
sitting before this committee after being nominated by the 
President of the United States. It is a testament to the fact 
that the American dream is very much alive for those willing to 
work for it. And it is my dream and my passion to work on the 
front lines of health care to improve our system.
    Throughout my career, I have brought people together from 
all sides of the political spectrum to forge solutions that 
worked for everyone. One of my proudest moments in my career 
was watching the Indiana legislature pass the Healthy Indiana 
Plan, which is a program for the uninsured, with a bipartisan 
vote.
    CMS is a $1-trillion agency and covers over 100 million 
people, many of whom are amongst our Nation's most vulnerable 
citizens. Providing high-quality, accessible health care for 
these Americans is not just a luxury, it is a necessity and 
often a matter of life and death.
    Should I be confirmed, I will work with the CMS team to 
ensure that the programs are focused on achieving positive 
health outcomes and improving the health of the people whom we 
serve. To achieve this goal, I will work towards policies that 
foster patient-centered approaches that increase competition, 
quality, and access, while driving down costs.
    Patients and their doctors should be making decisions about 
their health care, not the Federal Government. We must find 
creative ways to empower people to take ownership for their 
health. We should support doctors in providing high-quality 
care to their patients and ensuring that CMS's rules and 
regulations do not drive doctors and providers from serving the 
people, our beneficiaries.
    If confirmed, I will work towards modernizing CMS's 
programs to address the changing needs of the people they 
serve, leveraging innovation and technology to drive better 
care. I will ensure that efforts around preventing fraud and 
abuse are a priority, because we cannot afford to waste a 
single taxpayer dollar. I will work towards ushering in a new 
era of State flexibility and leadership to drive better 
outcomes.
    If I have the honor of being confirmed, I will carry this 
vision along with my strong belief in open communication, 
collaboration, and bipartisanship. I will work with you, be 
responsive to your inquiries and concerns, and value your 
counsel.
    I thank you for the consideration of my nomination.
    The Chairman. Well, thank you so much. We really appreciate 
your willingness to serve. And I look forward to getting you 
through this process.
    [The prepared statement of Ms. Verma appears in the 
appendix.]
    The Chairman. I have some obligatory questions to ask you. 
First, is there anything that you are aware of in your 
background that might present a conflict of interest with the 
duties of the office to which you have been nominated?
    Ms. Verma. Sir, I have met, consulted with the Office of 
Ethics, and have indicated any areas where I thought there 
would be an issue. And I will be recusing myself of any matters 
that would present any potential conflict.
    The Chairman. Well, thank you.
    Do you know of any reason, personal or otherwise, that 
would in any way prevent you from fully and honorably 
discharging the responsibilities of the office to which you 
have been nominated?
    Ms. Verma. I do not.
    The Chairman. Do you agree, without reservation, to respond 
to any reasonable summons to appear and testify before any duly 
constituted committee of the Congress, if you are confirmed?
    Ms. Verma. I do not.
    The Chairman. You are willing to do that?
    Ms. Verma. I am willing to do that.
    The Chairman. All right.
    Finally, do you commit to provide a prompt response in 
writing to any questions addressed to you by any Senator on 
this committee?
    Ms. Verma. I do.
    The Chairman. Well, thank you.
    Let me now just get into some questions. I know you are 
aware of the historic bipartisan Medicare Access and CHIP 
Reauthorization Act of 2015, which I had a lot to do with, or 
what is called MACRA. Among other things, the law got rid of 
the dreaded SGR formula and made improvements to how Medicare 
pays physicians.
    And I am pleased that our work on the implementation of 
these changes continues to be bipartisan, both in how 
Republicans and Democrats in the Congress have worked together 
and how Congress had worked with the Obama administration. In 
fact, the Obama administration took great pains to engage 
physicians and other stakeholders through the initial 
implementation phase.
    Now, it strikes me that this process of consultation early 
and often should be the rule and not the exception.
    What is your view on how to engage stakeholders to arrive 
at the best policy decisions for Medicare and other CMS 
programs?
    Ms. Verma. Thank you, Senator. And I applaud Congress's 
efforts to pass MACRA. I think it is an important step forward, 
not only to providing more stability for providers, but also 
moving us towards better outcomes.
    You know, in terms of stakeholders, I think that the most 
important thing that we can do is engage with stakeholders as 
quickly as possible on the front end and all the way through 
the process, understanding stakeholder perspective and what 
folks are going through on the front end, what their challenges 
are. And, as we are developing policies and programs, to have 
that open communication I think is helpful towards any 
successful implementation. It is not a one-time thing. It is 
not just on the front end. It is all the way through the 
process.
    And even after the program is established, it is always 
important to have that dialogue with stakeholders, because they 
can tell you what is working and what is not working. And when 
you think of new ideas and you are thinking about implementing 
them, they can help you figure out whether it is going to work 
or not.
    I know I have had that experience in my career, and I have 
always found it very helpful and an integral part of success.
    The Chairman. As the baby boomer generation ages, the 
number of persons age 65 and older in the United States is 
expected to dramatically increase, fueling an increase in the 
demand for long-term services and supports.
    Notably, Medicaid is the primary payer of these services. 
What changes, if any, should be made to meet the expected 
increase in demand while ensuring the fiscal sustainability of 
the Medicaid program?
    Ms. Verma. I think Medicaid is a very important program. It 
has been the safety net for so many vulnerable citizens.
    When I think about the Medicaid program, I think about some 
of the individuals whom I have met. One person in particular I 
think about is a quadriplegic. He is on a breathing machine, 
and he requires 24-hour care. I think about the mother of a 
disabled child. And this is the face of the Medicaid program.
    As we think about the Medicaid program and where we are 
today, I think that we can do better. We have the challenge of 
making sure that we are providing better care for these 
individuals, but the program is not working as well as it can. 
This is a very intractable program, it is inflexible; States 
are in a situation where they are having to go back and forth 
doing reams of paperwork, trying to get approvals from the 
Federal Government. And at the end of the day, are we achieving 
the outcomes that we want to achieve?
    So as I think about the Medicaid program, I think there is 
an opportunity to make that program work better so that we are 
focusing on improving outcomes for the individuals who are 
served by the program.
    The Chairman. All right. In 2014, I worked closely with 
Senator Wyden and leaders from the House Ways and Means 
Committee to enact a bipartisan, bicameral law called the 
Improving Medicare Post-Acute Care Transformation, or IMPACT, 
Act.
    The IMPACT Act serves as a critical building block to 
achieve future Medicare post-acute quality measurement and 
payment reform.
    Specifically, the IMPACT Act requires the collection of 
standardized data to help Medicare not only compare quality 
across the different post-acute care settings, but also improve 
hospital and post-acute discharge planning. And our goal was to 
produce data-driven evidence that Congress can use to debate 
the best ways to align Medicare post-acute payments that 
improve patient outcomes and save taxpayer dollars. And our 
intention was to ensure that we are able to do this type of 
thing.
    We want to ensure that beneficiaries are receiving the 
highest-quality post-acute care services in the right setting 
at the right time.
    Now, will you commit to working with me and members of 
Congress and this committee and the post-acute provider 
community on the implementation of the IMPACT Act?
    Ms. Verma. It would be my pleasure to work with the 
committee, stakeholders, and anyone else who is interested in 
making that program a success.
    The Chairman. Well, thank you.
    We will turn to Senator Wyden.
    Senator Wyden. Thank you very much, Ms. Verma. And thank 
you for your testimony.
    I want to start with a comment you made that you were 
committed to coverage, which, of course, is what this is all 
about.
    Unfortunately, what I have seen since the beginning of the 
year has been basically about rolling back coverage. And in 
fact, Congressman Price sat in your seat a couple of weeks ago 
and refused to commit to making sure that no one would be worse 
off in terms of coverage.
    Now, the President said in his campaign, and I will quote, 
``We are going to have insurance for everybody. The American 
people are going to have great health care, much less expensive 
and much better.'' That is what the President said.
    Yesterday, CMS did the exact opposite. The first rule to 
come out of the agency--the agency that you would head--after 
Secretary Price was confirmed meant less coverage, higher 
premiums, and more out-of-pocket costs for working families.
    How would you square what President Trump said in the 
campaign with what CMS did yesterday?
    Ms. Verma. Sir, in terms of the rule that you speak of, I 
have not been involved in the development of that rule. Out of 
respect for the committee and for the nomination process, I 
have not been involved in that, have not been to CMS, so I have 
not been involved in that and I cannot speak to that.
    What I can tell you is that I am committed to coverage. I 
have been fighting on this issue for 20 years. And I will 
continue to do that if I am confirmed.
    Senator Wyden. But I just read you quotes, and it is not 
like, you know, atomic secrets or classified materials. What 
the President said is very different than what CMS did 
yesterday.
    And you read newspapers; you are a very informed person. It 
talked about cutting the enrollment period. I am looking at the 
headline, ``cut the enrollment period in half,'' which really 
is going to limit our ability to get the very people we need 
most, the younger, healthier people.
    So one more try. How would you square what the President 
said with what happened yesterday?
    Ms. Verma. I think the President and I are both committed 
to coverage. I cannot speak to the rule. I have not had an 
opportunity to review that. But again, I think the President 
and I both agree that we need to fight for coverage and make 
sure that all Americans have access to affordable, high-quality 
health care.
    Senator Wyden. What troubles me about yesterday is, once 
again insurance companies are coming first and patients come 
later. Tell me one thing you would change to put patients 
first.
    Ms. Verma. One thing that I would do is--I think what is 
very important is that patients be in charge of their health 
care, that patients get to drive the decisions about their 
health care, that they get to make the choices about what kind 
of health care plan works well for them.
    I think it is important that our patients have access to 
quality coverage, to their choice of doctors and their choice 
of plan.
    Senator Wyden. Could you give us a specific on that? 
Because that is an admirable philosophy, but I still do not 
know----
    Yesterday was good for insurance companies, and it was bad 
for patients. I would like to have a specific example, and we 
will keep the record open, of something you would do to put 
patients first.
    And I respect the fact that you have articulated a 
philosophy, but I really want to know a specific about what you 
would do to put patients first.
    Let us move on with respect to another area of 
responsibility you will have, and that is prescription drugs 
and Medicare, because we all know that these prescription costs 
are just clobbering families and seniors, the Federal 
Government, and a whole variety of stakeholders that you 
referred to.
    As the Administrator of the agency, you are going to have 
an opportunity to address this problem. The President has been 
vocal on it. Again, give me a specific change to Medicare Part 
D that you would suggest to bring costs down.
    Ms. Verma. Well, I think that the issue of drug pricing is 
something that all Americans are concerned about. And the 
President is concerned about that as well. People want to make 
sure that when they need the drugs, when they're going through 
an illness--I mean, I think about my mom, I think about my 
neighbor Aidan, and when they need the drugs that they need, 
they want to know that they have access to them and that they 
are affordable. So I think we are all concerned about that 
specific issue.
    Part D, I think, has been a good program. It has expanded 
access to medications for people who did not have them before. 
And I think the structure of the program in terms of how it 
puts senior citizens in charge of their health care, they can 
go on Plan Finder, go online----
    Senator Wyden. My time is up, Ms. Verma. I voted for Part 
D. I still have the welts on my back to show for it. I asked 
you for a specific change going forward that you would do to 
help seniors and others hold down their costs.
    As you know, there is discussion of making changes so that 
Medicare could bargain. Is there one specific you could give 
me?
    And the reason that the Medicare question is so important 
is, not only does this affect older people so dramatically, but 
your experience is on the Medicaid side, and I respect that. 
People have different experiences. So I very much would like to 
hear a specific on this key Medicare issue that you would 
actually be for.
    Ms. Verma. I would be for policies that continue to put 
senior citizens in charge of their health care, that put them 
in the driver's seat of making the decisions that work best for 
them so that they can figure out what plan covers the 
medications that they need, what plan is affordable to them and 
allows them to make the decisions about their health care and 
that gives them access to the medications that they need, that 
doesn't limit that in any way and that is affordable to them.
    Senator Wyden. My time has expired.
    I still did not get a specific example. I happen to be for 
a host of things on transparency, on negotiation, on trying to 
make sure that we squeeze more cost savings out of the middle 
men.
    I am going to hold the record open, but I have asked you 
for specifics in two areas: putting patients first and how you 
would hold down the costs of Part D. Respectfully, I did not 
get a specific. We will hold the record open for it.
    I think, Senator Grassley, you are going to call out names 
on your side?
    Senator Grassley. Got next. [Laughter.]
    Senator Wyden. That did not take much time.
    Senator Grassley. What I am going to talk to you about is 
things that have happened at CMS in the past. And hopefully, 
coming from an administration that wants to drain the swamp, I 
think I would expect changes to be made under your leadership 
in this agency.
    And I would suggest that you probably cannot do anything 
about the suggestion I am going to give you to respond to the 
last question of my colleague, but if you would push doing away 
with pay-for-delay programs between brand drugs and generics, I 
think it would go a long ways to helping get drugs cheaper.
    CMS has told me that it does not have much authority to do 
anything about some frauds committed against its programs, even 
if those actions are in CMS's own words, quote, unquote, ``a 
clear violation of the laws.''
    And common sense tells me that if it is a clear violation 
of the law, CMS can do something about it. And if that is their 
attitude there, I would ask you to see whether the past 
interpretation is right by checking that interpretation.
    But in a January 28th letter to me about the Medicaid drug 
rebate program, CMS said it could tell a manufacturer when its 
drugs are misclassified and then, quote, unquote, ``attempt to 
reach an agreement.'' In other words, after the money has been 
stolen from the taxpayers, it takes some trouble to get it 
back, if you can reach an agreement.
    But there are a lot of tools that the government has to 
fight fraud. And the most effective one we have is the False 
Claims Act. Since 1987 when I got that law in place, the 
Department of Justice has used the False Claims Act to recover 
more than $33.9 billion lost from just health-care fraud alone. 
But cooperation between the Department of Justice and the 
health-care program administrators is very important in these 
cases.
    It seems like CMS could at least have picked up the phone 
and given the Department of Justice a heads-up when these 
manufacturers refused to cooperate and properly classify their 
drugs.
    So a pretty simple question; it might even be called a 
softball question, but it is pretty important to me. Would you 
commit to proactively cooperating with the Department of 
Justice in fraud cases and to fully supporting the use of the 
False Claims Act to combat fraud on government health-care 
programs?
    Ms. Verma. I will absolutely do that. And I applaud your 
efforts on the False Claims Act. I think it has been an 
integral component of preventing fraud and recovering dollars 
when there is fraud. So I thank you for your service and your 
work on that.
    Senator Grassley. Next question: in the fall of 2016 and in 
January of 2017, I sent several oversight letters to CMS 
regarding the steps that it took to hold Mylan accountable for 
misclassifying the EpiPen as a generic under the Medicaid drug 
rebate program. CMS has publicly stated that it, quote, 
``expressly advised Mylan that their classification of the 
EpiPen for purposes of the Medicaid drug rebate program was 
incorrect.''
    However, CMS has failed to fully respond to my oversight 
requests and refuses to provide records of communication with 
Mylan. CMS has also not been entirely clear as to what has to 
be done to correct drug misclassifications. Because of EpiPen's 
misclassification, the government and States are owed hundreds 
of millions of dollars from Mylan. Congress and the American 
people are owed answers.
    So if confirmed, would you commit to fully responding to my 
oversight request and providing the requested records of 
communication between Mylan and CMS? I hope that is a short 
``yes.''
    Ms. Verma. That is a short ``yes.''
    Senator Grassley. All right. In light of EpiPen's 
misclassification and potentially other drugs that have been 
misclassified under Medicaid, what steps will you take to 
ensure that drugs are properly classified under Medicaid?
    Ms. Verma. I think what happened with Mylan and the EpiPen 
issue is very disturbing. The idea that perhaps Medicaid 
programs, which are struggling to pay for those programs, that 
they could have potentially received rebates, is disturbing to 
me.
    And so, if I am confirmed, I would like to review the 
processes in place there in terms of the classifications, in 
terms of brand and generic, to assure that that type of thing 
does not happen again.
    Senator Grassley. And what you just said you want to do, I 
want to do, and that is why I want those communications from 
CMS. I hope you can get them for me.
    Ms. Verma. Well, I will be happy to work with you on that, 
Senator.
    Senator Grassley. Senator Stabenow?
    Senator Stabenow. Well, thank you very much.
    And welcome. Welcome to you and your family.
    First thing--there are many, many questions I have--but 
first, regarding Medicare, do you believe that Medicare 
programs should negotiate the best price for seniors on 
Medicare?
    Ms. Verma. I think that we need to do everything that we 
can do to make drugs more affordable for seniors. And I am 
thankful that we have the PBMs in the Part D program that are 
performing that negotiation on behalf of seniors.
    Senator Stabenow. Do you believe we could get a better 
price if Medicare was negotiating as the V.A. does, as other 
private entities do to get the best price for seniors?
    Ms. Verma. I think that competition is the key to getting 
good prices.
    Senator Stabenow. So is that ``yes'' or ``no'' on 
negotiation?
    Ms. Verma. I do not think that is a simple ``yes'' or 
``no'' answer, because I think there are many ways to achieve 
that goal. And the goal is to make sure that we are getting 
affordable prices for our seniors.
    I mean, if we look at the Part D program and the way the 
PBMs have negotiated this, we know that when there is a lot of 
competition, the price goes down. So I think we have to figure 
out ways--and I am happy to work with you on that--that we can 
increase our competitiveness and support the Part D program.
    What I like about the Part D program is that it puts 
seniors in charge of making the decisions about the drugs that 
they need. Using the Plan Finder tool, they can go in there, 
they can put in the medications that they need, and then they--
--
    Senator Stabenow. No, I understand that. I am going to stop 
you, just because I do not have a lot of time.
    Ms. Verma. Sure.
    Senator Stabenow. Under the repeal of the Affordable Care 
Act, actually seniors would begin to pay more, because the gap 
in coverage for those who use a lot of medicine would appear 
again. So we have closed that, no gap for seniors, and that 
would reopen.
    Do you support that as part of the repeal?
    Ms. Verma. I think that, as I said before, it is important 
to help seniors get the most affordable drug prices that they 
can get.
    Senator Stabenow. Do you support returning to a gap in 
coverage for seniors under Medicare Part D?
    Ms. Verma. I support seniors having access to affordable 
medications and the medications that they need, that they 
choose.
    Senator Stabenow. All right. Let me ask this now to follow 
up a little bit more on yesterday's decision regarding CMS.
    One of the things that they decided to do yesterday was to 
cut in half the open enrollment period for people to be able to 
get insurance, from 3 months to 6 weeks. Do you support that?
    Ms. Verma. You know, I have not had a chance to review that 
rule. I was not involved in the development of that with 
respect to the process.
    Senator Stabenow. Does it seem like a good idea?
    Ms. Verma. I am sorry?
    Senator Stabenow. Does it seem like a good idea, from your 
standpoint, to shorten the amount of time?
    Ms. Verma. You know, I want to review the implications of 
that. I was not, as I said before, with respect to this 
process, I have not been to HHS, have not been to CMS, and have 
not been involved in the development of that rule. So I would 
look forward to reviewing that and would be happy to report 
back to you after I have had a chance to review that.
    Senator Stabenow. When we look at another really important 
set of provisions in the Affordable Care Act--it is something I 
call patient protections--everybody with insurance, it does not 
matter who it is, has more ability right now to get the care 
that they are paying for through their insurance. It is not 
just the decision of the insurance company.
    So there are a number of different things that folks can 
now count on. And one is having an essential set of basic 
health-care services that is defined so that insurance 
companies are betting that everybody knows there is a basic set 
of services, that as a woman you will get maternity care, that 
mental health will be covered the same as physical health, or 
substance abuse services, and so on. So there is a basic set of 
services.
    Do you support having that basic set of essential services 
in our health-care system?
    Ms. Verma. I support Americans being in charge of their 
health care. I support Americans being able to decide what 
benefit package works best for them. I think it is hard to 
know. What works for one person might not work for another 
person. And I think it is important that people be able to make 
the decisions that work best for them and their families.
    As a mother of two children, you know, in a family, I know 
what we are looking for. But what I am looking for might not 
work for another family. And so I support Americans being in 
control of their health care and making the decisions that work 
best for them and their families.
    Senator Stabenow. Do you believe that women should have to 
pay more to get prenatal care and basic maternity care, as a 
rider, as an extra coverage?
    Ms. Verma. You know, I am a woman, so I certainly support 
women having access to the care that they need. I have two 
children of my own, and I have appreciated that the services 
they want----
    Senator Stabenow. Should we as women be paying more for 
health care because we are women?
    Ms. Verma. I think that women should be able to make the 
decisions that work best for them.
    Senator Stabenow. But if the decision is made by the 
insurance company as to what to charge, how do we make that 
decision?
    Prior to the Affordable Care Act, I have said many times, 
about 70 percent of the insurance companies in the private 
marketplace did not cover basic maternity care and basically 
looked at being a woman as a preexisting condition. Different 
kinds of health services that we need were not provided, were 
not viewed as essential services.
    And that has changed now, where women have what are basic 
services for us covered as basic services, where we do not have 
to pay extra as a rider in order to get basic care.
    And so I am just asking, do you think that makes sense?
    Ms. Verma. You know, obviously, I do not want to see women 
being discriminated against. I am a woman, and I appreciate 
that.
    But I also think that women have to make the decisions that 
work best for them and their family. Some women might want 
maternity coverage and some women might not want it, might not 
choose it, might not feel like they need that.
    So I think it is up to women to make the decision that 
works best for them and their families.
    Senator Stabenow. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. As you can imagine, we are now having two 
votes. And there is nobody here to question, so I think what I 
will do is recess for about 15 minutes. Sorry to interrupt like 
this, but that is the life of a U.S. Senator.
    And we surely appreciate you and appreciate your patience. 
And I appreciate the way you are answering these questions 
straight-up, and your expertise really comes through.
    So with that, I will just recess for about 15 minutes. 
Hopefully I can get to the second vote and be right back.
    Ms. Verma. Thank you.
    The Chairman. We will revoke the recess, and we will turn 
to Senator Roberts.
    Senator Roberts. Well, thank you, Mr. Chairman.
    And congratulations on your nomination, Ms. Verma. Thank 
you for paying a courtesy call to my office. We had a very, 
very good discussion. You have a very impressive record with 
regard to Medicaid, more especially pushing for greater 
innovation and flexibility in the program.
    I must say, your opening statement was not only relevant, 
right on point, but inspiring as well. Thank you for that. I 
think I would speak for all members of the committee. We need 
to make a copy of her statement available, Mr. Chairman, to 
virtually every member, maybe test them on it to see if we, you 
know, can bring things back together.
    The Chairman. I agree with that, and we might do that. All 
right.
    Senator Roberts. As co-chair of the Senate Rural Health 
Care Caucus, I am particularly concerned with how regulations 
coming out of your agency work or often do not work for our 
small and rural providers. We talked about that.
    And I am also interested in how we harness their innovation 
to develop payment and delivery models that are better-tailored 
to their communities and their needs, given their low volume of 
patients and high number of Medicare and Medicaid patients. I 
know you are very familiar with that with your work in Indiana.
    How do we work to include our small and rural providers in 
quality improvement programs without disadvantaging them due to 
the unique populations they serve?
    Secondly, would rural-relevant quality measures or 
different data thresholds be more appropriate to encourage 
participation in certain value-based purchasing and/or pay-for-
performance programs?
    Ms. Verma. Thank you for your questions, Senator. You know, 
rural health providers have very unique and special challenges. 
I mean, often they are the only providers in their communities 
that are providing services, and so when people come to them, 
they are dealing with a variety of different health issues. It 
is not just primary care and preventative care. It could be 
specialty care. And they do not always have access to those 
services.
    The challenge for them is that even attracting a workforce 
and finding providers to come out to those regions is a 
challenge and it is difficult. And because they have those 
multiple challenges, it is difficult for them when there are 
lots of rules and regulations coming down from the Federal 
Government.
    As a small-business owner and working with small physician 
offices, we sort of understand that it is difficult sometimes 
when they are on the front lines and they are trying to manage 
such very complex situations. To also deal with rules and 
regulations is difficult.
    That being said, we want to assure that all Americans have 
access to high-quality health care. But I think we have to be 
very careful with our rural providers to make sure that we are 
not putting additional burdens on them that actually, you know, 
impact accessibility to care or quality of care.
    So I think when it comes to rural providers, we need to 
support them through the process. We need to make sure that 
they have the appropriate technical assistance to get where 
they need to be and understand that the demands they have on 
their time might impact their ability to implement those 
regulations.
    Senator Roberts. I really appreciate that. I think we have 
83, probably more today, critical access hospitals. And I know 
you have the same situation in Indiana. Thank you for your 
statement.
    As a member of both the HELP and Finance Committees, as 
many of my colleagues are, we often see a disconnect between 
new and exciting therapies that are approved by the FDA and 
reimbursement policies from CMS.
    Take biosimilars, for example. Last year, only one, one 
biosimilar, was approved by the FDA. And guidance documents 
were still outstanding. CMS proposed and then finalized a 
payment policy that could stifle innovation in this area.
    How would you anticipate working with the FDA to ensure CMS 
is developing the best payment policies for patients, 
providers, and the taxpayer?
    Ms. Verma. Well, I think collaboration and coordination are 
critical within HHS. I appreciate Secretary Price and his 
leadership there. Careful coordination and collaboration 
between similar agencies or sister agencies are important.
    I think being on the front end and discussing with them, 
understanding what their intentions are, what is coming down 
the pipeline, and making sure that CMS is prepared and 
coordinated with any efforts that the FDA has, is important.
    Senator Roberts. I must tell you that, in the rural health 
care delivery system, in talking to many of my hospital 
administrators and the rural providers--you are in charge of 
CMS--the term used a lot in the past has been ``it is a mess.'' 
I know you are going to fix that.
    But there is CMS's Center for Consumer Information and 
Insurance Oversight; CCIIO, that is the new acronym. I was not 
aware of that. I thought I knew most of them. It has 
responsibility for developing and implementing policies and 
rules governing and administering the Affordable Care Act's 
marketplace.
    What role do you see CCIIO playing under your leadership?
    Ms. Verma. If I am confirmed as Administrator, my job will 
be to implement the law. CCIIO is playing a role with the 
current law, and so I would look to Congress and its efforts 
around addressing the Affordable Care Act. And my assessment of 
the role of CCIIO will depend on what Congress decides to do 
with the Affordable Care Act. And so I will make that decision 
based on the ultimate outcome of Congress's decisions around 
the Affordable Care Act.
    Senator Roberts. I must say, Mr. Chairman, that I am 
impressed with your statement. I know that we have had several 
Senators talk about unraveling Obamacare. We had an entire 
insurance company leave the market. We have another one 
describing it as a death spiral.
    I think we need to see a rescue team to make sure that that 
bridge is still there, but build new bridges. And I think that 
would be my take on that.
    Thank you so much for your testimony. And thank you for the 
leadership that I know you are going to bring to CMS.
    Ms. Verma. Thank you, Senator.
    The Chairman. Well, thank you, Senator.
    While we are waiting for other questioners, let me just ask 
a question.
    One of the issues this committee has focused on over the 
past 3 years is the large backlog of Medicare appeals resulting 
from audits performed by CMS contractors. At the same time, 
improper payments pose a real threat to the financial well-
being of the Medicare and Medicaid programs.
    So what are your views on how to balance the need for 
robust program integrity and claims accuracy with the need to 
ensure timely payment to providers without causing them too 
much undue burden?
    Ms. Verma. Well, I think that that is a very important 
question. Fraud and abuse, if I am confirmed, would be a top 
priority. That is what I would call, you know, low-hanging 
fruit as we look at the Medicare program and assure its 
sustainability over the long term. And given the Medicare 
trustees' report about the future of Medicare and running out 
of money at some point, we just cannot afford to waste a single 
taxpayer dollar.
    And so, if I think about fraud and abuse, and especially 
fraud prevention, it is looking to have an effort to really be 
on the front end, not waiting to do a pay and then chase, but 
really addressing fraud on the front end.
    And so, as we are developing programs, we need to make sure 
that we are putting those procedures and policies in place so 
that we can identify fraud and abuse on the front end.
    I think the issue that you raise in terms of the backlog 
and the burden that it puts on providers is something that 
concerns me. And we want to make sure, with CMS's policies, 
that we are not preventing providers from participating in the 
program and being active in it.
    And the backlog and things like that have really made it 
difficult for providers when they are not getting paid for 
these types of issues. And so I think it is a balance that we 
have to strike with being aggressive on fraud and abuse and 
focusing our penalty efforts on the bad players without 
penalizing providers that are trying to do the right thing.
    The Chairman. Well, thank you. States are increasingly 
moving their Medicaid programs into a managed care delivery 
system, with managed care now representing almost 40 percent of 
Federal Medicaid spending.
    Now, in the last year, CMS released an updated regulatory 
framework for Medicaid managed care. What if any changes do you 
believe are important to Federal and State oversight of 
Medicaid managed care?
    Ms. Verma. Well, I think that managed care has been an 
important opportunity for States. It gives them the ability to 
set a capitation rate with providers and hold the managed care 
companies accountable for meeting that financial demand.
    And it is also an opportunity to identify goals and 
outcomes and hold these companies accountable for the care and 
the outcomes that they provide.
    In terms of the regulatory framework and the managed care 
role, I think that we probably need to move to an era where we 
are holding States accountable for outcomes, but having States 
go through pages and pages of regulations--my question would 
be, for that regulation, what does it do to improve health 
outcomes for the individual?
    I am all about wanting to make sure that we are being 
appropriate with our health-care dollars and managing resources 
effectively. But when we look at a regulation, is that 
regulation helping States improve health outcomes?
    States will spend millions of dollars implementing that 
particular regulation. And I think we have to ask ourselves, 
what will we achieve?
    So I think there are some important developments within the 
managed care regulation, but if I am confirmed, I would want to 
take a look at that to make sure that we are not burdening 
States with additional regulations.
    The Chairman. All right. Let me ask you this. Your written 
statement alludes to providers struggling to deal with 
administrative burdens. And while we certainly need providers 
to be accountable for the care they provide and the associated 
government spending, it is crucial to minimize the regulatory 
requirements that take time away from treating patients.
    Now, we have heard concerns regarding the very specific 
requirements that are a part of the Medicare and Medicaid 
Electronic Health Record Incentive Program. We also hear that 
many other requirements are unneeded or outdated.
    So how do you think CMS could best go about the important 
task of reducing unnecessary regulations?
    Ms. Verma. Well, I think one of the places to start is by 
talking to doctors and having open communication and 
collaboration with physicians. If I am confirmed, that would be 
a priority for me: to touch base with our providers and 
understand the issues that are getting in the way of them being 
able to provide high-quality care to the patients that they 
serve.
    I would want to identify the types of regulations and 
provisions that are causing providers perhaps to consider maybe 
not participating in the program. So I think I would start with 
that open communication and dialogue and work with them to 
understand what their concerns are.
    The Chairman. Well, thank you.
    I think I will turn to Senator Wyden for any questions he 
has.
    Senator Wyden. Thank you very much, Mr. Chairman.
    And you know, again, Ms. Verma, I am just trying to get a 
sense of how you would approach some of these things. That is 
why I asked apropos of what CMS did--just one example, a 
specific example about putting patients first. Same thing with 
respect to, you know, Medicare Part D.
    On this committee, as the chairman touched on, colleagues 
touched on, members feel very strongly about rural practices 
and rural patients, and we feel very strongly about making sure 
that we get MACRA right.
    And when I am home in Oregon, I get asked about two key 
parts of the new payment system a lot. I get asked about 
virtual groups and the definition of ``more than nominal 
risk.'' And people say, hey, what is this going to mean for the 
small and rural practice?
    Now obviously, you know this is not dinner table 
conversation either. But for the doctors in rural Oregon, small 
practices, they say this is really going to tell us about 
whether we are going to get to succeed in this brave new world 
of payment systems.
    So tell me a little bit about how you as Administrator 
would look at something like this. I mean, Senator Thune, for 
example, has also been concerned about the virtual groups. How 
would you go about structuring and implementing these virtual 
groups?
    Ms. Verma. I think that, you know, I think small providers, 
rural providers, in terms of MACRA, I think it is going to be a 
challenge for them. I think it is a worthy goal, but we are 
going to have to be supportive of them through the process of 
implementing it.
    In terms of providers taking risk, and especially smaller 
providers, I think that that is a larger mountain to climb. I 
think they are going to be reluctant to take risk. When they 
are starting out, many small providers and rural providers do 
not have large financial reserves that the bigger health 
systems have.
    And you know, in terms of putting them on the hook, when we 
think about health outcomes and holding providers accountable 
for outcomes, a lot of that also depends on patients. And I 
think thinking about strategies about how we can engage 
patients to be a part of that equation so that they have the 
same investment, they have some investment to work with their 
providers towards achieving outcomes----
    But you know, in terms of smaller providers and rural 
providers taking on risk, I think that is going to be a 
formidable challenge.
    Senator Wyden. And on virtual groups, what is your take on, 
let us say, the most important thing to make them work?
    Ms. Verma. Well, I think that we have to continue to work 
with them to understand what their specific concerns are and 
try to address them. But I think at the end of the day those 
are going to be challenges that we are going to have to work 
through with them.
    You know, what I have found is, listening to folks, 
understanding what their concerns are and trying to see, to the 
best of our ability, if we can try to address those concerns--
--
    Senator Wyden. And what about the whole question of nominal 
risk? And again, I want to keep this open-ended enough so this 
is not, you know, I want to hear about paragraph 3, line 2. I 
just want to get a general sense of how you would approach it, 
because this is what rural physicians and patients are going to 
talk to me about. I am going to have town hall meetings in a 
couple of days. So how about nominal risk?
    Ms. Verma. Well, you know, I think that this is the 
challenge here. I do not know that rural providers and small 
providers want to take risk at all. And I think that, you know, 
when we are designing these programs, we have to keep in mind 
their specific needs.
    Taking on risk is something that insurance companies have 
done, some of the larger health-care systems have done. If we 
look at some of the ACO models, we know that very few 
providers, even large health-care systems, have been 
comfortable taking on risk. So I think this is going to be a 
considerable challenge for the smaller providers. Some of them 
may not want to do that.
    Senator Wyden. So does that mean--when I listen to that, it 
sounds to me a little bit like Ms. Verma wants to keep fee-for-
service.
    Ms. Verma. You know, I think fee-for-service, there are 
definitely some concerns with fee-for-service. That is 
rewarding volume over quality and outcomes. And so I am not 
suggesting that that works better.
    I think that there is something to be said--and I support 
efforts to increase coordination of care and to hold providers 
accountable for outcomes. I think, though, in terms of also 
holding providers accountable for outcomes, it is another thing 
altogether to have them accepting risk.
    Senator Wyden. So let us do this like we did the other two 
questions. I would like in writing--because this is so 
important for rural practices, rural providers--I would like 
just even one specific that you would pursue to try to address 
these issues.
    And the reason I am asking is because it is a big lift. 
There is no question about that. There is no question that 
trying to keep a rural practice open is a big lift.
    But these are the questions that providers are going to ask 
me. When they see me, they are going to say, ``Ron, you are on 
this committee; you deal with these issues. How is the 
government going to go about doing it?''
    So I will have one additional question later, Mr. Chairman. 
But let us add that to the matter of the specifics, both with 
respect to putting patients first as opposed to insurance 
companies first, as we heard yesterday, and the pharmaceutical 
question where I would like a written answer.
    And I think, given the fact that these matters are moving 
on a fast track, we are going to need to have your answers 
certainly within the next 3 days or so. All right?
    I will have one additional question later, Mr. Chairman. 
Thank you.
    The Chairman. Why don't you ask it now since----
    Senator Wyden. I think we only have a couple of more 
minutes on the vote. That is part of the reason that we have so 
few----
    The Chairman. Is this the second?
    Senator Wyden. Yes, this is the second.
    The Chairman. Yes, we both have to go, don't we?
    Senator Wyden. Mr. Chairman, if you are willing, we could 
do the vote. I have one additional question. I assume you will 
want to make a closing statement at the end. And I would like 
to too. And we also have some Senators coming back.
    The Chairman. Right.
    Senator Wyden. So I think we will come back.
    The Chairman. We still have 10 minutes on a vote here.
    Senator Wyden. We will come back.
    The Chairman. All right. Well, let me use a little bit of 
this 10 minutes and ask another question.
    There is great provider interest in participating in 
various Medicare projects that change the way payment is made 
to incentivize providers to change the way that they deliver 
care. Now, many of these alternative payment arrangements are 
being run through the Center for Medicare and Medicaid 
Innovation. But others are being conducted independent of it, 
such as a good portion of the Accountable Care Organizations 
program.
    And while all of these programs involve some type of formal 
evaluation, there is understandably great interest in knowing 
what works and what does not and as soon as possible.
    What is your view to testing different Medicare payment 
approaches and how to best assess the results?
    Ms. Verma. I think--a couple of things. I mean, one, first 
of all, I would say that I support efforts around innovation. 
It is important that we are always trying to climb the highest 
mountain and that we are never satisfied with where we are, 
always trying to figure out how to do better, how to get better 
quality care, better health outcomes, improved delivery 
services. And so innovation is important.
    But as we are looking at testing new ideas, I think that 
process has to make sure of a couple of things. We need to make 
sure that we are not forcing, not mandating individuals to 
participate in an experiment or some type of a trial that there 
is not consent around. I think that that is very important. So 
that is what I would say first off.
    In terms of evaluation, evaluation is an important 
component. Obviously, that is why we are doing it: to 
understand whether that can be transferred or whether it can be 
used for a larger population or for policy of the program.
    So evaluation is a critical component of that. That needs 
to be set up on the front end. It needs to be before the 
evaluation goes full scale. I think it should be done on a 
small population or on a small frame first before it is 
expanded. But that evaluation needs to be done on the front end 
and all the way throughout the process.
    And I think as it is expanded or before it is expanded, 
those results should be shared with stakeholders and I hope 
with members of Congress. And there should be discussion about 
that before that becomes formal policy.
    The Chairman. Well, thank you. Let me just ask one more 
question while we are waiting for some of the Senators to get 
back, and then I am going to have to go vote again.
    Seniors have a choice whether to enroll in the traditional 
government-run Medicare fee-for-service program or in an 
alternative private insurance option called Medicare Advantage. 
According to CMS, approximately 18.5 million people, roughly 32 
percent of all Medicare beneficiaries, are estimated to have 
signed up for a Medicare Advantage plan this year.
    Now, generally, Medicare Advantage plans offer extra 
benefits, such as dental, vision, hearing, and wellness or 
require smaller copayments or deductibles than traditional 
Medicare. Sometimes seniors pay a higher monthly premium to get 
these extra benefits. But also, they are financed through the 
plan's savings.
    Traditional Medicare does not limit the patient out-of-
pocket spending for Part A and Part B services, causing some 
seniors to buy supplemental Medicare coverage called Medigap 
insurance.
    People who do not have retiree coverage or who cannot 
afford Medigap supplemental insurance find Medicare Advantage 
plans offer the extra benefits traditional Medicare does not 
cover and protect them from higher-than-expected out-of-pocket 
spending.
    I had a lot to do with Medicare Advantage, by the way, so I 
will tell you that in advance.
    Ms. Verma, can you commit to working with this committee 
and Congress to preserve and strengthen the successful Medicare 
Advantage program?
    Ms. Verma. I can. And it would be my pleasure to work with 
you on that.
    I think that the Medicare Part C or Medicare Advantage has 
been a great program for seniors. What I like about it is that 
it is offering choices for seniors. They have the ability to 
figure out, again just like in Part D, what plan works best for 
them.
    And the fact that it provides them the opportunity to have 
additional benefits, vision and dental services, I think, is 
very important. And the fact that it just provides more choices 
for seniors is an important component of the program.
    So I would be happy to work with you on that.
    The Chairman. Well, thank you.
    Now, I notice that Senator Crapo is going to pass and Dr. 
Cassidy is here, so I am going to call on him next. And then I 
have to have staff follow up on this. All right.
    Thank you for being here. I do not think I am going to be 
able to even get back, but we will just continue on until we 
get this hearing over.
    Senator Cassidy?
    Senator Cassidy. We are both familiar with the data from 
MIT, the National Bureau of Economic Research, that showed the 
expansion in some States, that Medicaid expansion, not 
necessarily de-expansion, but Medicaid expansion really did not 
do much for outcomes. But the Healthy Indiana Plan seems to 
have had an effect upon outcomes.
    Can you just comment on the nature of the structure of 
giving folks health savings accounts, requiring some input on 
their part, what that did both for expenses as well as for 
outcomes?
    Ms. Verma. Thank you for your question. It is always a 
pleasure to talk about the Healthy Indiana Plan, so I 
appreciate the opportunity.
    The Healthy Indiana Plan is about empowering individuals to 
take ownership for their health. We believe in the potential of 
every individual to make decisions about their health care.
    Senator Cassidy. Now, I am going to interrupt you 
occasionally. There are some who say that health savings 
accounts, even pre-funded, are not appropriate for those who 
are lower-income, suggesting they lack the technical ability or 
the sophistication with which to handle that.
    But you are suggesting that the Healthy Indiana Plan, which 
I assume was, what, 100 to 138 percent of Federal poverty 
level----
    Ms. Verma. The Healthy Indiana Plan actually starts at the 
very lowest level of the poverty spectrum, so even people at 
zero percent or people who do not have income.
    Senator Cassidy. And they were enrolled in your plan as 
well.
    Ms. Verma. They were enrolled in our plan. What we find is 
that, just because individuals are poor does not mean that they 
are not capable of making decisions. It does not mean that they 
do not want to be able to have choices and that they should not 
have those choices.
    They are very capable of making decisions about their 
health care. And just because somebody is poor does not mean 
that they should not have choices and that they are not capable 
of making decisions that work best for them and their families.
    Senator Cassidy. So what I find intriguing about your plan, 
again--it is my understanding that E.R. visits were down, 
whereas in other States, when there was an expansion, there was 
a bump up in E.R. visits. And in the Healthy Indiana Plan, E.R. 
visits actually went down.
    But concomitantly, I think you have data that outcomes 
improved, unlike the National Bureau of Economic Research, 
which found that outcomes did not improve. Do you want to 
elaborate, please?
    Ms. Verma. Yes. So the Healthy Indiana Plan, what we have 
seen is that the individuals who were actively engaged and 
making contributions to their health savings accounts had 
better outcomes. They had more primary care, more preventative 
care; they had lower E.R. use. They were more satisfied with 
their care. And we also showed that they had better adherence 
to the drug regimens that their doctors prescribed--so, all 
across the board.
    Senator Cassidy. A skeptic might say that, wait a second, 
by splitting it between those who made contributions and those 
who did not, you ended up with two different populations, that 
the ability to contribute reflected something underlying. I 
assume you all did a regression analysis of some sort. Did you 
find that to be the case?
    Ms. Verma. No. What we found is that the individuals who 
were actually making contributions toward their care, they were 
actually sicker individuals, so they had more complex 
illnesses. And yet, when they were making contributions toward 
their care, they actually had better health outcomes than 
individuals who were healthier to start with.
    Senator Cassidy. Really? So the folks who were sicker, 
theoretically with less disposable income--they certainly 
cannot work as much--nonetheless valued health care more. This 
reflected in their contribution, but there was a positive 
correlation between adherence----
    Ms. Verma. That is correct. They had better drug adherence. 
They had more primary care, more preventative care.
    And these were not by small margins, I would add. You know, 
when we look at primary care and their preventative care, these 
were margins of about 20 percent for primary care and 
preventative care. So there were significant differences for 
individuals.
    And I think what it shows is that we can empower 
individuals to take ownership for their health, and that 
people, just because they do not have income, does not mean 
that they are not capable and that they do not want to have 
choices.
    We believe in the dignity and the potential for individuals 
to make decisions. And they are happy to do that, and they have 
better outcomes.
    Senator Cassidy. Now, I think the key factor here--I think 
in the academic literature, they speak of the ``activated 
patient.'' You are using the term ``empowered,'' but that seems 
to be the critical factor here.
    To what degree is the patient empowered as they partner in 
their health? To what degree does she participate? Both related 
to each other, but that, in turn, ends up--again, causative 
outcomes, lower cost.
    Ms. Verma. That is exactly what we have seen. And even with 
the Healthy Indiana Plan, if we compare the Healthy Indiana 
Plan to other States, we have actually been able to do it. It 
costs less, and we have been able to reduce the number of 
uninsured in our State at higher levels than other States that 
have run more traditional programs.
    So we have done it at a lower cost, had better outcomes, 
and reduced the number of uninsured.
    Senator Cassidy. But inevitably, there is a Federal role in 
this. And so is it possible that you could reduce the Federal 
role to zero and have a plan such as yours still be viable in a 
State with a high poverty rate?
    Ms. Verma. So in Indiana, negotiating the Healthy Indiana 
Plan and being able to achieve the waivers, I mean, this was 
something that Governor Daniels actually asked the Federal 
Government: ``Can we use the Healthy Indiana Plan for the 
Medicaid expansion?'' And he even asked this before the Supreme 
Court decision, which made it optional.
    So he wrote that first letter in 2010, and it took the 
Federal Government almost 5 years to make a decision about 
whether this program could work.
    So I think that, you know, that is something that we need 
to look at or that I would hope that Congress would want to 
work on, because that type of back-and-forth----
    Senator Cassidy. So the approval process can be made more 
efficient. But again, there are Federal dollars which would 
seem essential as well.
    Ms. Verma. Exactly.
    Senator Cassidy. Thank you. I yield back.
    Senator Isakson [presiding]. Thank you, Senator Cassidy.
    Senator Nelson?
    Senator Nelson. Good morning. I enjoyed talking to you on 
the telephone.
    Do you support turning the Medicare program into a voucher 
system?
    Ms. Verma. I support the Medicare program being there for 
seniors. People are making contributions into that program.
    Senator Nelson. So would that include the voucher system?
    Ms. Verma. You know, I think that I do not support that. I 
think what I do support is giving choices to seniors and making 
sure that that program is in place.
    What we have seen is, I think, efforts--I think there is a 
lot of concern about the future----
    Senator Nelson. Excuse me for interrupting. I did not 
understand. The fellow who is now the Secretary of HHS had 
taken a position as a Congressman supporting the voucher 
system, turning Medicare into a voucher system. Do you support 
that?
    Ms. Verma. So let me back up with my answer here and try to 
explain this a little bit more. You know, I think that what I 
have seen in terms of different types of options that are being 
discussed around Medicare, those are borne out of individuals 
who want to make sure that that program is around. I want to 
make sure the program is around for my kids.
    And so, you know, what we know from the trustees' report is 
that----
    Senator Nelson. So to make sure that it would be around, 
you are saying that you would consider alternatives.
    Ms. Verma. You know, I think that I am not supportive of 
that. I think that we need to make--but I think it is important 
that we look for ways of making sure that the program is 
sustainable for the future.
    Senator Nelson. All right, let me give you one of the 
alternatives. One of the alternatives is to increase the age 
from 65 to 67. Do you support that?
    Ms. Verma. You know, I think ultimately what direction that 
we go into is up to Congress. As the Administrator of CMS, my 
job would be to carry out whatever Congress decides is the best 
course of action for the Medicare program.
    And I would hope that we would work towards making the 
program more sustainable so that it does exist for future 
generations and that it is a program that provides high-quality 
care, accessible care, and gives seniors options.
    Senator Nelson. So you do not think you should be involved 
in policy? You said, ``Leave it up to Congress.''
    Ms. Verma. I think it is the role of the CMS Administrator 
to carry out the laws that are created by Congress.
    Senator Nelson. All right, let me ask you--there is another 
availability that seniors enjoy, which is that the doughnut 
hole was closed, which means that seniors in Florida spend 
about a thousand dollars less out of their pockets by drugs 
being reimbursed through Medicare.
    So in the Medicare prescription drug program--now I know 
that you just had a question close to this, but what I need to 
know is, do you support the provisions in the ACA that closed 
the coverage gap to make prescription drugs more affordable, or 
closing the doughnut hole, ``yes'' or ``no''?
    Ms. Verma. I support efforts to make the availability of 
medications affordable and accessible for seniors. I want to 
make sure that they have choices about the medications that 
they need and that that coverage is affordable to them. So I 
support efforts in terms of----
    Senator Nelson. I am running out of time. I am just trying 
to get clear your thinking on this. So if a senior, since you 
support making drugs affordable to seniors, but if a senior had 
to pay a thousand more dollars out of their pocket per year for 
their drugs, is that something that you would support?
    Ms. Verma. You know, ultimately what happens with the 
doughnut hole is really up to Congress and how we move forward 
on this.
    In the role of Administrator, my job would be to implement 
the policy or the legislation that is developed by Congress.
    Senator Nelson. All right, so back to the policy by 
Congress. All right.
    Here is one you may be able to answer. How about--as you 
know, on dual-eligibles, the Federal Government gets a discount 
from the drug companies for the dual-eligibles who are eligible 
through Medicaid until they get to 65, then they get their 
drugs from Medicare, but then there is no discount.
    Would you support requiring drug manufacturers to pay drug 
rebates to Medicare for the dual-eligibles?
    Ms. Verma. Yes, as I said before, I support efforts to make 
drugs more affordable to seniors. And I think this is an issue 
that we are all concerned about, the President is concerned 
about as well, that we need to make it more affordable.
    And I would look forward to working with Congress on 
strategies that can help it be more affordable while 
maintaining accessibility and ensuring that our seniors have 
access to the drugs that they need.
    Senator Nelson. I am sorry that you have the constraints 
put on you so that you cannot answer these questions 
forthrightly. And those are the questions that I can tell you 
senior citizens are begging to hear the answers to.
    Because if you had approached this as candidate Trump had, 
saying he was going to protect Medicare and Social Security and 
not have any cuts, your answers would be different, and they 
would be clear. But you have chosen to go the route that you 
have, and I am sorry that you have those kind of constraints.
    Thank you, Mr. Chairman.
    Senator Isakson. Thank you, Senator Nelson.
    For the benefit of the members of the committee, the order 
remaining of those who have not asked questions is Isakson, 
Brown, Heller, and Scott. And that is the order we will go in, 
unless someone comes in who is still on the list.
    And I will take my time now.
    First of all, and I will just make a statement, you do not 
have to really comment unless you want to, but words are a 
strange thing sometimes. They can be used depending on what you 
want the ultimate goal to be.
    In the Veterans' Administration--and I am the chairman of 
the Veterans' Affairs Committee--3 years ago Republicans and 
Democrats joined together to create what is known as the Choice 
Program in terms of V.A. health care benefits to try to 
expedite veterans getting services and to maximize the use of 
the V.A. and the private sector.
    In the first year of that program, there were 2 million 
more appointments filled through the V.A. than had been in the 
previous year, and all those were because the access to the 
private sector gave the veterans better access. So the veteran 
had the choice and used the private sector and the Veterans' 
Administration to do it.
    I think that is a good example of where choice made a 
difference, delivered health care, did not change the cost, 
made accessibility better, and made the program work better. So 
``choice'' is not a bad word. Choice can be a very good word. 
And the Congress did that 3 years ago in August, and it has 
been a program, it has worked ever since.
    Are you familiar with that program?
    Ms. Verma. I am not familiar with that program. But I do 
believe I agree with you that choice is critical. When there 
are choices, then there is competition, and we have folks who 
are trying to attract our beneficiaries to the system. So 
choice and competition are very important to driving better 
quality in outcomes and lower cost.
    Senator Isakson. In Georgia, we have 1.9 million Georgians 
on Medicaid; 1.3 million of those 1.9 million are children. 
Half of the children born in my State are born with Medicaid 
benefits.
    Are you committed, as we go through the reforms and the 
enhancements and the improvements of the program, to make sure 
we keep children foremost in our mind for coverage?
    Ms. Verma. I am, absolutely. As a mother of two children, I 
certainly understand the importance of health care for 
children. And one of the things that I am reminded of in my 
work with the Medicaid program and with the CHIP program--I 
remember hearing a story about a woman. And it was after the 
CHIP program had been passed. But she talked about how she had 
a child who was an infant, probably 1 or 2 years old, maybe an 
infant, about 1 year old, and she had gone to the doctor, and 
her child had an ear infection. And the doctor gave her a 
prescription just for a simple antibiotic to treat the ear 
infection.
    And she went home that night and she had a choice to make. 
If she filled the prescription, she would not have enough money 
to pay for meals for the whole family. And so she made the 
painful decision of not filling the prescription and feeding 
her family for the whole week.
    And what happened to that child is that, because of his 
untreated ear infection, he ended up losing his hearing and 
going deaf. And so I am always reminded of that story. And that 
child now needs lots of different services to help him through, 
and that is something that could have been prevented.
    So it is very important that children have access to high-
quality services. That is really important so that we do not 
have situations like that.
    Senator Isakson. Thank you for your answer.
    Are you familiar with the 21st Century Cures Act that 
passed?
    Ms. Verma. I am.
    Senator Isakson. It is a great piece of legislation. And 
Senator Warner and I had one of the provisions in that bill, 
which is very important to us, on home health care. It provided 
for reimbursement for durable medical equipment under Part B 
and home infusion and home health care through Medicare.
    And it is something we wanted to make sure we had, because 
under the ACA home health care was almost totally removed from 
being reimbursed. And having had personal experience, I know 
home health care is the best environment to deliver health care 
services and the least costly to the government.
    I hope you will look closely at that 21st Century Cures Act 
and the home infusion provisions we put in it, to see to it 
they get implemented.
    Ms. Verma. I would be happy to work with you, Senator, on 
that. And I agree. I think the Cures Act--and I applaud 
Congress for coming together on a bipartisan basis to pass that 
law--I think it is going to have a tremendous impact on the 
health care of Americans. And I appreciate your efforts on that 
and would be happy to work with you.
    Senator Isakson. And lastly, just really quickly, when I 
was in the State legislature years ago, the biggest thing we 
fought was a lot of fraud in Medicare and Medicaid. And that 
still is a problem today.
    I am very familiar with it from the business I was in. The 
verification of eligibility is very important to make sure you 
have minimal fraud and minimal waste. Are you committed to 
using the commercial resources that are available in the 
private sector to verify eligibility where that is important?
    Ms. Verma. I am absolutely committed to that.
    Senator Isakson. Thank you very much.
    Senator Brown, I am sorry to tell you, but Senator Menendez 
slipped in, so he is going to be one ahead of you.
    Senator Menendez?
    Senator Menendez. Thank you, Mr. Chairman.
    Ms. Verma, congratulations on your nomination.
    One of the successes of the Affordable Care Act was the 
establishment of a nationwide benefit standard called the 
essential health benefits package. And one of my amendments to 
the law, which was adopted by this committee, was to ensure 
that coverage for behavioral health services, like therapies 
for children with autism, are available in every plan purchased 
through the marketplace. That is to ensure that a child in 
Georgia or Indiana or New Jersey has equal coverage and equal 
access to the care that they need.
    I have heard from countless families about the anxiety they 
have over losing access to critical autism services through a 
change in the essential health benefits that allows insurance 
companies to deny coverage, which is especially acute in States 
that lack a State-based requirement.
    Do you agree that a child's access to insurance that covers 
a condition like autism should not be based on what State they 
live in?
    Ms. Verma. I appreciate your question. My husband is a 
child psychiatrist, so he deals with those issues on a day-in 
and day-out basis. So I certainly understand the concern.
    I have been advised by the Office of Government Ethics not 
to participate on issues regarding mental health services 
because my husband is a psychiatrist and that it could impact 
his practice. And so----
    Senator Menendez. Well, with all due respect, autism is not 
a mental health issue. Autism is an illness where we are still 
trying to develop the essence of its cause. But at the end of 
the day, I use it by way of example. Are you suggesting that 
you cannot tell the committee a simple answer to the question 
that it should not matter where you live in the Nation, that in 
fact you should have access to the same coverage as any other 
child?
    Ms. Verma. I think that all Americans should have access to 
the health-care services that they need. However, in the issue 
that you are asking me to comment on, I have been advised by 
the Office of Government Ethics not to participate on matters 
that, because of my relationship, my husband's practice, to not 
offer----
    Senator Menendez. Did they define to you the list of things 
that fall under this category?
    Ms. Verma. He does treat children with autism, and so they 
have asked me not to engage on matters that involve his 
practice.
    Senator Menendez. That is pretty amazing to me.
    Let me ask you this. As you know, Congress has to act this 
year on a package of Medicare extenders. Which of those 
Medicare policies do you consider to be your top priority?
    Ms. Verma. I have not reviewed that particular regulation, 
but I would be happy to review that, if I am confirmed, and 
work with you on that.
    Senator Menendez. Well, let me just say, Medicare is a big 
part of what CMS deals with. And I would have thought that, in 
preparation for this hearing, you would have a sense of these 
extenders that are almost on an annual basis or a biannual 
basis. But it is the heart of giving us a sense of what you as 
the potential Administrator would be advocating as it relates 
to Medicare.
    Your role as the CMS Administrator is more than just 
executing simply the laws of the country, which certainly you 
would. But it is also a policy development-heavy position that 
the President and the Secretary of Health and Human Services 
and the Congress rely on when drafting laws that ultimately 
would have impact in your parameters.
    So you have no idea as to which one you consider the most 
significant?
    Ms. Verma. At this point, I would want to review that 
before I gave you my opinion on that particular area.
    Senator Menendez. Let me ask you this. During our meeting 
in my office, you referred several times to so-called able-
bodied beneficiaries as we were speaking about Medicaid.
    Do you believe that low-income and working-class 
individuals who gained access to Medicaid thanks to the 
Affordable Care Act's expansion should be eligible for 
Medicaid?
    Ms. Verma. I think that when I think of----
    Senator Menendez. I think that is a simple ``yes'' or 
``no,'' because my time is limited. Do you believe that they 
should have access to Medicaid eligibility?
    Ms. Verma. I think that all Americans should have access to 
high-quality health-care services.
    Senator Menendez. That is not an answer. That is not 
responsive to my question.
    Ms. Verma. But I think----
    Senator Menendez. I am asking about Medicaid specifically--
--
    Ms. Verma. When I think about the Medicaid program, I think 
about it almost in two different parts. There is the part of 
the Medicaid program that serves the aged and the blind and the 
disabled. That is a very different population than some of the 
able-bodied individuals.
    But at the end of the day, all Americans should have access 
to high-quality, affordable health-care coverage.
    Senator Menendez. Well, I will just simply say, 
``unresponsive to my questions.'' I cannot vote for someone to 
be the Administrator of one of the most significant agencies 
that affects the health care of people in the country if I 
cannot glean from you in an open hearing under oath what your 
answers are to these questions. I have no answers, and so it is 
very difficult, very difficult. And I have not reflexively been 
against the President's nominees. I have voted for several of 
them. But you have to give me more than that. I hope that your 
responses to written questions will be more enlightening for 
me.
    Thank you, Mr. Chairman.
    Senator Isakson. Senator Cantwell?
    Senator Cantwell. Thank you.
    Congratulations on your nomination. We had a great 
discussion about innovation in the Pacific Northwest, and so I 
wanted to follow up on that.
    But to my colleague's point, you know, there has been a lot 
of discussion about block-granting Medicaid. Are you in favor 
of that?
    Ms. Verma. You know, when I think about the Medicaid 
program, I will say that the Medicaid program as a status quo 
is not acceptable. I think that we can do a lot better for the 
many people who depend on this program. We are talking about 
disabled individuals, quadriplegics, people who are 
developmentally disabled, mentally disabled, and we can do a 
better job than what we have today in the program.
    We know that we are not delivering great health outcomes. 
There has been study after study that shows that even people 
who do not have Medicaid have better health-care outcomes.
    Senator Cantwell. Do you think there are problems with 
block-granting Medicaid?
    Ms. Verma. I think that, you know, when I look at this, I 
think we need to think about how we can make this program work 
better. The status quo is not acceptable. This is the United 
States of America, and we can do better for our vulnerable 
populations. We can hold States accountable for producing 
better outcomes.
    Senator Cantwell. So are you endorsing block-granting?
    Ms. Verma. I am endorsing the program being changed to make 
it work better for the citizens who rely on it.
    Senator Cantwell. So you are not endorsing block-granting? 
I am just trying to understand, because this is the debate du 
jour as far as I am concerned. And I know that several of our 
colleagues, probably those in the House, are very adamant about 
this.
    And so I am just trying to understand where you are on that 
question, whether you either are for it or against it or have 
concerns about it or endorse it. It is a spectrum, so I am 
giving you a little more room than my colleague gave you.
    Ms. Verma. Well, I appreciate that. Thank you. You know, 
what I support is the program working better, and whether 
that's a block grant or a per-capita cap, there are many ways 
that we can get there.
    But at the end of the day, the program is not working as it 
should. When you have one State spending $4,000, you have 
another State spending $15,000 for the same population, can we 
show that the outcomes are better; can we show that that 
individual had accessibility to high-quality care?
    What we know is going on at the State level is that, you 
know, in terms of accessibility, one-third of doctors are not 
taking Medicaid patients. And that means for a disabled person 
that when they are sick, they call the doctor, and some of the 
doctors will not even take them, and the doctors who are taking 
them--they are having to wait for a long period of time to get 
care.
    I mean, I think we can do better for these people. And I 
support efforts to get us there.
    Senator Cantwell. All right. Well, I would say this. This 
whole notion of capitating or block-granting, we know what the 
results of those programs have been. We have numbers here that 
it has resulted in a 37-percent cut. So if you just 
extrapolated that out, unless you assume that you have these 
States that would step up and cover those populations--my 
colleague Senator Hatch was talking earlier about the increase 
in population. The increase in population is what is driving 
the cost.
    So coming up with a better strategy for that population, 
like rebalancing that I had a chance to talk to you about, is 
way more cost-effective. In our State, we saved $2.5 billion by 
taking people out of nursing home care and putting them in 
community-based care. But trying to capitate or say we are 
going to block-grant it ends up--you know, if you just said to 
my State, well, and the State did not come up with anymore 
funds, if you applied that same 37 percent, you would be 
cutting over 100,000 people in King County off, or you would be 
cutting 43,000 people in Spokane off.
    I calculated the numbers, again just in extrapolation, and 
with that 37-percent reduction that other block-granting 
programs have received over the last 15 years, it would be like 
cutting a million people in Ohio off of Medicaid unless the 
State came up with more money.
    So my point about this is, I hope you will be much more an 
advocate for the innovation in Medicaid, that instead of trying 
to nickel-and-dime poor people on a copayment or administrative 
cost, come up with the strategies, like rebalancing, that give 
people real opportunities to deal with this population, save 
cost, and keep people in a better, healthier situation.
    So that is why I have grave, grave concerns about this 
notion of block-granting Medicaid or the capitation, as you 
mentioned.
    Ms. Verma. Well, you know, I agree with you. This is what 
it should be about: innovation. But what is going on in the 
Medicaid program today is that we have a very inflexible system 
when States are trying to do creative things.
    And I agree with you in terms of rebalancing incentives and 
giving Medicaid beneficiaries the option of being served in the 
community. That is something that we should support and we 
should do.
    But the way the system is set up is that States have to go 
to the Federal Government for any routine changes. Anytime they 
want to do something innovative and creative, it can take years 
to get a waiver done. And so we need to create a Medicaid 
program that allows States to be innovative and to have that 
flexibility so that they can focus on producing better outcomes 
for individuals.
    And I, you know, I strongly do not want to see anyone not 
get health services. We are talking about the most disabled and 
vulnerable people in our population. And we can do better. We 
should be able to deliver better outcomes for these individuals 
and hold States accountable for accessibility and high-quality 
coverage. This is not about kicking people off the program. 
This should be about improving outcomes.
    Senator Cantwell. Well, we will have many more chances. My 
time has expired, but I just hope you will remember: innovate, 
do not capitate. Innovate.
    Thank you, Mr. Chairman.
    Senator Isakson. Senator Cardin?
    Senator Cardin. Thank you, Mr. Chairman.
    I am going to follow up on Senator Cantwell's points, 
because I think the essence of her comments is absolutely 
accurate.
    And, Ms. Verma, first of all, welcome. You are a product of 
my State of Maryland in education, and we are very proud of 
your accomplishments. It is nice to have your family here.
    And I want to talk about minority health and health 
disparities in this country. Part of the Affordable Care Act 
was to put a focus on that. We now have a National Institute 
for Minority Health and Health Disparities. And there is a good 
reason, because historically minorities have been discriminated 
against in our health-care system.
    We look at health-care results on diabetes, heart disease, 
hepatitis, HIV/AIDS, infant mortality, and other indicators, 
and we know we have a problem. And we have been making progress 
on that problem, and that is why I want to refer to Senator 
Cantwell's point about resources.
    Resources are important. And I wish every policy decision 
we make in this committee and we make in Congress and make at 
the White House was driven by what is the right policy results. 
But far too often, it is driven by the budget numbers. And that 
is the reality; that is what we deal with.
    And Senator Cantwell's point is that, if you move to block-
grant the Medicaid program, the odds are it is going to fill a 
budget number, not fill a policy-driven objective. And who is 
vulnerable? The most vulnerable people in our society.
    In Maryland, almost 70 percent of the Medicaid population 
are from communities of color. That is in my State of 
Maryland--70 percent. So when we expanded the opportunities for 
Medicaid under the Affordable Care Act, it made a big 
difference.
    You may be familiar with the Greater Baden Health Center in 
Prince George's County. You are familiar with that community. I 
have been visiting that center for many years, and they are now 
able to provide mental health services and pediatric dental 
services and give access to care in a vulnerable community 
because of the expansion of Medicaid. And if we were to go to a 
program that is innovative but does not have the resources to 
implement, vulnerable people are going to get hurt.
    So I just want to get your understanding as to the 
importance of resources. We are not going to improve our 
health-care system by telling people of means that they cannot 
spend money on health care. They can get the health care that 
they need. It is the vulnerable population that is going to be 
challenged.
    And as tough as budgets are here, budgets in Annapolis and 
other State capitals around the Nation are even tougher. 
Medicaid is such a large part of the State budget that when you 
say, well, we are going to innovate, but we need to invest to 
innovate, they do not have the money to invest to innovate. And 
then they have to look at, well, let us eliminate dental or let 
us eliminate the essential benefits that Senator Menendez was 
talking about.
    So tell me how you are going to advocate for the poor, how 
you are going to advocate for those who are challenged in our 
system?
    I do not know all the answers of the Indiana system. You 
and I had a chance to talk about it, and I applaud you for 
looking for innovation in your State. But I know that some 
interpret it to mean that those copayments that some have to 
pay, they do not have the resources to pay. And then if they do 
not pay, they are put into a system where they are denied 
certain benefits that they desperately need.
    So I am interested as to how you see this system being fair 
to our most vulnerable.
    Ms. Verma. Well, first of all, I would say I have fought 
for coverage, for better outcomes for vulnerable populations, 
my entire career, starting with individuals with HIV and AIDS, 
working with low-income mothers to improve birth outcomes.
    The issues that you raised around minority health are near 
and dear to my heart. I am a minority, and I understand that 
things are different. You have different cultural norms that 
impact how care is delivered and the types of advice that we 
give to individuals who are minority. So I certainly understand 
that.
    You know, you talked about the Healthy Indiana Plan and 
making sure people have resources for their health care. You 
know, we looked at in the Healthy Indiana Plan--it was all 
about choices. We believe in the individual dignity and the 
empowerment of individuals to make their choices about their 
health care. And what we found is that when we gave people 
those choices, they made good choices and they had better 
health outcomes.
    We saw emergency room usage go down. We saw individuals 
having more primary care and more preventative care.
    Senator Cardin. And of course, that is what we are seeing 
under the expansion of Medicaid in the State of Maryland with 
many more people insured. We are seeing less use of emergency 
room care, much more preventive health care, because we now 
have more people in the Medicaid system, about 250,000 more in 
our State.
    So yes, the expansion of third-party coverage is critically 
important, but the quality of third-party coverage is also 
critically important. If you do not have preventive care, if 
you do not have pediatric dental, we know what happened. We 
know what happened in our own State of Maryland in 2007 with a 
tragic death.
    So I appreciate that we are looking for innovation, but if 
you do not have the basic coverage, if you do not have the 
ability to provide the essential services, it is the vulnerable 
who are going to suffer.
    Ms. Verma. Well, I do not want to see the vulnerable 
suffer. Like I said, I have been working on that particular 
issue my entire career. I have done this on the local level, 
creating programs in Marion County for uninsured individuals, 
and I have done that on the State level. And if confirmed, I 
will continue that fight.
    Senator Cardin. I thank you.
    Thank you, Mr. Chairman.
    Senator Isakson. Thank you, Senator Cardin.
    Senator Brown, you finally made it.
    Senator Brown. Thank you. Thank you, Mr. Chairman.
    Thank you for your willingness to serve, Ms. Verma. Nice to 
see you again. And thanks for coming to my office and speaking.
    I was a little disturbed with Senator Nelson's question 
about Medicare eligibility age at 67 or even 70, as your future 
boss has sponsored legislation on, at least at 67, and he was 
not willing to tell the committee that he had changed his mind 
or was opposed to it.
    And on voucherizing or privatizing Medicare, I was 
concerned when you said it is up to Congress. Of course it is, 
but I would hope that you would--I am not asking this as a 
question, but I would hope that you would look at CMS as a 
platform to, one, tell your boss, the Secretary of HHS, and 
your ultimate boss, the President--who has said he would not do 
those things in the campaign, but then he nominates Congressman 
Price--but I would hope you would use that as a platform to 
stand up against those two things, because they are devastating 
to working-class Americans.
    A couple of questions. The first question is simple. 
Governor Kasich recently named a new Director for the 
Department of Medicaid, former Ohio legislator Barbara Sears. 
Governor Kasich, as you know, extended Medicaid in Ohio; 
700,000-plus people now have Medicaid coverage. Ohio's former 
Medicaid director, John McCarthy, he had an excellent 
relationship with CMS.
    My question is--this one is the easy one--I would like to 
ensure this positive working relationship, and I would like to 
ask you to commit to sitting down in person with Director Sears 
and perhaps, if she chooses and you choose, a group of Medicaid 
administrators from around the country, to discuss my State's 
and their States' priorities and concerns when it comes to the 
Medicaid program.
    And I would like to ask you to do that in the first few 
months on the job.
    Ms. Verma. That would be my pleasure to do that. I feel 
strongly about working with States----
    Senator Brown. All right, good. Thank you. All right.
    Ms. Verma [continuing]. In an open relationship and 
partnership.
    Senator Brown. Thank you.
    During our meeting, you spoke glowingly about CHIP and what 
it has done. In 2010, Congress improved CHIP by streamlining 
enrollment processes and increasing outreach efforts and other 
things. We now have 95 percent of children in America who have 
affordable, comprehensive health insurance. What is not to love 
about that?
    Secretary Price mentioned in his hearing that he would 
support an 8-year--8-year--extension of CHIP, of the current 
CHIP program.
    It is important that when we upgraded CHIP in 2010 and 
streamlined it so it is a clean law now and easily understood--
do you agree with Secretary Price that Congress should act 
quickly to pass an 8-year extension? And do you agree that that 
should be an 8-year extension of the current CHIP program to 
provide certainties for families and State budgets?
    And please give me a ``yes'' or ``no.'' Pretty simple, 8 
years and clean CHIP.
    Ms. Verma. I support the reauthorization of the CHIP 
program and agree with Congressman Price that we need to do 
this to the fullest extent possible, and I look forward to 
working with Congress on that. I have two kids of my own.
    Senator Brown. All right. But the questions were more 
precise. Do you agree to the 8 years that he suggested?
    Ms. Verma. I support the reauthorization as long as 
possible.
    Senator Brown. All right. Eight years would be possible.
    Ms. Verma. Eight years or more.
    Senator Brown. I know it is up to Congress, but, I mean, 
what you do not either want to acknowledge or do not understand 
is, your recommendation to this Congress--you can say it is up 
to Congress. Of course, ultimately laws are, but your 
recommendation to Congress matters. If you and Secretary Price 
would say we want 8 years' extension and you would also say we 
want a clean extension, not a rollback, but what we had in 
2010, what the present law is now, it would really, really 
matter.
    And I think you would get every Democrat and you would get 
most Republicans, and that would take that off the table. It 
would take the uncertainty out of all these programs where we 
just kind of limp along, extending them a year or two or three 
or five at a time.
    So I ask you again, will you recommend 8 years, and will 
you recommend a clean CHIP extension?
    Ms. Verma. I will recommend and support the reauthorization 
of the Children's Health Insurance Program for as long as 
possible. I think it is very critical that children have access 
to high-quality services.
    You and I talked about this in your office, about my 
experience with this. So I support children having access to 
health coverage.
    Senator Brown. It would have been important to me more if 
you had said ``yes'' and ``yes,'' but I appreciate the answer.
    Beginning March 8th--let me ask you about another issue--
hospitals will be required to give Medicare Outpatient 
Observation Notices to applicable Medicare beneficiaries as 
required under the NOTICE Act, which Congress, I am sure you 
are aware, passed just last year.
    If confirmed as the CMS administrator, will you commit to 
aggressively enforcing those notice requirements for hospitals, 
``yes'' or ``no''?
    Ms. Verma. If I am confirmed as the CMS Administrator, it 
is my job to follow the law and to implement the programs as 
designed by Congress.
    Senator Brown. All right. The MOON notice, it is an 
important first step towards giving beneficiaries additional 
information, but it does not fix the issue of observer status, 
the underlying 3-day stay requirement. Hospitals are 
increasingly caring for Medicare beneficiaries as outpatients 
under observation status as opposed to admitting them as 
inpatient patients. While the classification of a hospital stay 
does not affect the level of care that a beneficiary receives, 
it has significant repercussions for the 3-day requirement and 
for Medicare coverage of significant care.
    Do you support changes to the 3-day stay requirement?
    Ms. Verma. That is something that I would want to review 
and would look forward to working with you on that.
    Senator Brown. Do you have opinions of the 3-day stay 
requirement?
    Ms. Verma. I would want to review that in more detail.
    Senator Brown. Do you know what it is?
    Ms. Verma. I do know what it is----
    Senator Brown. Tell me a little about it.
    Ms. Verma [continuing]. But I would like to review that at 
this point and would be happy to work with you on that.
    Senator Brown. All right. Secretary Price, who apparently 
knows more about the observation status issue, raised it during 
his confirmation hearing. He specifically mentioned he would 
like to work on improving this rule. I assume you would work 
with him on that.
    So can you give me any thoughts on what you would do at CMS 
to improve the 3-day requirement?
    Ms. Verma. Well, I think we need to work with providers on 
this. I know that there have been some issues there in terms 
of, you know, skilled nursing facilities and the impact of the 
rule on patients' ability to get in with that. So I would want 
to review that more carefully and would be happy to give you my 
comments.
    Senator Brown. All right. That was less than satisfactory, 
but I appreciate the effort. Observation status is a huge 
concern for beneficiaries across my State. And we get calls, as 
I am sure in Indiana some of your counterparts who were doing 
Medicare got calls. But I know that Senator Cardin, Senator 
Nelson, and others have been working this issue for years. And 
I hope we can work on it. Thank you.
    Thank you, Mr. Chairman.
    Senator Isakson. Senator Heller, I apologize, but Senator 
Thune slipped in under the transom, so I am going to have to go 
to him next.
    Senator Thune?
    Senator Thune. Thank you, Mr. Chairman. And I hate it when 
that happens when I am down here, so my apologies.
    Ms. Verma, thank you for being here. Welcome and thank you 
for your willingness to serve.
    I know this has been touched on already, but I wanted to 
follow up because, when the MACRA final rule was released last 
November, I was concerned about the decision to delay 
implementation of virtual groups.
    And then Acting Administrator Slavitt indicated that 
details were being worked out and that CMS was soliciting 
feedback from physicians. The rule stated that implementation 
would not come until 2018. Well, being from South Dakota, I am 
continuously concerned with how we roll out new payment systems 
in rural areas.
    Will you make it a priority of yours to ensure that virtual 
groups are timely and effectively implemented?
    Ms. Verma. I would be happy to do that and happy to work 
with you on that issue.
    Senator Thune. And how do you plan on engaging with those 
rural and sole practitioners to ensure that this is a viable 
option that they can take advantage of?
    Ms. Verma. I think that the rural providers and frontier 
providers are in very unique situations. And when we are 
thinking about policies, we need to engage with them on the 
front end to understand what their concerns are before policies 
are rolled out to make sure that we are understanding the 
impact on them.
    You know, things that work well in an urban community do 
not necessarily work well. And I think sometimes living in DC, 
we do not have that understanding. So any time I think we have 
a policy, we need to work with rural providers, with frontier 
providers, on the front end to understand what their concerns 
are and what the potential impact could be.
    And then, once something is out there, we need to make sure 
that we have that continued collaboration and communication so 
that if there are problems and if there are issues, we can 
address them in a timely way so that we are not impacting 
patient care and that we have a commitment to providing high-
quality care and access.
    Senator Thune. Yes, I am glad to hear you say that. 
Additionally, the GAO had recently released a report, in fact 
it was in December, that lists the hurdles that small and rural 
practices may face when trying to participate in MACRA's new 
payment models.
    As CMS moves away from fee-for-service and toward rewarding 
quality, I want to ensure that rural providers in my State will 
be able to participate in new and innovative methods that 
increase quality and reduce costs.
    Aside from the previously mentioned virtual groups, the 
last question is, how would you go about ensuring that small 
and rural providers have access to these programs?
    Ms. Verma. Well, I think it is critical that we make sure 
in rural areas and frontier communities that we have that high-
quality health care. And again, it goes back to collaborating 
with them.
    These programs, I think, have enormous promise to deliver 
high-quality care and move us in a different direction, but we 
need to work with those providers on the front end to make sure 
that they can handle these new regulations and rules.
    What I find is that, in the rural communities and frontier 
communities, I mean, they are stressed in providing care. They 
have a lot of enormous burdens. And we need to be careful that 
rules and regulations do not prohibit them from providing high-
quality care.
    And when you are out there on the front lines and you are 
trying to provide care, having to deal with a lot of rules and 
regulations can be difficult. And so we need to be supportive 
of them by providing technical assistance, making sure that we 
are available for communication, and support them throughout 
the process of implementation.
    Senator Thune. I would like to turn just quickly to one 
other issue, and that is the meaningful use program for 
electronic health records.
    Given the program's somewhat rocky track record, what do 
you believe is the future of the meaningful use program at this 
point?
    Ms. Verma. Well, I think that electronic health records 
have enormous promise. And I think they are helpful for 
physicians in terms of prompts, in terms of doing data and 
evaluation, but it has been a rocky start.
    I think, as a patient, I have gone to the doctor's office 
and even seen signs in the waiting room that say, you know, we 
are going to be delayed or it is going to take a while because 
we are still getting used to electronic health records.
    I have been in the room with my doctors where they are 
staring at their computer instead of looking at me as I tell 
them about my health-care issues. And so we need to make sure 
that it is working and it is working for providers and 
patients.
    Interoperability--you know, if we are going to have 
electronic health records, then we should make sure that they 
fulfill their promise so that if somebody goes to the emergency 
room, even if they were in a different hospital or a different 
provider system, that the doctors can pull up the information 
and that they have those tools about what medications the 
person is on. And so we need to make sure that they are 
fulfilling their promise and not being more burdensome.
    You know, I think there is a lot of potential there, in 
terms of prompts. I mean, I hear that physicians like the 
ability to, when they are talking to a patient, be able to say, 
well, what pharmacy do you like, and immediately send that 
script. So there is a lot of value there.
    But we need to make sure that it is also fulfilling its 
promise and that it is giving us the things that it is supposed 
to do, so when you go show up to an emergency room, you 
actually have all that information. And sometimes I know we 
have come up short on some of those things. So that is 
something where I think we need continued efforts around that.
    Senator Thune. All right. Final point. I look forward to 
working with you. I mentioned in our discussion, our meeting, 
better coordination between the Indian Health Service and CMS. 
That is an issue that we have had lots of issues and problems 
with in my State of South Dakota. And I hope that we can make a 
lot of headway there. So thank you.
    And thank you, Mr. Chairman.
    Senator Isakson. Thank you, Senator Thune.
    Senator Heller?
    Senator Heller. Mr. Chairman, thank you.
    Senator Isakson. Your time has arrived.
    Senator Heller. Terrific, terrific. [Laughter.]
    Ms. Verma, congratulations to you and also to your whole 
family who is there behind you. Your kids are very patient. I 
notice that Shaan is getting a little fidgety, so maybe we need 
to hurry up just a little bit. [Laughter.]
    But we are glad you are here and glad the family is here 
also.
    Twenty percent of the State's population in Nevada is on 
Medicaid and another 15 percent of the population is on 
Medicare. And we discussed in my office how important it is for 
you to strengthen and protect these programs and how critical 
that is for the State of Nevada. I just want you to know I 
appreciate the conversation that we did have in my office.
    And like everybody else, I would assume on this committee 
that everybody is a strong supporter of Medicare. And I share 
that.
    And I will say also that I have not supported, will not 
support legislation that does weaken Medicare.
    So before I get started, Mr. Chairman--and I am not quite 
sure who is playing Mr. Chairman at this point--I would like to 
submit for the record a letter that I received from the Speaker 
of the House in the Nevada legislature and also the majority 
leader.
    I asked Secretary Price if he would----
    Senator Wyden [presiding]. Without objection, it will be 
made a part of the record.
    [The letter appears in the appendix on p. 62.]
    Senator Heller. All right, terrific.
    All right, let us go to a couple of questions. I want to 
maintain the conversation that we have been having here on 
Medicaid today, if you do not mind.
    Nevada, as you are probably well aware of, is one of 32 
States that chose to expand eligibility for the Medicaid 
program. Numbers since the expansion: Nevada Medicaid 
enrollment increased from 350,000 to over 600,000. As of July 
2016, Medicaid enrollment in Nevada is over 200,000 people 
greater than what was projected before the expansion.
    I have had numerous conversations. I had a conversation 
with the Governor. I have had conversations with State 
employees. Our State legislature, our hospitals are all very 
seriously concerned about moving this program to a block grant.
    They are concerned that they will not have the appropriate 
funding to cover clearly all 600,000 Nevadans who are on the 
program and who are on Medicaid. And they are concerned that 
they do not have the staff to implement such significant 
changes.
    They are also concerned that with a part-time legislature, 
the State will not have the time needed to establish 
drastically different Medicaid programs. So I guess my question 
to you is whether or not you are sympathetic to these concerns 
for these block-grant States, these expanded block-grant States 
like Nevada. And so you understand those concerns?
    Ms. Verma. I absolutely understand those concerns. I have 
worked with States for almost 20 years now, so I understand the 
concerns. I understand the State budgets. I understand the 
States that have expanded and the States that have not 
expanded.
    You know, I think in terms of the Medicaid program, for me, 
the opportunity is about improving health outcomes. We are 
talking about a very vulnerable population. You know, these are 
individuals who--you know, it is a safety net. Medicaid is a 
safety net. They do not have another place to turn. If you are 
disabled, if you are a quadriplegic, if you are paralyzed, 
Medicaid is the program.
    But what we have today does not work well. I mean, we know 
that studies after studies have shown that the outcomes are not 
great. We know that States are spending different amounts of 
money, $4,000 in one State, $12,000 in another State, and do we 
know that we are getting better outcomes? Do we ask these 
individuals about their care?
    So, you know, I think that the conversations that we are 
having should all be around improving health outcomes and 
trying to do a better job here. I do not want to be about 
hurting States. That is where I come from, and that is what I 
understand. I have worked with a lot of different Governors, 
and I understand, you know, where they are in terms of State 
budgets. And there is not a whole lot of extra money.
    But I think this is about giving States, putting States in 
a leadership role so that they can manage their programs 
better. I think that States are closer to the people whom they 
serve than the Federal Government and they have a better 
understanding of what can work in their State than the Federal 
Government.
    You know, I think we have heard from some of the Senators 
today about rural areas, for example. You know, they have 
special challenges there in frontier areas. So some of the 
things that are coming down from Washington in terms of a one-
size-fits-all approach do not always work. And I think States 
should have that flexibility to design a program that works 
better for the people whom they are serving. And they are 
better positioned to make those decisions than we are in DC.
    So I think that this is an opportunity to create 
flexibility so that they are not having to go to the Federal 
Government every time they want to make a simple and routine 
change.
    And what we have seen in the Medicaid program is that, you 
know, because it is so inflexible, there is not a whole lot 
that you can do in designing your program. And so what States 
do often when times are tough is, they cut provider rates.
    In 2012, we had over 44 States either freeze or cut 
provider rates. And that has an impact on access to care. But 
they are doing that not because they do not care about the 
people whom they serve; it is because the program is so 
inflexible.
    So I think an opportunity to give States more flexibility 
is an opportunity to improve health outcomes for individuals.
    Senator Heller. So is it fair for me to say that you are 
pushing a block-grant approach?
    Ms. Verma. I am pushing an approach that improves the 
Medicaid program, because I do not think the status quo is 
acceptable. I think we can do better for disabled people and 
for people who are very vulnerable and who are dependent on 
this program.
    I think we can do better improving outcomes and making sure 
that individuals are not receiving health care in the emergency 
room and that their health is actually improving.
    Senator Heller. All right. My time is up. Are block grants 
on the table or off the table?
    Ms. Verma. I think anything should be on the table that can 
improve health outcomes for this very vulnerable population.
    Senator Heller. All right. So it is my understanding then 
that block grants are on the table.
    Ms. Verma. You know, I think block grants, per-capita caps, 
anything that we can do to help improve outcomes and create a 
level of accountability for States--I think we should explore 
all of those options. And I look forward to working with 
Congress on this.
    Senator Heller. Ms. Verma, thank you.
    Mr. Chairman, thank you.
    The Chairman. Senator Scott?
    Senator Scott. Thank you, Mr. Chairman.
    Thank you, Ms. Verma, for being here. We are excited about 
your opportunity that lies before you.
    I am the co-chair of the Sickle Cell Caucus. And every 
Valentine's Day I have a chance to go to the Children's 
Hospital at the Medical University of South Carolina and hang 
out with some of the kids who have been hospitalized several 
times a year, oftentimes for cancer or a chronic condition that 
can consistently resurface. As a matter of fact, the sickle 
cell disease has accounted for somewhere around 246,596 
emergency room visits as a principal diagnosis in 2014.
    The gentlelady behind me, Jordan, who is a student at my 
alma mater, Stall High School, she has been in and out of the 
hospital as a youngster, 15 years old, a number of times.
    And having an opportunity to see the challenges that so 
many families face and the necessity of Medicaid as their 
primary provider, raises a lot of questions. And one of the 
questions I would love to get your input on is, what are your 
thoughts about innovative things CMS can do to reduce 
readmissions, decrease costs for providers and payers, and 
improve care for those with sickle cell and similar chronic 
conditions?
    Ms. Verma. You know, I think one of the things that we can 
do is that, you know, anybody on the Medicaid program, they are 
in a vulnerable situation, whether it is being aged, blind, 
disabled, or having a disease-specific condition. They are 
completely dependent on this program.
    And as I said in my opening statement, sometimes this is a 
matter of life and death for these individuals. They have no 
place to turn. So we need to assure that we have the best 
possible program, better quality, better outcomes.
    And I think that those decisions and the ability to do that 
should come at the State level. And the State has a better 
understanding of the delivery system and of the citizens they 
serve. So they are in a better position to make those 
decisions.
    So in terms of, you know, readmissions and really focusing 
on outcomes, I think on the Federal level it is important to 
establish what are the expectations of the program. What are we 
going to hold States accountable for? You know, it should be 
quality, and it should be accessibility.
    Senator Scott. Have you found, working with the State of 
Indiana, that there were a couple of things that you thought 
worked really well on the State level that you would like to 
see on the national level?
    Ms. Verma. Well, you know, first I would say that every 
State is different.
    Senator Scott. Is different, I know.
    Ms. Verma. And you know, as I worked with States--you know, 
I am known for the Healthy Indiana Plan--people would say, do 
the Healthy Indiana Plan nationally. Every State has a 
different opinion. I have never actually had a State that 
wanted the Healthy Indiana Plan, you know, in entirety. They 
looked at it, they took things that they liked about it and 
applied them and they designed their own programs. So I think 
that that is why we need to have a program that is flexible and 
allows States to do what works best for them.
    Senator Scott. There is no doubt that most of us consider 
the 50 States the laboratories of our democracy, where good 
things happen. Without any question, having a national model 
where we have taken the best ideas from those States is an 
important part of your responsibility moving forward.
    I know that you have consulted with a number of States, 
including South Carolina, for programs like the pay-for-success 
financing models where Medicaid basically pays for performance, 
which I think is a fantastic model.
    What do you see as the future of the pay-for-success model 
in Medicaid? And what is the appropriate role for CMS in that 
process?
    Ms. Verma. Well, I think that the concepts around that 
program are critical. I think you know, instead of 
micromanaging the process, we need to say definitively, here 
are the outcomes that we are driving towards. I think right now 
what we are doing is, we are managing the process, we are not 
holding States accountable.
    You know, in terms of South Carolina, one of the very 
innovative things that they have done there is the application 
of the nurse/family partnership for low-income families or for 
low-income first-time mothers. And having that home visiting 
program, I think, is an excellent idea.
    But again, that program, you know, had a lot of thought. It 
took many, many, many months to get that program approved 
through CMS. And that is a great example of how the State has 
this idea and it is innovative, it has been proven in other 
communities. And to be able to do that on a ready basis without 
having to go through that long process of approvals, I think 
that is an important idea, the importance of having State 
flexibility.
    Senator Scott. Thank you, Mr. Chairman.
    Thank you, Ms. Verma.
    The Chairman. Well, thank you, Senator.
    Senator Enzi?
    Senator Enzi. Thank you, Mr. Chairman.
    First of all, I want to thank you for the opportunity I had 
to meet with you before. I do want to ask unanimous consent 
that a statement that I have could be put in the record.
    The Chairman. Without objection.
    [The prepared statement of Senator Enzi appears in the 
appendix on p. 55.]
    Senator Enzi. We do have an outstanding nominee before us 
who has had a good life outside of Washington. And she does not 
need to be subject to personal attacks or made into a symbol of 
partisan discord.
    I really get distressed at the way these hearings go, where 
we try to push for some things in actual legislation that ought 
to be reviewed. And again, be reminded that she gets to make 
good suggestions, but we get to pass the final laws.
    And since I met with you, I have read a lot more about you. 
You have not just studied Medicaid and Medicare and other 
health situations, you have actually been hands-on; you have 
done things. You have actually helped States to make their 
process work better. You have a track record. And it is very 
impressive.
    I think around here that makes you overqualified, 
unfortunately.
    You have not been cutting people off of Medicaid and 
Medicare. You have experience that has worked at the State 
level.
    You and I talked about frontier and rural and that has been 
emphasized here again, because we have several States 
represented that are frontier and rural.
    Wyoming has the lowest population in the Nation, and we 
have also had a devastating economic hardship because the last 
administration did not like energy. And we are the energy 
State. And so our State has had to make some very tough 
decisions.
    A year ago, the legislature, in their biannual budgeting, 
had to cut 8 percent. And when the session finished, they found 
out that that was not enough, so the Governor had to cut 8 
percent. And now they are into the second year on the biannual 
budget. And when they came back, they found that revenues are 
down so much they have to cut another 8 percent.
    And that presents a lot of problems, not just in the 
health-care area, but across the board, and education 
particularly is being devastated by that. But they are working 
through it, and they will get it.
    When I met with you, I also talked about Medicare's 
competitive bidding program. And we talked about some of the 
unique challenges of rural and frontier States.
    I want to know if you will be willing to continue to have a 
dialogue about how that competitive bidding process can ensure 
that people actually get what they think they are getting and 
what we think that we are buying.
    In your view, is it going to be important for CMS to look 
at avoiding putting in place the one-size-fits-all programs?
    Ms. Verma. I think that is absolutely critical. And you 
know, working for States, what I see is that they are all 
different, their delivery systems are different, their patient 
population is potentially different. So a Federal one-size-
fits-all approach does not always work.
    And I think what you are bringing up in terms of the 
competitive bidding is an excellent example where we have some 
providers who are being paid--they are rural providers--but 
they are being paid at a rate that is more appropriate for an 
urban area.
    And so I think that is the type of policy where we need to 
understand how that is going to impact a rural provider or a 
frontier provider on the front end and have that discussion so 
that we do not have problems later on down the line.
    And if we are having issues, then we need to be responsive 
to that, because we want to make sure that we are not impacting 
beneficiary access and that seniors and other folks who depend 
on CMS programs always have high-quality care and 
accessibility.
    We do not want to see that our policies and our programs 
are actually preventing providers or that we are losing 
providers or that they do not want to see Medicaid or Medicare 
beneficiaries anymore. We should be very careful with policies 
so that we are not pushing providers out of the system, but 
that we are actually attracting providers to the program.
    When we attract providers to the program, we are giving our 
seniors, Medicaid beneficiaries, we are giving them more 
choices. And when they have choices, that is what is going to 
drive quality in the system and hopefully lower costs.
    Senator Enzi. Again, you have demonstrated what you talk 
about. You are not just talking about something that you have 
studied in a book or that you wrote a Ph.D. paper on.
    As you know, dual-eligible individuals are a complex and 
expensive patient population. They affect both Medicare and 
Medicaid. So are you committed to working at the Federal level 
and with States at the State level to address the mounting 
financial concerns about the dual-eligible population?
    Ms. Verma. I think we must address that issue. I mean, as 
we have an aging baby boomer population and we have more and 
more folks going to be coming into the Medicaid program and 
Medicare program, we are going to need to have closer 
collaboration and make sure that we have the incentives in 
place to manage that program well and to assure that we are 
providing comprehensive, coordinated, quality care to those 
individuals.
    I think it is difficult and confusing for them when they 
are on two different programs. And we need to make sure that 
those programs work well for those beneficiaries.
    Senator Enzi. Thank you. And thank you for your outstanding 
presentation. And your family has to be really impressed, as am 
I, with your capability of answering and your vast knowledge. 
Thank you.
    Ms. Verma. Thank you, Senator.
    The Chairman. Thank you, Senator Enzi.
    The ranking member would like to ask a question or two, and 
then we will wrap it up.
    Senator Wyden. Thank you, Mr. Chairman. I do have a couple 
of questions and a quick wrap-up.
    But let me also say that I very much appreciate how this 
hearing has been handled by you. You have made it clear that 
Senators get to ask the questions that are important, and that 
is the best bipartisan tradition of the Finance Committee.
    The Chairman. Thank you.
    Senator Wyden. And as we move to wrap up, I just want to 
make that clear.
    I have two questions for you that remain, Ms. Verma. One 
stems from this horrible tragedy you described where the family 
was forced to choose between putting food on their table or 
paying for a prescription to treat a child's ear infection. And 
the family, as you stated, a horrible account, chose food, and 
the child lost his hearing permanently.
    What I have been told about the Healthy Indiana Plan that 
you designed is, if you had an individual who was making barely 
$12,000 who had the same kind of choice to make and chose not 
to pay their premium, they would be cut off from coverage for 6 
months. So that individual would not get treatment for an ear 
infection or other such condition.
    Is that correct? This is what I have been told, and I would 
just like you to tell me if that is correct or not.
    Ms. Verma. The Healthy Indiana Plan is about empowering 
individuals to take ownership for their health.
    Senator Wyden. With all due respect, just is that correct? 
Because we looked at the figures with respect to poverty, and, 
as I understood it, at $12,000 that person would be cut off. Is 
that right?
    Ms. Verma. The way the Healthy Indiana Plan works is that 
people who are above the poverty level, above 100 percent of 
the poverty level, make contributions into their health savings 
account. They make those contributions into their savings 
account, and they get monthly statements so they can see how 
that money is being spent.
    If they complete their preventative health-care services, 
then they have the ability to roll over that amount that is in 
there in their savings account to offset their contributions.
    If they have not completed their preventative services, 
they can still roll over, because that contribution that they 
are making is theirs and they own that.
    In terms of what you indicated, if somebody does not make a 
contribution into their account or chooses not to make that 
contribution, just like it is in the Affordable Care Act, just 
like it is in the exchanges for the same population, 
individuals make contributions. They have 30 days to make that 
contribution. If they do not, they are terminated from 
coverage, and they cannot reenter until the open enrollment 
period.
    So that is the exact same coverage, that is the exact same 
policy. In fact, the policy that we have in the Healthy Indiana 
Plan gives people 60 days----
    Senator Wyden. Whoa, whoa, whoa, whoa. There is a 3-month 
grace period in the ACA.
    Ms. Verma. There is a 30-day period where they continue 
your health coverage, but after that they suspend payment. So 
the individual actually does not have payment for their health-
care services, and then they cannot reenter the program until a 
special enrollment period.
    With the Healthy Indiana Plan, they actually have a 60-day 
grace period before they are terminated from the program.
    Senator Wyden. I am going to ask for this in writing. But 
we have reviewed this, and if they make $12,000, they are 
terminated. And I am going to ask you that in writing.
    Let me go on to the ethics question. This was reported in 
The Indianapolis Star--I guess that is the big paper in your 
State--that while you were running the State of Indiana's 
Medicaid program, you and your consulting firm were paid 
millions of dollars by companies that did business with the 
State, including Hewlett-Packard and Milliman and Maximus and 
Health Management Associates. And these companies provided 
financial, actuarial, administrative, and management services 
to Indiana Medicaid.
    So the question became, the Indiana ethics regulations on 
conflicts of interest do not technically apply to you because 
you were a contractor and not a State employee.
    But my question deals with essentially basic ethics 
principles, because it is hard to see how it is okay to 
basically orchestrate the State's health programs and then get 
paid by the contractors the State hires to carry out those very 
programs.
    So let us set aside Indiana law. We understand that, I 
understand that those Indiana rules do not technically apply to 
you because you are a contractor.
    But how is this not a conflict, because you were sitting, 
in effect, on both sides of the negotiating table?
    Ms. Verma. Let me start by saying that I hold honesty and 
integrity and adherence to a high ethical standard as part of 
my personal philosophy. That is for me. I demand that of my 
employees, and I set that example for my own children.
    In terms of the issues that you raise, in Indiana we sought 
an ethics opinion, so we sought counsel on this to make sure 
that there were no issues. On a practical level, on a day-to-
day level, we were not negotiating for HP. And what we were 
doing for HP was helping HP develop communication materials for 
when they were putting out system changes so that people 
understood what those changes were. So we were helping them 
with communications materials.
    What we were doing for the State was around policy and 
helping them develop programs. And so there was no overlap.
    When there was, when there was sort of the potential or 
when we were working on programs, we would recuse ourselves. So 
we were never in a position where we were negotiating on behalf 
of HP or any other contractor with the State that we had a 
relationship with.
    We were transparent. The State knew about our 
relationships. I think that they issued a statement indicating 
in a response to The Indianapolis Star article that they were 
aware of our relationship, we disclosed that relationship, and 
on a practical, day-to-day level we did not engage in anything 
that would, you know, put us in a situation where we were 
supervising their work, negotiating their contracts. And we 
made that very transparent on the front end.
    So if there was ever an issue--you know, I have been in 
meetings where we were talking about contractors, talking about 
implementing a program, and when it came to a vendor that we 
had a relationship with, I would recuse myself, I would get up 
and leave the meeting so that there was never any issue.
    And I think the State has spoken on this. And the work that 
we have done with HP and these other vendors has extended over 
three separate Governors and over six Secretaries of Health.
    Senator Wyden. So the recently ousted head of the State 
agency administering your contract told this paper, The Star, 
that you once attempted to negotiate with State officials on 
behalf of 
Hewlett-Packard while being paid by the State.
    So let us do this, because obviously there are differences 
of opinion. My concern was, it was not just one company. It was 
not just Hewlett-Packard, but it was the wide array of 
companies that I listed: Milliman, Maximus, and a wide variety 
of services.
    And my concern is, it is very clear that Indiana ethics 
rules do not apply to you in a technical sense because you were 
a contractor. No dispute about that. But it sure looks to me 
like you were on both sides of the table as a lot of money was 
being allocated.
    And I think that really leads me to my last kind of point 
for today, Ms. Verma.
    You have been asked a lot of questions. And my own sense 
is--and I have listened carefully to my colleagues--these were 
not ``gotcha'' questions. These were questions that were 
appropriate given the fact that, if confirmed, you are going to 
head an agency that is involved with a trillion dollars of 
spending and the health care of 100 million people or 
thereabouts.
    And I think these questions were designed to get a sense of 
how you would approach them. And I felt very strongly--I 
enjoyed our conversation, and I decided I was going to try to 
give you as much real estate as I could in getting a sense of 
how you would approach them. That is why I asked the question 
about pharmaceutical prices, which is huge and so important to 
people.
    And I said, I am going to ask Ms. Verma to give me one 
example, just one example of what she would do if confirmed in 
this position. And we did not get it in that area and in the 
rural area and in a variety of others.
    So the chairman will take us through the rules for getting 
the questions for the record, but I am going to be reviewing 
those questions and responses very carefully. Because what I am 
troubled about today is, for questions that I thought were 
appropriate for a job like this, a trillion dollars' worth of 
spending, we are not really getting much of a sense of how you 
would approach them.
    And I think that this committee needs answers. I think the 
public needs answers. And I will look at your written questions 
very carefully and look forward to talking with your further.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator.
    I want to thank Ms. Verma for appearing here today. This 
hearing is an important part of our committee vetting process. 
And I must say that, not surprisingly, you, Ms. Verma, have 
acquitted yourself very well.
    I look forward to Ms. Verma being reported out of the 
committee and being confirmed by the Senate. And my goal is for 
this to all happen expeditiously.
    It is critical that we get a strong, skilled leader in as 
CMS Administrator. It is essential to our efforts for 
collectively addressing our Nation's many health-care 
challenges.
    Our current Administrator, who is not confirmed, had all 
kinds of conflicts, but we allowed him to go forward, a very 
bright guy who had a lot on the ball. And here you are as 
somebody who really has proven to be a tremendous leader in 
health care, not just in Indiana, but as an example to the rest 
of the States. And all I can say is that you will be a strong, 
skilled leader as CMS Administrator.
    Now, it is essential for our efforts for collectively 
addressing our Nation's many health-care challenges that we get 
you there.
    Senator Wyden. Senator Portman is over there.
    The Chairman. Oh, Senator Portman, do you still have some 
questions? [Laughter.]
    I did not notice that you came in. I am ready to wrap up.
    Senator Portman. I am not very noticeable, I guess, Mr. 
Chairman.
    I apologize, Mr. Chairman. I have been here twice, 
listening dutifully, and I have had separate hearings going on 
at the same exact time, so I have been bouncing back and forth. 
But I would like the opportunity to ask my questions. I have 
not had a chance to do that yet.
    The Chairman. Then go ahead; proceed.
    Senator Portman. Thank you, and I apologize.
    Thanks for your patience mostly, Ms. Verma, to your 
children who have been very patient. I have been watching them. 
Amazing. At their age my kids never could have done that.
    So I heard a lot of the back-and-forth earlier. And let me 
just go to some of these issues.
    First of all, I like what you are saying about patients 
taking more responsibility for their own health and how you can 
have a health-care system that encourages that. I think we 
talked about innovation earlier. Part of the innovation has to 
do with that. We want people to lead healthier, stronger lives, 
and part of that is providing that incentive within our health-
care system.
    We talked about leveraging technology and innovation. I 
like that. And many of us in our States are doing some things 
that are innovative.
    As you know, the State of Ohio has an innovative health-
care director whom I know you have worked with before. And a 
lot of this is about taking the existing dollars and using them 
more effectively to create better care. And I think that is a 
great opportunity, frankly, in a health-care system that is in 
need of more innovation.
    And the technology part can be exciting; it can also be 
very expensive. So it has to be dealt with appropriately.
    You said more State flexibility. And later you talked about 
holding States accountable for health outcomes--so looking not 
at the input as much and the volume, but looking at the output 
and the quality. And I think that is something where you are 
going to find a lot of agreement on both sides of the aisle 
here.
    You also made the comment with regard to Medicaid that it 
sometimes can take years to get a waiver. And I have to say it 
is worse than that. Sometimes you cannot get a waiver. And as 
you know, because you were involved in putting together Ohio's 
waiver, we were not able to get a waiver to be able to give the 
State the flexibility that it wanted to be able to provide more 
innovation, better quality care, more holistic care, focusing 
more on prevention and wellness and getting people into the 
health-care system, not just when they have an emergency, but 
to have a better health outcome by having primary care 
physicians, and so on.
    And that is something that concerns me, that it is not just 
about how it takes too much time often to go through this 
process, but literally we cannot get these waivers sometimes. 
And the Obama administration HHS rejected the Ohio application.
    The Healthy Indiana Plan was accepted, and you were very 
involved, not just in developing that, but in implementing 
that.
    So if you could just speak briefly about what is the best 
thing about the Healthy Indiana Plan. Is it some of these 
characteristics I talked about earlier or others? And how could 
that be taken nationally? And then I want to talk to you about 
Medicaid expansion specifically.
    Ms. Verma. All right. You know, I think about the Healthy 
Indiana Plan, and what it has done is that it gives dignity to 
individuals. It empowers them. It recognizes their potential to 
fulfill their dreams. We do not assume just because somebody is 
poor that they do not want choices about their health care, 
they do not deserve choices, that they do not want to be 
involved, that they are not capable of making decisions.
    And what we have found is that when we do that, when we 
create a situation, they are actually more engaged in their 
health care and their engagement leads to better outcomes. It 
leads to lower emergency room usage, more primary care, more 
preventative care, higher satisfaction, and better drug 
adherence.
    Senator Portman. All right. Now, that is what I want to 
hear, because that is what we should all hope for, that people 
have access to affordable care and that the results are, you 
know, better health outcomes because they are taking more 
responsibility for their own health and have the ability to do 
that, including access to primary care.
    So here is the situation in Ohio. We have about 200,000 
people who get coverage through the exchange, 212,000 as of 
yesterday, but we have over 700,000 people in Medicaid 
expansion. So when people talk about the Affordable Care Act in 
Ohio, they talk about it in terms of some of the mandates on 
small businesses, some of the issues obviously that have 
resulted in higher costs to provide health care, the higher 
premiums.
    We have gone up 91 percent in the individual markets just 
in the last 4 years; 82 percent for small businesses. I mean, 
you know, people just cannot afford it.
    But there is a lot of focus here in Washington on the 
exchanges, which are important in Ohio, but frankly in Ohio, 
what is more important for us is those over 700,000 people who 
are in expanded Medicaid. And again, you have talked a lot 
about this today and what you might support and not support in 
terms of how you give more authority and responsibility back to 
the States.
    So that is my question for you. I am very concerned that we 
not move forward too quickly with the replacement and leave 
those people behind. I am also very supportive of a better 
system, including much more State flexibility, along the lines 
of what Governor Kasich wanted with his waiver request that was 
rejected.
    So help me to understand how we can ensure that we do 
provide coverage to these people, particularly in my State. You 
know, the prescription drug, heroin, now fentanyl issue is 
huge. And the treatment that is provided to people in Ohio is 
often now through Medicaid expansion. And we want people to get 
into this treatment. Again, that provides them better health 
outcomes in every respect.
    So talk to me just briefly about that. I know you do not 
have much time thanks to me being at the end here. But how can 
we ensure we can get a good, flexible plan to cover those 
people and even a better way than they are currently getting 
under Medicaid expansion?
    Ms. Verma. Well, I think that, first of all, I support 
coverage. And I think that, you know, the individuals who are 
being served in Medicaid, served through the exchange, I 
support people having coverage for the issues that you raised. 
I mean, as people are facing substance abuse, opioid addiction, 
they are going to need coverage, and we need to address that 
issue.
    But if we look at what the Affordable Care Act has done, 
and people talk about coverage--well, coverage does not 
necessarily translate to access to care.
    You know, I was today with an Uber driver and asking him 
about his coverage. And he said he had gotten coverage through 
the exchanges, through the Affordable Care Act, but he said, 
``I cannot do anything with it because my deductible is $6,000. 
And, you know, I cannot get to the doctor. I still cannot 
afford it.''
    And so I think that that is a great story of how coverage 
does not necessarily translate into access. And so, you know, 
as we move to a different system, I think those are things that 
we need to keep in mind, whether that is through the Medicaid 
program or through another coverage vehicle. And we need to 
make sure that we are providing high-quality care and also 
providing accessible care.
    Senator Portman. Thank you. And we look forward to 
continuing that conversation. And I know I am over time, but I 
do think this is going to be the key issue for us in Ohio: how 
do we ensure in that transition that we provide that coverage?
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator.
    Ms. Verma, you have been very patient, and you very 
intelligently have answered these questions of my colleagues.
    And the committee has received several letters in support 
of Ms. Verma's nomination that I ask to be added to the record, 
without objection.
    [The letters appear in the appendix beginning on p. 57.]
    The Chairman. And finally, I would ask that any written 
questions for the record be submitted by 5 p.m. tomorrow, 
February 17, 2017.
    With that, we want to thank you for being here. Thank you 
for your answers. Thank you for your patience.
    And we will adjourn this hearing. Thanks so much.
    Ms. Verma. Thank you, Senator.
    The Chairman. You bet.
    [Whereupon, at 12:51 p.m., the hearing was concluded.]

                            A P P E N D I X

              Additional Material Submitted for the Record

                              ----------                              


              Prepared Statement of Hon. Michael B. Enzi, 
                      a U.S. Senator From Wyoming
    Thank you for the opportunity to say a few words, Mr. Chairman. The 
nominee before us today is someone who has the background, the 
knowledge, and skill set to be an outstanding Administrator of the 
Centers for Medicare and Medicaid Services.

    Ms. Verma is a talented person who is eminently qualified to 
oversee CMS. Her experience with State Medicaid programs has given her 
insight into the functional side of CMS. She knows the frustrations of 
interacting with the agency and can see where changes could make 
meaningful improvements for State flexibility and in improving 
processes throughout CMS.

    I am hopeful that, under her leadership, CMS can emerge as a place 
where health-care innovation can thrive and, more importantly, a 
government agency that does not slow down or stop innovation.

    I have spoken to Ms. Verma about the challenges facing both 
Medicare and Medicaid in a rural and frontier State like Wyoming, and 
she understands the importance of not creating one-size-fits all 
programs that leave rural communities without access to vital health-
care services.

    I look forward to working with Ms. Verma in the future and am 
excited to see someone with her qualifications and background willing 
to step away from her great success in the private sector to serve her 
country in this capacity.

    I'd like to just focus on that, because we are in the nominations 
business right now, and there has been a degree of rancor in the 
nominations process which is unfortunate. I sometimes wonder why 
anybody would want to put themselves through this grueling process.

    We have before us a nominee who has a good life outside of 
Washington. She doesn't need to be subject to personal attacks or made 
into a symbol of partisan discord. But, she is willing to be under an 
extremely high level of scrutiny to do what she thinks is the right 
thing.

    Ms. Verma is impressive; she has practical, not just theoretical, 
knowledge of our Federal health care programs, and I particularly 
appreciate what she has said about the need to focus on the outcome for 
patients. At the end of the day, that should be our primary objective. 
I look forward to working with her as CMS Administrator.

    Thank you, Mr. Chairman.

                                 ______
                                 
              Prepared Statement of Hon. Orrin G. Hatch, 
                        a U.S. Senator From Utah
WASHINGTON--Senate Finance Committee Chairman Orrin Hatch (R-Utah) 
today delivered the following opening statement at a hearing to 
consider the nomination of Seema Verma to head the Centers for Medicare 
and Medicaid Services (CMS):

    Today we will consider the nomination of Seema Verma to serve as 
Administrator of the Centers for Medicare and Medicaid Services. 
Welcome, Ms. Verma, to the Finance Committee. I appreciate your 
willingness to lead this key agency at this critical time. I see that 
your family has joined you here today to lend support. I extend a warm 
welcome to them as well.

    CMS is the world's largest health insurer, covering over one-third 
of the U.S. population through Medicare and Medicaid alone. It has a 
budget of over $1 trillion, and it processes over 1.2 billion claims a 
year for services provided to some of our Nation's most vulnerable 
citizens.

    Ms. Verma, having dealt with CMS extensively in your capacity as a 
consultant to numerous State Medicaid programs, you know full well the 
challenges the agency deals with on daily basis.

    I suspect you also know that the job you've been nominated for is a 
thankless one, fraught with numerous challenges.

    The good news is that there are opportunities in those challenges, 
and I believe you are the right person for the job and that you will 
make the most of those opportunities to improve our health-care system.

    The failings of Obamacare are urgent and must be addressed in short 
order.

    Over the past 6 years, we have watched as the system created under 
Obamacare has led to increased costs, higher taxes, fewer choices, 
reduced competition, and more strains on our economy.

    Under Obamacare, health insurance premiums are up by an average of 
25 percent this year alone.

    Under Obamacare, Americans, including millions of middle-class 
Americans, have been hit with $1 trillion in new taxes.

    And, under Obamacare, major insurers are no longer offering 
coverage on exchanges, and earlier this week, we learned that another 
major carrier will exit the market in 2018.

    As Congress works to change course with regard to our ailing 
health-care system, CMS will play a major role in determining our 
success. I applaud the step the agency took yesterday under the 
leadership of HHS Secretary Price with its proposed rule to help 
stabilize the individual insurance markets, but there is much more work 
to be done and I am confident that, if you are confirmed, you will be a 
valuable voice in driving change.

    I'd like to talk specifically about Medicaid for a moment.

    The Medicaid program was designed to be a safety net for the most 
vulnerable Americans. As such, I understand and value the moral and 
social responsibilities the Federal Government has in ensuring health-
care coverage for our most needy citizens. I am committed to working 
with States and other stakeholders, and the American public to improve 
the quality and ensure the longevity of the Medicaid program.

    But we must also acknowledge that the Medicaid program is three 
times larger--both in terms of enrollment and expenditures--than it was 
just 20 years ago. Additionally, the Medicaid expansion under Obamacare 
exacerbated pressures on the program at a time when many States were 
already facing difficult choices about which benefits and populations 
to serve. As a result, we have a responsibility to consider alternative 
funding arrangements that could help to preserve this important 
program.

    We also need to consider various reform proposals that can improve 
the way Medicaid operates. Ms. Verma, we will need your assistance in 
both of these efforts, and your experience in this particular area 
should serve you well.

    On the subject of Ms. Verma's experience, I want to note for the 
committee that she has been credited as the creative force behind the 
Healthy Indiana Plan, the State's Medicaid alternative. This program 
provides access and quality health care to its enrollees, while 
ensuring that they are engaged in their care decisions. The program 
continues to evolve while hitting key metrics and, overall, enrollees 
are very satisfied with their experience.

    While we may hear criticisms of this program from the other side of 
the dais here today, we should note that HHS and CMS leaders under the 
Obama administration repeatedly approved the waiver necessary to make 
this program a reality.

    Ms. Verma has assisted a number of other State Medicaid programs as 
well. Her efforts all have the same focus--getting needed, high-quality 
care to engaged patients in a fiscally responsible way. This is exactly 
the mind-set we need in a CMS Administrator.

    Now, Ms. Verma, as if the challenges associated with Medicaid are 
not enough to keep you busy as CMS Administrator, you will also be 
tasked with helping to ensure the longevity and solvency of the 
Medicare trust fund, which is projected to go bankrupt in 2028.

    All told, between now and 2030, 76 million baby boomers will become 
eligible for Medicare. Even factoring in deaths over that period, the 
program will grow from approximately 47 million beneficiaries today to 
roughly 80 million in 2030.

    Maintaining the solvency of the Medicare program while continuing 
to provide care to an ever expanding beneficiary base is going to 
require creative solutions. It will not be easy. But, we can't put it 
off forever, and the longer we wait, the worse it will get.

    Now that I've had a chance to discuss the challenges facing CMS and 
some of Ms. Verma's qualifications, I want to speak more generally 
about recent events.

    We've gone through a pretty rough patch recently on this committee, 
particularly as we've dealt with President Trump's nominations. I don't 
want to rehash the details of the past few weeks, but I will say that I 
hope that recent developments do not become the new normal for our 
committee.

    As I've said before, I'm going to do all I can to restore and 
maintain the customs and traditions of this committee, which has always 
operated with assumptions of bipartisanship, comity, and good faith. 
With regard to considering nominations, that means a robust and fair 
vetting process, a rigorous discussion among committee members, and a 
vote in an Executive Session.

    On that note, maybe the icy treatment of nominees is starting to 
thaw today, at least I hope it is. One tradition that has been absent 
here this session has been the introduction, on many occasions, of 
nominees by Senators of both parties from the nominees' home States, 
especially in cases when the nominee and the home State Senator have a 
relationship. I'm pleased to say that the Senior Senator from Indiana 
is re-affirming that tradition by appearing here today. I thank the 
Senator for taking the time to appear today and introduce his 
constituent. I'll give him a chance to do so in just a few minutes.

    With that, I look forward to Ms. Verma sharing her vision and views 
here today. I also look forward to what I hope will be a full and fair 
committee process that allows us to process this nomination and report 
it to the full Senate in short order.

                                 ______
                                 
                     America's Essential Hospitals

                      401 Ninth St., NW, Suite 900

                          Washington DC 20004

                            t: 202-585-0100

                            f: 202-585-0101

                     e: [email protected]

                    https://essentialhospitals.org/

February 15, 2017

The Honorable Orrin Hatch           The Honorable Ron Wyden
Chairman                            Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
Washington, DC 20510                Washington, DC 20510

Dear Chairman Hatch and Senator Wyden:

On behalf of America's Essential Hospitals and its nearly 300 member 
hospitals across the country, I write to support the appointment of 
Seema Verma, MPH, as administrator of the Centers for Medicare and 
Medicaid Services (CMS).

America's Essential Hospitals is the leading association and champion 
for hospitals and health systems dedicated to high-quality care for 
all, including the vulnerable. Our members are cornerstones of care in 
their communities, providing primary care through trauma care, disaster 
response, health care workforce training, research, public health 
programs, and other vital services. But they do more than keep people 
healthy and productive--they bolster the economic health of their 
communities. Each year, our members generate more than $165 billion of 
economic activity for their respective State economies and contribute 
to more than 1.25 million jobs nationally.

We believe Ms. Verma is well-qualified to lead CMS, given her deep 
understanding of both health-care delivery and policymaking. Through 
her work at essential hospitals, she has firsthand experience 
delivering care to low-income and other vulnerable people. She 
previously served as vice president of planning for the Health and 
Hospital Corporation of Marion County, an association member in 
Indiana, and as a director for the Association of State and Territorial 
Health Officials, in Washington, DC. In 2001, she graduated from 
America's Essential Hospitals' Fellows Program, which helps rising 
health-care leaders transform the culture of care. Also of note, Ms. 
Verma served as Indiana's health reform lead, a role in which she 
oversaw implementation of the State's Medicaid expansion waiver under 
then-Governor Mike Pence.

Ms. Verma will contribute an important, State-level perspective on 
Medicaid, insurance, health-care delivery, and public health. As States 
grapple with options for the future of their Medicaid program, Verma's 
background in innovative waivers and her proven ability to work 
effectively with States will engender confidence in the agency's 
actions.

We stand at a crossroads for health care. As CMS leads the charge for 
high-quality care at lower costs and with better health outcomes for 
all people, the agency's role and responsibilities take on heightened 
importance. At this critical juncture, Ms. Verma would contribute 
needed and valuable knowledge about Medicaid and Medicare, the complex 
programs on which our Nation's vulnerable people and their hospitals 
depend.

We look forward to working with Ms. Verma to ensure essential hospitals 
can sustain their commitment to those in need and to underserved 
communities, and to continue national efforts to foster innovation and 
reduce disparities in care.

We urge the committee to swiftly confirm Ms. Verma.

Sincerely,

Bruce Siegel, M.D., MPH
President and CEO

                                 ______
                                 
February 13, 2017

The Honorable Orrin G. Hatch
Chairman
U.S. Senate
Committee on Finance

The Honorable Ron Wyden
Ranking Member
U.S. Senate
Committee on Finance

        Re: Nomination of Seema Verma to be Administrator, Centers for 
        Medicare and Medicaid Services

Dear Chairman Hatch and Ranking Member Wyden:

In previous Republican administrations, we all had the honor of leading 
the agency now known as the Centers for Medicare and Medicaid Services 
(CMS). With expenditures of $1 trillion per year and oversight over the 
Medicare, Medicaid, SCRIP, and now ACA programs, CMS's 5,000 employees 
are responsible for managing and regulating the largest health 
insurance program in the country. At the top of this critical agency 
sits the Administrator.

Regardless of how you might feel about each of these programs and the 
administration's policy initiatives, effective leadership of the agency 
is essential. Being CMS Administrator is a critical job in the 
executive branch, helping to assure that CMS is able to continue 
improving its payment capabilities, better support providers and 
beneficiaries, assist States, implement a wide range of broadly-
supported legislative initiatives such as the major reforms in Medicare 
physician payments, and respond to beneficiary and Congressional 
requests. Having someone who understands its mission, is an expert in 
health policy, and has experience working with the agency is important 
to being a successful leader.

Seema Verma has the traits necessary to be a successful CMS 
Administrator. The heart and soul of the agency's work is supporting 
beneficiaries--seniors, low-income mothers, children or those seeking 
insurance through the exchanges. Seema understands that all CMS 
employees come to work every day with the mission of serving these 
diverse groups, and that the Administrator plays a critical role in 
supporting CMS employees in that mission.

But at the same time, to best serve beneficiaries, the policies and 
regulations guiding these programs must be market-based, calling upon 
and encouraging the best ideas of the private sector for delivering 
care. CMS must be a good primer to the health care sector as realized 
by fair and realistic regulation, to improve the quality of our 
country's health care while at the same time keeping tighter control of 
costs. Providers and patients work to get the right care at the right 
time, but no agency can do as much as CMS to help or hinder those 
efforts. Therefore the Administrator must understand the complexity and 
competition within the health care system, including the all-important 
dynamic that exists between payers and providers.

The Administrator must assure that the agency makes timely and coherent 
decisions in the best interests of the beneficiary and taxpayer with a 
focus on making health care more affordable for all. And of course, it 
is important to both the employees of CMS and to the public that there 
be a strong degree of transparency in the decisions and actions of the 
Administrator and her senior advisors. With trillions of dollars and 
the health of millions of beneficiaries at stake, taxpayers and elected 
officials must understand the process and rationale for CMS decisions 
and actions. This is particularly important for decisions related to 
the implementation of new legislation--and CMS has many such decisions 
ahead, including countless decisions to assure the effective 
implementation of physician payment reform and changes in the ACA.

While all of us might have our preferred policies and ideas for how CMS 
can improve the health care delivery system, Seema Verma has the kind 
of health policy leadership experience needed to carry out these 
essential responsibilities. Through her interactions with CMS as she 
negotiated Indiana's Medicaid waiver and other state reform proposals, 
she understands the kind of leadership and commitment needed to make 
the agency work well. Through her career-long commitment to improving 
the well-being of beneficiaries and the quality and efficiency of 
insurance programs, she has the heart to succeed as well.

For these reasons, most importantly for the over 100 million Americans 
served by CMS and for American taxpayers, we support Seema Verma's 
confirmation as soon as possible. We believe CMS and its critical 
responsibilities will be in good hands.

Sincerely,

William L. Roper
Gail R. Wilensky
Leslie V. Norwalk
Mark B. McClellan
Thomas A. Scully

                                 ______
                                 

                           February 15, 2017

The Honorable Orrin G. Hatch
Chairman
U.S. Senate
Committee on Finance
Washington, DC 20510

Dear Chairman Hatch:

We write to endorse without reservation the nomination by President 
Donald J. Trump of Ms. Seema Verma for the position of Administrator of 
the Centers for Medicaid and Medicare Services. Ms. Verma has decades 
of experience working with State health care and industry leaders to 
reform and improve services for the most vulnerable in our communities.

There are few professionals in the Nation who possess the respect, 
hands-on experience, and relationships with State leaders that will be 
critical as the Congress and administration work to repeal and replace 
the Affordable Care Act. Medicaid represents an enormous burden on 
State budgets combined with an unprecedented opportunity to reform a 
Federal entitlement program long in need of structural changes. Ms. 
Verma is the ideal candidate to oversee the reform of Medicaid design 
and ensuring pending State waivers are fast-tracked and with the 
underlying premise that Medicaid is a State-Federal partnership.

As a consultant working alongside States and industry leaders 
throughout the legislative process and implementation of the Affordable 
Care Act, Ms. Verma has a unique understanding of the nexus between the 
health insurance marketplace and the States and the impact of the ACA 
on coverage and cost.

President Trump and Vice President Pence have made an inspired choice 
for CMS Administrator in Ms. Seema Verma. We look forward to working 
with Congress and the administration to truly reform health-care 
delivery and insurance coverage in our great Nation.

Sincerely,

 
 
 
Governor Eric Holcomb    Governor Robert Bentley  Governor Douglas A.
Indiana                  Alabama                   Ducey
                                                   Arizona
 
Governor Asa Hutchinson  Governor Nathan Deal     Governor Edward J.
Arkansas                 Georgia                   Baza Calvo
                                                  Guam
Governor Sam Brownback   Governor Matt Bevin      Governor Paul R.
Kansas                   Kentucky                  LePage
                                                  Maine
 
Governor Rick Snyder     Governor Phil Bryant     Governor Eric R.
Michigan                 Mississippi               Greitens
                                                  Missouri
 
Governor Chris Christie  Governor Doug Burgum     Governor John R.
New Jersey               North Dakota              Kasich
                                                  Ohio
 
Governor Mary Fallin     Governor Dennis          Governor Bill Haslam
Oklahoma                  Daugaard                Tennessee
                         South Dakota
 
Governor Greg Abbott     Governor Gary R.         Governor Scott Walker
Texas                     Herbert                 Wisconsin
                         Utah
 

                                 ______
                                 

                        Commonwealth of Kentucky

                         Office of the Governor

                     700 Capitol Avenue, Suite 100

                          Frankfort, KY 40601

                             (502) 564-2611

                          Fax: (502) 564-2517

                      KentuckyUnbridledSpirit.com

                           February 15, 2017

The Honorable Orrin G. Hatch
Chairman
U.S. Senate
Committee on Finance
Washington, DC 20515

Dear Chairman Hatch:

    I want to personally reach out to you and offer my unequivocal 
endorsement of Ms. Seema Verma who was nominated by President Donald J. 
Trump to serve in the position of Administrator of the Centers for 
Medicaid and Medicare Services (CMS). As Governor of Kentucky, I look 
for three key attributes when making appointments to my cabinets--
character, competence, and commitment. Ms. Verma will unquestionably 
bring these positive characteristics and much more to the position.

    Ms. Verma is well positioned and uniquely qualified to serve in her 
role. As you are aware, the administration of the Medicaid program is a 
partnership between the State and the Federal Government--specifically, 
CMS; however, in recent years, it has not felt this way. The Affordable 
Care Act (ACA) was forced upon Americans with minimal input from States 
or the public. CMS, under the former administration, gave very little 
flexibility to States to be innovative or tailor Medicaid programs to 
fit the needs of their unique populations or obtain relief from the 
burdens of the ACA. During this time, Ms. Verma successfully navigated 
mountains of regulation to guide States through the frustrating process 
of getting permission to enact innovative policies. Ms. Verma is 
ideally suited to eliminate unnecessary red tape and to grant much 
needed flexibility to States to develop solutions for their 
populations.

    In fact, I can speak to this first hand as I was fortunate enough 
to work with Ms. Verma in the development of Kentucky HEALTH, an 
innovative section 1115 waiver designed to improve health outcomes and 
create fiscal sustainability for Kentucky's Medicaid program. Ms. 
Verma's deep understanding of the Medicaid program and her experience 
navigating CMS, was invaluable as we made policy decisions in crafting 
our waiver. This understanding and experience will be especially 
valuable to the Trump administration and Congress as much needed 
changes to America's health system are considered.

    Additionally, I am especially appreciative of her understanding of 
Medicaid from the State's perspective. Such perspective is critical as 
policies and regulations are crafted that will impact how States 
administer the Medicaid program.

    For these reasons, and many more, I enthusiastically encourage the 
Senate to confirm the appointment of Ms. Seema Verma. Kentucky looks 
forward to working with Congress, President Trump, Vice President 
Pence, and the new leadership at the U.S. Department of Health and 
Human Services on much-needed and meaningful healthcare reform.

            Sincerely,

            Matthew G. Bevin
            Governor of Kentucky

                                 ______
                                 
                Partnership for Quality Home Healthcare

February 15, 2017

The Honorable Orrin G. Hatch
Chairman
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510-6200

The Honorable Ron Wyden
Ranking Member
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510-6200

Dear Chairman Hatch and Ranking Member Wyden:

On behalf of the Partnership for Quality Home Healthcare (Partnership), 
we are writing in strong support of the nomination of Seema Verma to 
serve as Administrator of the Centers for Medicare and Medicaid 
Services (CMS).

As the nation's premier association of leading skilled home health 
agencies, the Partnership is committed to delivering high quality 
health-care services in the home, offering value to taxpayers and to 
families. Our nurses, therapists and caregivers provide essential 
skilled care services in an increasingly complex regulatory environment 
that is unnecessarily duplicative, burdensome and challenging.

The Partnership supports Ms. Verma's nomination because of her 
extensive experience in the private sector health-care field, which we 
believe contributes to her understanding of the complexity of 
delivering care in such a highly regulated and tightly controlled 
environment. The Partnership is eager to work with Ms. Verma on common-
sense solutions to reduce regulatory burden and make Medicare's home 
health benefit more accessible to seniors in need. We also believe that 
it is critical that the largest health-care payer in the Nation have a 
confirmed, permanent Administrator.

Accordingly, we enthusiastically support Ms. Verma's nomination and 
urge her expeditious confirmation.

Very Truly Yours,

Colin Roskey
Executive Vice President

                                 ______
                                 
    Letter Submitted by Hon. Dean Heller, a U.S. Senator From Nevada

                           Nevada Legislature

                            January 10, 2017

The Honorable Dean Heller
324 Hart Senate Office Building
Washington, DC 20510

Dear Senator Heller:

We are writing to express our concern regarding plans to repeal the 
Affordable Care Act. Specifically, we are concerned that Republicans in 
Congress are pushing ahead with a repeal of the Affordable Care Act 
despite having no viable replacement legislation ready to enact.

Failure to immediately enact replacement legislation risks creating 
uncertainty in the insurance marketplace. Such uncertainty will likely 
result in higher out-of-
pocket costs and fewer insurance options for Nevada's families while 
simultaneously placing an increased burden on our State budget.

As you are aware, Governor Sandoval worked closely with the Legislature 
and ultimately signed legislation creating the Silver State Health 
Exchange in 2011. Subsequently, more than 300,000 Nevadans have gained 
access to health-care coverage, either by purchasing it on the exchange 
or by meeting the expanded Medicaid eligibility requirements.

In light of these facts, we hope that you will address the following 
questions regarding the planned repeal of the Affordable Care Act:

    1.  What steps do you plan to take to ensure that the more than 
88,000 Nevadans who have purchased health insurance through the Silver 
State Health Exchange continue to have the ability to purchase health 
insurance with adequate coverage in a transparent marketplace?

    2.  What steps do you plan to take to ensure that the more than 
77,000 Nevadans who are eligible for Federal tax credits under the 
Affordable Care Act to help purchase private insurance will continue to 
have access to affordable health insurance options with adequate 
coverage?

    3.  What steps do you plan to take to ensure that the 217,000 
Nevadans who are receiving health care under the Medicaid expansion 
remain covered?

    4.  The Affordable Care Act guarantees coverage vital to 
preventative services for women, including cancer screenings and birth 
control. What steps do you plan to take to ensure that the Affordable 
Care Act's coverage guarantees remain intact for women's health?

    5.  The Affordable Care Act guarantees that Nevadans with pre-
existing conditions will not be denied health care and ends lifetime 
minimums on coverage. It also allows younger people, many of whom are 
saddled with college debt and cannot afford insurance, to stay on their 
parents' insurance until they are 26. What steps do you plan to take to 
preserve those coverage guarantees?

The lack of clarity regarding viable alternatives to the Affordable 
Care Act from the incoming administration and Republican congressional 
leadership is troubling. While Congress has expended considerable time 
and energy over the past several years talking about the law, hundreds 
of thousands of Nevadans have relied in good faith on the Affordable 
Care Act to obtain health insurance. Repealing the law without 
implementing an adequate replacement will put those Nevadans' health 
and well-being at risk.

Further, any congressional action that creates a large gap in insurance 
coverage will likely result in more Nevadans relying on State-funded 
social service programs. Most of these programs are already under 
resourced. Nevada cannot afford to shoulder this new financial burden 
created by politicians in Washington failing to live up to guarantees 
that the Federal Government previously made to our citizens.

We hope you will use your position as Nevada's senior United States 
Senator and a member of the majority party to protect the thousands of 
Nevada families who are now at risk of losing their health insurance. 
We also hope you will take steps to ensure that our State does not bear 
any unfair and unnecessary costs of caring for people who stand to lose 
that coverage in the near future.

We look forward to your prompt reply.

Sincerely,

Aaron D. Ford                       Jason Frierson
Majority Leader                     Speaker
Nevada State Senate                 Nevada State Assembly

                                 ______
                                 
   Prepared Statement of Seema Verma, Nominated to be Administrator, 
 Centers for Medicare and Medicaid Services, Department of Health and 
                             Human Services
    Chairman Hatch, Ranking Member Wyden, members of the committee, 
thank you for allowing me to appear before you today. I am deeply 
honored to be here, and am grateful for your consideration of my 
nomination by President Trump to be Administrator of the Centers for 
Medicare and Medicaid Services. I appreciate the time many of you and 
your staffs have taken to meet with me in advance of this hearing.

    Before I begin my statement, I would like to take a moment to 
introduce my family. I am truly grateful for the love and support of my 
parents Mr. and Mrs. Verma, my husband Sanjay Mishra and my two 
children Maya and Shaan.

    I have often been asked, by my family as well as by the members of 
this committee, why I would be interested in a job as complex and 
difficult as running a trillion dollar government agency such as CMS.

    I humbly accepted President Trump's call to service because I 
understand what is at stake. I have never stood on the sidelines of our 
Nation's health-care debate, merely pointing out what is wrong with our 
health-care system. I have spent my entire life helping the most 
disadvantaged in our society receive the kind of accessible, affordable 
and competent health-care service that our country's health-care system 
is renowned for.

    More than 20 years ago, when I graduated from college, I started my 
career working on national policy on behalf of people with HIV and 
AIDS, as well as low-income mothers to improve birth outcomes. I fought 
for coverage, for greater health-care access and for improving the 
quality of care--and have continued to fight for these issues for the 
past 20 years.

    But, sadly, I am deeply concerned about our health-care system. 
There is frustration all around. Doctors are increasingly frustrated by 
a number of costly and time-consuming burdens, and quite frankly, many 
Americans are not getting the care that they need.

    We have a long way to go in improving health outcomes. Health care 
continues to grow more and more expensive, and the American people are 
tired of partisan politics. They just want their health-care system 
fixed.

    And I know this, not simply because I have worked in health care, 
but because of how intimately it has affected my personal life.

    Two people I truly love have been immensely affected by enormous 
health-care challenges.

    My own mother is a breast cancer survivor due to early diagnosis 
and treatment, and I thank God that she is with me today.

    Also, a few years back, my neighbor was diagnosed with a stage 4 
neuroblastoma. A large tumor had been growing for some time, wrapping 
around his kidney. Aidan went through excruciating chemotherapy, 
radiation, stem cell treatment, surgeries, and countless trips to the 
hospitals and doctors. Experimental treatments were used by his medical 
team. This treatment regimen would be excruciating for anyone to 
endure, but Aidan was only 4 years old. At such a young age, we didn't 
know if he would live or die.

    But this May Aidan will celebrate his 12th birthday.

    Both my mom and Aidan are testaments to the ingenuity of the 
American medical system that saved their lives, as well as to the grace 
of God. This is why people travel from around the world to get care 
here in the United States.

    I want to be part of the solution making the system work for all 
Americans. I want to be able to look my children in the eye and tell 
them I did my part to serve my country and make things better for 
people who often do not have a voice. I want to tell my children that I 
fought to ensure that all American families, like Aidan's and my own, 
have the care that they need.

    This is a formidable challenge, but I am no stranger to achieving 
success under difficult circumstances.

    My father left his entire family to immigrate to the United States 
during the 1960s to pursue four degrees while he worked to earn money 
to pay for school, as well as to provide for his family.

    On my mother's side, my grandmother was married at the age of 17 
with no more than a 5th-grade education, but my mother was the first 
woman in her family to finish a master's degree.

    My parents made a lot of sacrifices along the way to provide me 
with opportunities they didn't have.

    I am extremely humbled as a first-generation American to be sitting 
before this committee after being nominated by the President of the 
United States. It is a testament to the fact that the American Dream is 
very much alive for those willing to work for it.

    And it is my passion to continue to work on the front lines of 
health care, changing and improving this country's health care delivery 
system.

    Throughout my career, I have brought people together from all sides 
of the political spectrum to forge solutions that worked for everyone. 
These consensus efforts have resulted in programs that have provided 
health-care coverage to over a million vulnerable Americans. One of the 
proudest moments of my career was watching the Indiana legislature pass 
the Healthy Indiana Plan with a bipartisan vote.

    For me, today's hearing is not simply a matter of finding a good 
executive to run a large government bureaucracy. It is about bringing 
someone to the table who fundamentally understands that the future of 
our country's health care is at stake.

    CMS is a $1 trillion agency, and through Medicare, Medicaid, the 
Children's Health Insurance Program, and the Health Insurance 
Marketplace, it covers over 100 million people, many of whom are among 
our most vulnerable citizens. Providing high quality, accessible health 
care for these Americans isn't just a luxury, it's a necessity and 
often a matter of life and death.

    Should I be confirmed, I will work to ensure that CMS's programs 
are focused on achieving positive outcomes. As the Nation's largest 
purchaser of health care, we must do more, achieve more than the mere 
distribution of insurance cards. We can use these programs to truly 
make a difference in people's lives to prevent and cure disease, manage 
chronic illnesses, and promote healthy lifestyles and independence from 
government assistance.

    In order to achieve our goals, I will work toward policies that 
foster patient-centered care and increase competition, quality, and 
access while driving down costs.

    Patients and their doctors should be making decisions about their 
health care, not the Federal Government. We need to ensure that people 
have choices about their care. We shouldn't assume that all vulnerable 
or low income populations don't want choices or aren't capable of 
making the best decisions for themselves and their families. We must 
find creative ways to empower people to take ownership of their health 
and be engaged in making cost and quality decisions as they seek care. 
CMS's rules and regulations shouldn't drive doctors and providers away 
or crowd out care, but should instead support them in delivering high 
quality care to their patients.

    If confirmed, I will work toward modernizing CMS's programs to 
address the changing needs of the people they serve, leveraging 
innovation and technology to drive coordinated, cost effective care. I 
will ensure that efforts around preventing fraud and abuse are a 
priority, since we cannot afford to waste a single taxpayer dollar. 
Ultimately, while we strive to provide the highest level of care to our 
current beneficiaries, we must solidify the programs' sustainability 
for future generations.

    I will work toward ushering in a new era of State flexibility and 
leadership. For too long our State partners have been sharing in the 
cost but have not been allowed to have a meaningful role in decision 
making. We need to guarantee that appropriate protections are in the 
place for our most vulnerable populations and hold States accountable 
for achieving outcomes around quality and access, but we also need to 
create an environment that incentivizes innovation over paper-pushing, 
so that we can find new and better ways of achieving our mutual goals.

    If I have the honor of being confirmed, I will carry this vision, 
along with my strong belief in open communication, collaboration, and 
bipartisanship with me to CMS. I will work with you, be responsive to 
your inquiries and concerns, and value your counsel.

    I will do everything I can to ensure that your constituents are 
being properly served by the programs at CMS, and that these programs 
operate in an efficient and transparent manner.

    I thank you for your consideration of my nomination.

                                 ______
                                 

                        SENATE FINANCE COMMITTEE

                  STATEMENT OF INFORMATION REQUESTED 
                               OF NOMINEE

                      A. BIOGRAPHICAL INFORMATION

 1.  Name (include any former names used): Seema Verma.

 2.  Position to which nominated: Administrator, Centers for Medicare 
and Medicaid Services.

 3.  Date of nomination: January 20, 2017

 4.  Address (list current residence, office, and mailing addresses):

 5.  Date and place of birth: September 27, 1970, Portsmouth, Virginia.

 6.  Marital status (include maiden name of wife or husband's name):

 7.  Names and ages of children:

 8.  Education (list secondary and higher education institutions, dates 
attended, degree received, and date degree granted): Johns Hopkins 
School of Hygiene and Public Health, Baltimore, MD, Master of Public 
Health--Health Policy and Management, 1996; University of Maryland, 
College Park 1988-1993, Bachelor of Science, Life Sciences, 1993.

 9.  Employment record (list all jobs held since college, including the 
title or description of job, name of employer, location of work, and 
dates of employment): Founder, president, and CEO, SVC Inc., 
Indianapolis, IN (2001-present); vice president, corporate planning, 
Health and Hospital Corporation, Indianapolis, IN (1999-2001); Director 
of Program Development/Healthy Babies Initiative, Marion County Health 
Department, Indianapolis, IN (1997-1999); Project Director HIV/AIDS and 
Consultant, Association of State and Territorial Health Officials 
(ASTHO), Washington DC (1993-1997).

10.  Government experience (list any advisory, consultative, honorary, 
or other part-time service or positions with Federal, State, or local 
governments, other than those listed above): As stated in Item 9 above, 
from 1997-1999, I was employed by the Marion County Health Department. 
Attachment 1 includes a list of consulting projects in which I have 
engaged on behalf of various State government agencies through prime 
contracts or subcontracts awarded to SVC, Inc.

11.  Business relationships (list all positions held as an officer, 
director, trustee, partner, proprietor, agent, representative, or 
consultant of any corporation, company, firm, partnership, other 
business enterprise, or educational or other institution): Owner, 
president, and CEO of SVC, Inc. Please also refer to Attachment 1 for 
consulting projects in which I have engaged through SVC.

12.  Memberships (list all memberships and offices held in 
professional, fraternal, scholarly, civic, business, charitable, and 
other organizations): I no longer hold positions with any such 
organizations. In 2016 I held the following positions with these 
organizations, from which I recently resigned: board member, Aidan 
Brown Foundation; chair of the International Festival, Teacher 
Luncheon's, Sycamore School.

13.  Political affiliations and activities:

    a.  List all public offices for which you have been a candidate.

      N/A.

    b.  List all memberships and offices held in and services rendered 
to all political parties or election committees during the last 10 
years.

      N/A.

    c.  Itemize all political contributions to any individual, campaign 
organization, political party, political action committee, or similar 
entity of $50 or more for the past 10 years.


                        Individual Contributions
------------------------------------------------------------------------
            Recipient               Amount       Date of Contribution
------------------------------------------------------------------------
Mitch for Governor Campaign          $1,001  March 21, 2007
 Committee
------------------------------------------------------------------------
Mitch for Governor Campaign          $1,001  March 21, 2007
 Committee
------------------------------------------------------------------------
Mitch for Governor Campaign          $1,000  June 10, 2008
 Committee
------------------------------------------------------------------------
Eric Holcomb for Indiana               $300  June 10, 2015
------------------------------------------------------------------------
Friends of Susan Brooks              $1,000  November 16, 2015
------------------------------------------------------------------------
Eric Holcomb for Indiana               $351  January 27, 2016
------------------------------------------------------------------------
Erin Houchin for Congress              $750  March 31, 2016
------------------------------------------------------------------------
Friends of Susan Brooks                $250  October 12, 2016
------------------------------------------------------------------------
Friends of Todd Young                  $500  October 18, 2016
------------------------------------------------------------------------




                         SVC, Inc. Contributions
------------------------------------------------------------------------
            Recipient               Amount       Date of Contribution
------------------------------------------------------------------------
Aiming Higher                        $5,000  May 16, 2012
------------------------------------------------------------------------
Mike Pence for Indiana                 $500  June 12, 2012
------------------------------------------------------------------------
Turner for State Representative        $500  June 13, 2012
------------------------------------------------------------------------
Turner for State Representative        $300  December 20, 2013
------------------------------------------------------------------------
Eric Holcomb for Indiana               $200  October 5, 2016
------------------------------------------------------------------------


14.  Honors and awards (list all scholarships, fellowships, honorary 
degrees, honorary society memberships, military medals, and any other 
special recognitions for outstanding service or achievement): Sagamore 
of the Wabash, an Indiana honorary award given to me by Vice President 
and former Governor of Indiana Mike Pence.

15.  Published writings (list the titles, publishers, and dates of all 
books, articles, reports, or other published materials you have 
written):

     ``Election Headlines Bury Need for a Discussion on Future of 
Health Care,'' The Hill, and Real Clear Health, October 22, 2016.

     ``Healthy Indiana 2.0 Is Challenging Medicaid Norms,'' Health 
Affairs, August 29, 2016.

     ``IN: Health Care Reform Amidst Colliding Values,'' Health 
Affairs, May 1, 2008.

16.  Speeches (list all formal speeches you have delivered during the 
past 5 years which are on topics relevant to the position for which you 
have been nominated):

     Testimony, Energy and Commerce Health Committee, June 12, 2013 
(attached at Attachment 2).

     I have given numerous speeches on the Affordable Care Act and 
Medicaid Reform. There are no formal transcripts, but PowerPoint 
presentations were previously provided.

       Lily Speakers Bureau
       America's Health Insurance Plans
       National Association of State Health Policy
       IU Life Sciences Collaborative
       Docs4Patient Care
       Civic Federation
       AHEC
       A-TriAcc
       Republican Governor's Association
       National Governor's Association
       Ascension Health Care Conference
       Energy and Commerce Medicaid Task Force

17.  Qualifications (state what, in your opinion, qualifies you to 
serve in the position to which you have been nominated):

     For over 20 years I have worked with government health-care 
programs on the Federal, State, and local level, and I started my own 
health-care consulting company 15 years ago. In this capacity, I have 
worked with a variety of health-care organizations on a range of issues 
from public health, insurance, and Medicaid giving me broad-based 
health-care expertise.

     I have spent my career working in the health-care sector trying to 
improve access to quality health-care services for vulnerable 
populations, including those with HIV/AIDS and pregnant women and their 
babies. More recently, I have worked extensively with Governors' 
offices across the Nation to develop market-driven approaches that 
empower individuals to engage in improving their health to achieve 
better health outcomes.

     I developed Governor Daniels's Healthy Indiana Plan and was named 
his Health Care Reform Lead. In this role, I was responsible for 
Indiana's response to the Affordable Care Act, across all State 
agencies. In addition, I advised Governor Pence on health-care issues. 
Following the election, I was asked to design and implement his 
signature health plan, the Healthy Indiana Plan 2.0. I supported 
negotiations with the Health and Human Services Agency (HHS) and 
coordinated the agency's successful implementation plan, execution, and 
launch of the program. In addition, I have worked with Governors Bevin, 
Branstad, Haslam, and Otter to develop their health-care programs, and 
was also involved in crafting Ohio's Medicaid waiver.

     Over the last 6 years, I have worked with a variety of State 
governments and other organizations to implement the Affordable Care 
Act, both on the Medicaid and insurance sides. I have developed a 
working knowledge of thousands of pages of regulations and have been on 
the front lines of implementation.

     The Medicare program is a critical and important program. I will 
bring my strong knowledge of health insurance and delivery of health-
care services to ensuring high quality health care for American's 
seniors.

     It would be an honor to serve my country as the Centers for 
Medicare and Medicaid Services Administrator, and I look forward to the 
opportunity.

                   B. FUTURE EMPLOYMENT RELATIONSHIPS

 1.  Will you sever all connections with your present employers, 
business firms, associations, or organizations if you are confirmed by 
the Senate? If not, provide details.

    Yes.

 2.  Do you have any plans, commitments, or agreements to pursue 
outside employment, with or without compensation, during your service 
with the government? If so, provide details.

    No.

 3.  Has any person or entity made a commitment or agreement to employ 
your services in any capacity after you leave government service? If 
so, provide details.

    No.

 4.  If you are confirmed by the Senate, do you expect to serve out 
your full term or until the next presidential election, whichever is 
applicable? If not, explain.

    Yes.

                   C. POTENTIAL CONFLICTS OF INTEREST

 1.  Indicate any investments, obligations, liabilities, or other 
relationships which could involve potential conflicts of interest in 
the position to which you have been nominated.

     In consultation with the ethics officials of the Department of 
Health and Human Services and the Office of Government Ethics, I have 
identified certain investments that I will divest to avoid potential 
conflicts of interest. In addition, I will recuse myself from matters 
involving my former employer, SVC, Inc. and a number of its consulting 
clients, and I am arranging for the purchase of SVC, which I plan to 
sell if confirmed by the Senate; and I also will recuse myself from 
issues that may pose a conflict with my husband's psychiatric medical 
practice.

 2.  Describe any business relationship, dealing, or financial 
transaction which you have had during the last 10 years, whether for 
yourself, on behalf of a client, or acting as an agent, that could in 
any way constitute or result in a possible conflict of interest in the 
position to which you have been nominated.

     As stated in my response to Item C.1, I have consulted with the 
ethics officials of the Department of Health and Human Services and the 
Office of Government Ethics to identify potential conflicts of 
interest, and have agreed to address those conflicts in an Ethics 
Agreement, attached as Attachment 3.

 3.  Describe any activity during the past 10 years in which you have 
engaged for the purpose of directly or indirectly influencing the 
passage, defeat, or modification of any legislation or affecting the 
administration and execution of law or public policy. Activities 
performed as an employee of the Federal Government need not be listed.

     I worked on the passage of the Healthy Indiana Plan and amendments 
to the law in the State of Indiana, as an advisor to the State/
Governor's offices.

 4.  Explain how you will resolve any potential conflict of interest, 
including any that may be disclosed by your responses to the above 
items. (Provide the committee with two copies of any trust or other 
agreements.)

     As stated in my responses to Items C.1 and C.2, above, I have 
consulted with the ethics officials of the Department of Health and 
Human Services and the Office of Government Ethics to identify 
potential conflicts of interest, and have agreed to address those 
conflicts in an Ethics Agreement. In the course of performing my 
duties, I will abide by any recommendations made to me by agency ethics 
officials.

 5.  Two copies of written opinions should be provided directly to the 
committee by the designated agency ethics officer of the agency to 
which you have been nominated and by the Office of Government Ethics 
concerning potential conflicts of interest or any legal impediments to 
your serving in this position.

     My Ethics Agreement is included as Attachment 3.

                       D. LEGAL AND OTHER MATTERS

 1.  Have you ever been the subject of a complaint or been 
investigated, disciplined, or otherwise cited for a breach of ethics 
for unprofessional conduct before any court, administrative agency, 
professional association, disciplinary committee, or other professional 
group? If so, provide details.

     No.

 2.  Have you ever been investigated, arrested, charged, or held by any 
Federal, State, or other law enforcement authority for a violation of 
any Federal, State, county, or municipal law, regulation, or ordinance, 
other than a minor traffic offense? If so, provide details.

    No.

 5.  Have you ever been involved as a party in interest in any 
administrative agency proceeding or civil litigation? If so, provide 
details.

     No.

 6.  Have you ever been convicted (including pleas of guilty or nolo 
contendere) of any criminal violation other than a minor traffic 
offense? If so, provide details.

    No.

 7.  Please advise the committee of any additional information, 
favorable or unfavorable, which you feel should be considered in 
connection with your nomination.

    None.

                     E. TESTIFYING BEFORE CONGRESS

 1.  If you are confirmed by the Senate, are you willing to appear and 
testify before any duly constituted committee of the Congress on such 
occasions as you may be reasonably requested to do so?

    Yes.

 2.  If you are confirmed by the Senate, are you willing to provide 
such information as is requested by such committees?

    Yes.

                                 ______
                                 

                              Attachment 1

Below are two charts setting forth information about consulting work 
done by SVC, Inc. The first chart shows direct contracts, and the 
second chart shows subcontracts.


                            Direct Contracts
------------------------------------------------------------------------
     State or Entity               Agency                  Period
------------------------------------------------------------------------
Indiana                   Family Social Services    2002-Present
                           Association, Indiana
                           State Department of
                           Health
------------------------------------------------------------------------
Virginia                  Department of Health,     2015-2016
                           OMPP
------------------------------------------------------------------------
Nebraska                  Department of Insurance   2012-2013
------------------------------------------------------------------------
Tennessee                 Health Care Finance and   2014-2015
                           Administration
------------------------------------------------------------------------
Maine                     Department of Health and  2012-2013
                           Human Services
------------------------------------------------------------------------
Richard M. Fairbanks                                2015-Present
 Foundation
------------------------------------------------------------------------
First Data                                          2013-2014
------------------------------------------------------------------------
Lilly USA                                           2013
------------------------------------------------------------------------
Eli Lilly and Company                               2013-2014
------------------------------------------------------------------------
Health Management                                   2009-2012
 Associates
------------------------------------------------------------------------
IN Hemophilia and                                   2015
 Thrombosis
------------------------------------------------------------------------
Indiana State Medical                               2014
 Association
------------------------------------------------------------------------
HSA Coalition                                       2014-2016
------------------------------------------------------------------------
Indiana Hand to Shoulder                            2014-2015
 Surgery Associates
------------------------------------------------------------------------
National AHEC                                       2014
 Organization
------------------------------------------------------------------------
Maximus                                             2016-Present
------------------------------------------------------------------------
Roche Diagnostics                                   2010-2012
------------------------------------------------------------------------
Indiana Dental                                      2012
 Association
------------------------------------------------------------------------



                              Subcontracts
------------------------------------------------------------------------
  Prime Contractor     State or Entity       Agency           Period
------------------------------------------------------------------------
Milliman Actuaries    Iowa              Department of    2013-Present
                                         Human Services
------------------------------------------------------------------------
Milliman Actuaries    South Carolina    Department of    2012-Present
                                         Health and
                                         Human Services
------------------------------------------------------------------------
Milliman Actuaries    Ohio              Department of    2015-Present
                                         Medicaid
------------------------------------------------------------------------
Milliman Actuaries    Michigan          Department of    2013-2014
                                         Community
                                         Benefit
------------------------------------------------------------------------
Milliman Actuaries    Jefferson                          2014-2015
                       County, AL
------------------------------------------------------------------------
Hewlett Packard       Indiana           FSSA             2008-Present
 Enterprises
------------------------------------------------------------------------
Hewlett Packard       Arkansas          Department of    2015-Present
 Enterprises                             Human Services
------------------------------------------------------------------------
Hewlett Packard       Kentucky          Cabinet of       2016-Present
 Enterprises                             Health and
                                         Family
                                         Services
------------------------------------------------------------------------
Boise State           Idaho             Department of    2013
 University                              Health and
                                         Welfare
------------------------------------------------------------------------
Health Management     Indiana           FSSA and         2006-2011
 Associates                              Lawrence
                                         County
                                         Community
                                         Health and
                                         Wellness
                                         Center
------------------------------------------------------------------------
High Point Global     Federal           CMS              2016-Present
                       Government
------------------------------------------------------------------------


                                 ______
                                 

                              Attachment 2

           The Need for Medicaid Reform: A State Perspective

_______________________________________________________________________

                  Testimony Presented by Seema Verma 
                               SVC, Inc.

                             June 12, 2013

Summary

Medicaid has undoubtedly played a considerable role in the lives of 
many, providing access to health care for our Nation's most vulnerable 
populations. There is no question it has helped many of its 
participants. However, designed in 1965, the program has not kept pace 
with the modern health-care market. Its rigid, complex rules designed 
to protect enrollees have created an intractable program that does not 
foster efficiency, quality, or personal responsibility for improvement 
in health status. Escalating State costs have not translated into 
quality or consistent outcomes.

Failure to reform the program will jeopardize States' ability to care 
for those Medicaid was envisioned to serve, including low-income 
children, pregnant women, and the aged, blind, and disabled. While the 
program is jointly funded by the State and Federal Government, it is 
not jointly managed. States are largely dependent on Federal policy, 
regulation, and permission to operate their programs. Administrative 
review and approval processes add layers of administrative bureaucracy 
to the program that thwart States' ability to innovate.

Notwithstanding the cumbersome regulatory review process, there are 
many examples of State innovation that have emerged. To transform 
Medicaid, States must be given the flexibility and opportunity to 
innovate without these undue Federal constraints. Reform efforts should 
center, at minimum, around encouraging consumer participation in health 
care, holding States accountable based on quality outcomes versus 
compliance with bureaucratic requirements, encouraging flexible managed 
care approaches, and allowing States to use flexible funding 
mechanisms.

INTRODUCTION

Good morning, members of the committee. My name is Seema Verma. I am 
the president of SVC, Inc., a policy consulting company, and in this 
role have been advising Governor offices, State Medicaid programs, and 
State Departments of Health and Insurance. I have worked in a variety 
of States including Indiana, South Carolina, Maine, Nebraska, Iowa, and 
Idaho. I am also the architect of former Indiana Governor Mitch 
Daniels's Healthy Indiana Plan, the Nation's first consumer-
directed health plan for Medicaid beneficiaries.

OVERVIEW

Designed in 1965 for our most vulnerable populations, the Medicaid 
program has not kept pace with the modern health-care market. Its 
rigid, complex rules designed to protect enrollees have also created an 
intractable program that does not foster efficiency, quality, or 
personal responsibility. The impact of these issues is more pronounced 
as States are entrenched in the fierce debate around Medicaid 
expansion. Reluctance to expand is not indifference to the plight of 
the uninsured, but trepidation for the fiscal sustainability of the 
program and knowledge that expanding without reform will have serious 
consequences on Medicaid's core mission to serve the neediest of 
Americans.

INCREASING COSTS OF MEDICAID AND STATE BUDGETS

Medicaid comprises nearly 24% \1\ of State budgets, and its costs are 
growing.\2\ This is due to enrollment growth, population demographics, 
and Federal requirements. The aging baby boomer population will soon 
require expensive long-term care. The Affordable Care Act (ACA) 
requires maintenance of effort and implementation of hospital 
presumptive eligibility, Modified Adjusted Gross Income which 
eliminates asset tests for the non-disabled, and the ACA insurer tax 
will cost States an estimated $13 to $14.9 billion.\3\ Additionally, 
there is the clawback provision burden where States have an 
unprecedented requirement to finance the Medicare program.
---------------------------------------------------------------------------
    \1\ National Governors Association and National Association of 
State Budget Officers (2012). The Fiscal Survey of States. Retrieved 
online: http://www.nasbo.org/sites/default/files/
Fall%202012%20Fiscal%20Survey.pdf.
    \2\ Deloitte (2010). Issue Brief: Medicaid Long-Term Care: The 
Ticking Time Bomb. Retrieved online: http://www.deloitte.com/assets/
Dcom-UnitedStates/local%20Assets/Documents/US_
CHS_2010LTCinMedicaid_062210.pdf.
    \3\ Milliman (2012). PPACA Health Insurer Fee Estimated Impact on 
State Medicaid Programs and Medicaid Health Plans. Retrieved online: 
http://publications.milliman.com/publications/health-published/pdfs/
ppaca-health-insurer-fee.pdf.
---------------------------------------------------------------------------

ACCESS AND QUALITY

Despite growing outlays of public funds, a Medicaid card does not 
guarantee access or quality of care. In a survey of primary care 
providers, only 31% indicated willingness to accept new Medicaid 
patients.\4\ In 2012, 45 States froze or reduced provider reimbursement 
rates,\5\ Medicaid access issues are tied to under-compensation of 
providers; on average Medicaid payments are 66% of Medicare rates,\6\ 
and many providers lose money seeing Medicaid patients. Medicaid 
beneficiaries struggle to schedule appointments, face longer wait 
times, and have difficulty obtaining specialty care.\7\ These access 
challenges will be more pronounced as Medicaid recipients compete with 
the tens of millions of newly insured under the ACA. Studies also show 
Medicaid coverage does not generate significant improvements in health 
outcomes,\8\ decrease emergency room (ER) visits or hospital 
admissions,\9\ and participants have higher ER utilization rates than 
other insured populations.
---------------------------------------------------------------------------
    \4\ Decker, S. (2012). In 2011 Nearly One-Third of Physicians Said 
They Would Not Accept New Medicaid Patients, But Rising Fees May Help. 
Health Affairs, 31(8), 1673-79. Retrieved online: http://
content.healthaffairs.org/content/31/8/1673.abstract.
    \5\ The Henry J. Kaiser Family Foundation (2012). Medicaid Today; 
Preparing for Tomorrow: A Look at State Medicaid Program Spending, 
Enrollment, and Policy Trends. Results from a 50-State Medicaid Budget 
Survey for State Fiscal Years 2012 and 2013. Retrieved online: http://
kaiserfamilyfoundation.files.wordpress.com/2013/01/8380.pdf.
    \6\ Kaiser Family Foundation. Medicaid-to-Medicare Fee Index. 
Retrieved online: http://kff.org/medicaid/state-indicator/medicaid-to-
medicare-fee-index/.
    \7\ Bisgaier, J., and Rhodes, K. (2011). Auditing Access to 
Specialty Care for Children with Public Insurance. The New England 
Journal of Medicine, 324(24), 2324-33. Retrieved online: http://
www.nejm.org/doi/pdf/10.1056/NEJMsa1013285.
    \8\ Baicker, K., Taubman, S., Allen, H., Bernstein, M., Gruber, J., 
Newhouse, J., Schnelder, E., Wright, B., Zaslavsky, A., and 
Finkelstein, A. (2013). The Oregon Experiment--Effects of Medicaid on 
Clinical Outcomes. New England Journal of Medicine, 368, 1712-22. 
Retrieved online: http://www.nejm.org/doi/full/10.1056/
NEJMsa1212321#t=abstract.
    \9\ Ibid.
---------------------------------------------------------------------------

STATE CONSTRAINTS

At Medicaid's core is a flawed structure. While jointly funded, by the 
Federal and State governments, it is not jointly managed. States are 
burdened by Federal policy and endure lengthy permission processes to 
make routine changes. Notwithstanding the cumbersome procedure, 1115 
waivers provide a pathway for State innovation. However, the approval 
route is so daunting that States often abandon promising ideas if a 
waiver is necessary. Absent are evaluation guidelines, required 
timelines, and there is a capricious nature to the approvals, as 
waivers do not transfer from one State to another. Even with positive 
outcomes, a new administration has the authority to terminate a waiver.

Despite intense Federal oversight, results vary substantially, and 
there are no incentives for States to achieve quality outcomes. For 
example, the average cost to cover an aged Medicaid enrollee is $5,247 
in New Mexico versus $24,761 in Connecticut,\10\ and annual growth 
rates also very.\11\ Replacing oversight of day-to-day administrative 
processes, the Federal and State governments should collaborate to 
identify program standards and incentives. States should be provided 
with flexibility to achieve these goals, and successful States should 
be rewarded with reduced oversight.
---------------------------------------------------------------------------
    \10\ Based on Kaiser Commission on Medicaid and the Uninsured and 
Urban Institute estimates based on data from FY 2009 MSIS and CMS-64 
reports. Retrieved online: http://kff.org/medicaid/state-indicator/
medicaid-payments-per-enrollee-fy2009/.
    \11\ Based on Urban Institute estimates from CMS Form 64. Retrieved 
online: http://kff.org/medicaid/state-indicator/growth-in-medicaid-
spending-fy90-fy10/.

Medicaid's uncompromising cost-sharing policies are illustrative of a 
key failure. These regulations disempower individuals from taking 
responsibility for their health, allow utilization of services without 
regard for the public cost, and foster dependency. While some policies 
may be appropriate for certain populations, in an era of expansion to 
non-disabled adults, they must be revisited. Revised cost-sharing 
policies should consider value-based benefit design and incent 
enrollees to evaluate cost, quality, and adopt positive health 
behaviors. Indiana's Healthy Indiana Plan (HIP) waiver applied 
principles of consumerism with remarkable results; lowering 
inappropriate ER use and increasing prevention.

CONCLUSION

Congress should reform Medicaid to assure long-term fiscal 
sustainability and access to quality services that improve the health 
of enrollees. A fundamental paradigm shift in management is required, 
and the program should be reengineered away from compliance with 
bureaucratic policies that do not change results to aligning incentives 
for States, providers, and recipients to improve outcomes. States are 
best positioned to develop policies that reflect the local values of 
the people they serve and should be given the flexibility to do so.

                                 ______
                                 

                              Attachment 3

                            January 31, 2017

Ms. Elizabeth Fischmann
Associate General Counsel for Ethics
Designated Agency Ethics Official
U.S. Department of Health and Human Services
Hubert H. Humphrey Building, Room 710-E
200 Independence Avenue, SW
Washington, DC 20201

Dear Ms. Fischmann:

    The purpose of this letter is to describe the steps that I will 
take to avoid any actual or apparent conflict of interest in the event 
that I am confirmed for the position of Administrator, Centers for 
Medicare and Medicaid Services (CMS), U.S. Department of Health and 
Human Services.

    As required by 18 U.S.C.Sec. 208(a), I will not participate 
personally and substantially in any particular matter in which I know 
that I have a financial interest directly and predictably affected by 
the matter, or in which I know that a person whose interests are 
imputed to me has a financial interest directly and predictably 
affected by the matter, unless I first obtain a written waiver, 
pursuant to 18 U.S.C. Sec. 208(b)(1), or qualify for a regulatory 
exemption, pursuant to 18 U.S.C. Sec. 208(b)(2). I understand that the 
interests of the following persons are imputed to me: any spouse or 
minor child of mine; any general partner of a partnership in which I am 
a limited or general partner; any organization in which I serve as 
officer, director, trustee, general partner, or employee; and any 
person or organization with which I am negotiating or have an 
arrangement concerning prospective employment.

    Upon confirmation, I will resign from my position with SVC, Inc. I 
will divest my financial interest in SVC, Inc. within 90 days of my 
confirmation. I will not participate personally and substantially in 
any particular matter that to my knowledge has a direct and predictable 
effect on the financial interests of this entity until I have divested 
it, unless I first obtain a written waiver, pursuant to 18 U.S.C. 
Sec. 208(b)(1), or qualify for a regulatory exemption, pursuant to 18 
U.S.C. Sec. 208(b)(2). During my appointment as Administrator, I will 
not provide any services to SVC, Inc., except to the extent that I may 
need to comply with any requirements involving legal filings, taxes, 
fees, or similar matters relating to divesting my financial interests 
in SVC, Inc. or winding it down. For a period of 1 year after I divest 
my financial interest in SVC, Inc., I will not participate personally 
and substantially in any particular matter involving specific parties 
in which I know SVC, Inc. or the purchaser of SVC, Inc. is a party or 
represents a party, unless I am first authorized to participate, 
pursuant to 5 CFR Sec. 2635.502(d). In addition, I will not participate 
personally and substantially in any particular matter involving 
specific parties in which I know a former client of mine is a party or 
represents a party, for a period of 1 year after I last provided 
service to that client, unless I am first authorized to participate, 
pursuant to 5 CFR Sec. 2635.502(d). Until I have received full payment 
from the purchaser for the sale of SVC, Inc., I will not participate 
personally and substantially in any particular matter that to my 
knowledge has a direct and predictable effect on the ability or 
willingness of the purchaser to make full payment to me, unless I first 
obtain a written waiver, pursuant to 18 U.S.C. Sec. 208(b)(1).

    I provided consulting services to the States of Arkansas, Indiana, 
Iowa, Kentucky, Ohio, South Carolina, and Virginia through SVC, Inc. 
Pursuant to 5 CFR Sec. 2635.502(d), I will seek a written authorization 
to participate personally and substantially in particular matters 
involving specific parties in which I know the States of Arkansas, 
Indiana, Iowa, Kentucky, Ohio, South Carolina, and Virginia are a party 
or represent a party.

    Additionally, following my appointment, my spouse and I will divest 
our interests in the following entities within 90 days of my 
confirmation:

    Alphabet Inc. Class A
    Alphabet Inc. Class C
    Biogen Inc.
    Columbia Seligman Communications and Information Fund
    Credit Suisse SPSIOP Index Market Linked Note (MLZKV)
    Exxon Mobile Corp.
    Fidelity Canada Fund
    General Electric
    Halliburton Company
    International Business Machines Corp.
    Johnson and Johnson
    McDonalds Corp.
    Merck and Company, Inc.
    Oracle Corp.
    Procter and Gamble Co.
    Schlumberger Limited
    Spectra Energy Corp.
    Travelers Companies Inc.
    Unilever PLC New ADR
    Vanguard Energy Fund

    With regard to each of these entities, I will not participate 
personally and substantially in any particular matter that to my 
knowledge has a direct and predictable effect on the financial 
interests of the entity until I have divested it, unless I first obtain 
a written waiver, pursuant to 18 U.S.C. Sec. 208(b)(1), or qualify for 
a regulatory exemption, pursuant to 18 U.S.C. Sec. 208(b)(2).

    I understand that I may be eligible to request a Certificate of 
Divestiture for qualifying assets and that a Certificate of Divestiture 
is effective only if obtained prior to divestiture. Regardless of 
whether I receive a Certificate of Divestiture, I will ensure that all 
divestitures discussed in this agreement occur within the agreed-upon 
time frames and that all proceeds are invested in non-conflicting 
assets.

    My spouse practices medicine as a psychiatrist with the Indiana 
Health Group, Indianapolis, IN. Additionally, he holds a financial 
interest in the Indiana Health Group. As Administrator, I will not 
participate personally and substantially in any particular matter that 
to my knowledge has a direct and predictable effect on the financial 
interests of the Indiana Health Group, unless I first obtain a written 
waiver, pursuant to 18 U.S.C. Sec. 208(b)(1).

    In order to avoid potential conflicts of interest during my 
appointment as Administrator, I, my spouse, or any minor children of 
mine will not acquire any direct financial interest in entities listed 
on the FDA prohibited holdings list or in entities involved, directly 
or through subsidiaries, in the following industries: (1) research, 
development, manufacture, distribution, or sale of pharmaceutical, 
biotechnology, or medical devices, equipment, preparations, treatment, 
or products; (2) veterinary products; (3) health-care management or 
delivery; (4) health, disability, or workers compensation insurance or 
related services; (5) food and/or beverage production, processing, or 
distribution; (6) communications media; (7) computer hardware, computer 
software, and related Internet technologies; (8) wireless 
communications; (9) social sciences and economic research 
organizations; (10) energy or utilities; (11) commercial airlines, 
railroads, shiplines, and cargo carriers; or (12) sector mutual funds 
that concentrate their portfolios on one country other than the United 
States. In addition, we will not acquire any interests in sector mutual 
funds that concentrate in any of these sectors.

    I have been advised that this ethics agreement will be posted 
publicly, consistent with 5 U.S.C. Sec. 552, on the website of the U.S. 
Office of Government Ethics with ethics agreements of other 
presidential nominees who file public financial disclosure reports.

    I understand that as an appointee I will be required to sign the 
Ethics Pledge required under the executive order dated January 28, 2017 
(``Ethics Commitments by Executive Branch Appointees'') and that I will 
be bound by the requirements and restrictions therein in addition to 
the commitments I have made in this ethics agreement.

                                 ______
                                 
           Questions Submitted for the Record to Seema Verma
               Questions Submitted by Hon. Chuck Grassley
    Question. Thirty million Americans suffer from a rare disease and 
many of these patients have no therapeutic option to address their 
condition. Timely access to innovative therapies for these patients 
with no other viable therapeutic options is critical. How can we ensure 
that Medicaid drug coverage processes include reviews by clinicians 
with expert knowledge and experience with the particular rare disease 
and its patient population?

    Answer. If confirmed, I commit to working with you and your 
colleagues in Congress as well as the FDA and other Federal agencies to 
prioritize access to innovative therapies for patients, especially our 
most vulnerable citizens who have unmet medical needs. I look forward 
to working with clinical experts and relevant Federal entities to 
ensure patients' needs are at the center of decision making.

    Question. CMS invests heavily in the training expenses of 
psychiatry residents serving in both institutions for mental disease 
(IMD) and general medical inpatient psychiatric units. But IMDs rules 
either prohibit the small number of IMD teaching hospitals from serving 
adults with Medicaid, or restrict IMDs from caring for the most 
severely ill who need care for slightly longer lengths of stay (15-20) 
days.

    This rule exacerbates the severe national shortage of treatment for 
people with severe mental illness. Resolving this issue would help with 
the shortage and would also provide psychiatrists in training with 
invaluable experience.

    How can CMS maximize its psychiatry training investments in IMD 
teaching hospital settings?

    Answer. As you know, the nationwide shortage of physicians and the 
more general health-care workforce policy questions are central to the 
health-care challenges our country faces. If confirmed, I look forward 
to implementing policies to address our Nation's opioid epidemic and 
improving Americans' access to psychiatric care. As such, I will 
carefully review and evaluate IMD rules. I should also note that in 
accordance with my Ethics Agreement, which was previously provided to 
the Senate, because of my husband's practice as a psychiatrist with the 
Indiana Health Group, Indianapolis, IN, and his financial interest in 
the Indiana Health Group, I have agreed not to participate personally 
and substantially in any particular matter that to my knowledge has a 
direct and predictable effect on the financial interests of the Indiana 
Health Group, unless I first obtain a written waiver, pursuant to 18 
U.S.C. Sec. 208(b)(1). Under the Federal ethics regulations, I am not 
required to recuse from consideration or adoption of broad policy 
options that are directed to a large and diverse group of persons. I 
will be required to recuse myself from matters that involve 
deliberation, decision or action that is focused upon the interests of 
the Indiana Health Group, or the discrete and identifiable class of 
persons or entities that includes Indiana Health Group. To the extent 
that I have questions on how to apply my recusal obligations to a 
particular matter, I will consult with the HHS Ethics Office for 
guidance on the scope of my recusal obligations.

                                 ______
                                 
                Questions Submitted by Hon. Pat Roberts
    Question. Health providers continue to ask for relief from the 
sheer amount of regulations that they must comply with, but also raise 
the issue of inconsistency in the application of rules and penalties 
that they are assessed. This is particularly true for our nursing 
homes. Ensuring program integrity and protecting our scarce taxpayers 
dollars are extremely important priorities for the agency. How do we 
balance those priorities so that we are striving toward quality 
improvements as opposed to our current enforcement system that is 
focused more on penalties? How would you work to provide more 
consistency in how regulations are applied?

    Answer. I agree that program integrity and the safeguarding of our 
scarce taxpayer dollars must be a top priority for CMS. Additionally, 
the enforcement of rules that health-care providers follow must be done 
consistently and fairly. In order to better treat and deliver high 
quality care to patients, health-care providers are better served 
spending more of their time on health care, and less of it trying to 
guess which laws and regulations will be enforced at the discretion of 
a Federal agency. The fair and consistent application and enforcement 
of the law will not only protect taxpayer dollars, but it will help 
enable health-care providers to do what they do best.

    Question. Critical access hospitals are required to provide acute 
inpatient care for a period that does not exceed, on an annual average 
basis, 96 hours per patient. This Condition of Participation was long 
established and well understood by these key rural safety net 
providers. However, in the FY 2014 hospitals IPPS final rule, CMS 
clarified they will also begin enforcing the condition of payment 
requiring physician certification that each patient will stay for 96 
hours or less. Will you commit to reviewing this condition of payment 
and the effect it has had on our hospitals and beneficiaries in rural 
areas?

    Answer. If confirmed, I look forward to working with you and your 
colleagues in Congress to ensure that critical access hospitals are 
best enabled to serve rural populations with the highest possible 
quality of care. I commit to working with you to review the impact of 
regulation on hospitals and beneficiaries, especially in rural and 
frontier areas. Rural providers and their beneficiaries face unique 
challenges, and CMS should prioritize communication and collaboration 
with rural providers and stakeholders early on in the regulatory 
process.

                                 ______
                                 
                Questions Submitted by Hon. John Cornyn
    Question. Many States are using section 1115 Medicaid waivers to 
provide flexibility and modernize their Medicaid program. It can take 
an average of 323 days from submission to approval, and have a lack of 
transparency during negotiations which leaves States and stakeholders 
in limbo.

    What do you think can be done to shorten this time frame for 
approval?

    What can be done to make the approval/renewal process more 
transparent between CMS and States?

    What, if anything, should be done to improve oversight of section 
1115 waivers?

    Answer. The uncertainty around the waiver approval process must 
change. The flexibility and incentives for States to innovate must be a 
top priority if we are to better care for our most needy citizens. If I 
am confirmed, I look forward to working with you to shorten and 
streamline the waiver approval process. Unfortunately, with the way the 
system is set up, States must report back to and receive permission 
from the Federal Government for even routine changes to their Medicaid 
programs. As a small business owner involved in the waiver process, I 
can attest that the uncertainty and lack of transparency you describe 
deters further innovations. As States are forced to spend a great deal 
of time and resources to receive approval for routine changes or 
updates to their program, far too often they decide that they don't 
have the resources or time to pursue more innovative approaches. This 
is especially important in a State like Texas, which is home to some of 
the most innovative health-care thinkers and actors in the country. 
Allowing those health-care organizations the flexibility to innovate, 
while being accountable to taxpayers and the citizens they serve, will 
reward reforms that work for patients. I look forward to working with 
you to improve the waiver process for Texas and other States seeking 
greater flexibility and consistency in waiver decisions.

    Question. Many States have been using waivers or demonstrations to 
operate portions of their Medicaid programs for years, sometimes 
decades. HHS estimates that a third of all Federal Medicaid spending is 
made under demonstrations. Please outline your thoughts (a) on the 
importance of evaluating the extent to which demonstrations are 
achieving the objectives of the Medicaid program, and (b) whether 
continued review and approval of long-standing demonstration projects 
are necessary.

    Answer. If I am confirmed, I will be committed to improving the 
waiver process and incentivizing innovation over redundant paper-
pushing. We will review the extent and role of evaluations as well as 
the need for waivers for long-standing demonstration waivers that are 
performing well. States are best equipped to design and understand the 
unique needs of their own populations, so it is crucial to ensure the 
successful innovations continue and that even more innovations that 
prioritize patients' access to quality care are encouraged and tried 
without duplicative or unnecessary paperwork.

                                 ______
                                 
                 Questions Submitted Hon. Richard Burr
    Question. Last October, the Centers for Medicare and Medicaid 
Service (CMS) issued a final rule titled, ``Medicare and Medicaid 
Programs; Reform of Requirements for Long-Term Care Facilities.'' The 
rule was designed to ensure protections are in place for seniors 
receiving care through these facilities. However, CMS's analysis shows 
that the cost of implementing these regulations will exceed $800 
million in the first year of implementation alone, which could create 
access issues for patients currently receiving this care.

    As Administrator, how do you plan to balance the need for seniors 
to have access to safe high quality care, while ensuring that health-
care providers, including nursing homes and skilled nursing facilities, 
are able to continue to provide this care to beneficiaries?

    What solutions, if any, do you see to decrease compliance costs and 
ensure access to care and needed protections for seniors?

    Answer. I have fought throughout my career for access to quality 
care, and I appreciate that an insurance card does not equal health 
care by itself. If confirmed as CMS Administrator, I look forward to 
working with you to ensure that seniors have access to safe, quality 
care while also considering the impact of government actions on health-
care providers and their ability to serve their patients. It is 
essential that all CMS actions carefully consider the impact they have 
on health-care providers and their ability to deliver quality care. I 
look forward to working with you to implement laws that allow health-
care providers to do what they do best: treat their patients. I will 
work with all parties and stakeholders to protect the doctor-patient 
relationship and root out inefficiencies so that greater care for 
patients and innovation may occur.

    Question. As you may know, the Patient Access and Medicare 
Protection Act of 2015 included a provision requiring the Secretary of 
Health and Human Services (HHS) to submit a report to Congress on the 
development of an alternative payment model (APM) for certain radiation 
therapy services this year. As Administrator of the Centers for 
Medicare and Medicaid Services (CMS), how will you ensure that the 
agency is engaging with the provider and patient community as it works 
on this report, and during the development of options for this APM and 
other APMs for specialty care?

    Answer. Communication with providers on the development of the 
report is paramount to ensuring that the report is successfully 
completed, and, if confirmed, I will ensure that CMS engages with the 
stakeholder community.

               Questions Submitted by Hon. Johnny Isakson
    Question. As part of 21st Century Cures, Senator Warner and I 
worked to include a provision that would provide a home infusion 
services payment for drugs administered through Durable Medical 
Equipment (DME) covered under Part B. CMS played a critical role in 
this success by providing thorough technical expertise to assist in the 
construction of this benefit. This was an enormous first step in 
allowing patients to receive care in their home at a lower cost than 
the hospital. I have seen the benefits of home infusion first hand and 
it is my hope that we will work together this year to expand this 
policy to antibiotics. I look forward to working with you and your 
staff to get the data needed to inform the inclusion of infused 
antibiotic drugs so as to further benefit patients that require home 
infusion therapy.

    Answer. Thank you, Senator Isakson and Senator Warner. If 
confirmed, I also look forward to working with you both on this 
priority.

    Question. There has been a lot of discussion around value-based 
pricing as a possible approach to addressing some cost barriers to 
drugs some patients are experiencing. As you know, currently any drug 
manufacturers must offer State Medicaid programs the lowest price it 
offers any other payer, except for Medicare Part D which is exempt from 
best price.

    Do you think value-based drug pricing in Medicaid and other 
programs should also be made exempt from Medicaid Best Price?

    Answer. If confirmed, I look forward to implementing payment 
reforms enacted by Congress to increase patients' access to medical 
therapies. I understand the importance of patients having access to 
life-saving and life-improving innovations. CMS should serve as a 
faithful steward of taxpayer dollars as it fulfills its role in 
ensuring Medicaid beneficiaries' access to care.

    Question. We are entering a new era where precision medicine can 
tailor treatments based on an individual's unique genetic makeup and 
target diseases that impact less than 1,000 patients per year, saving 
and lengthening lives while reducing unnecessary utilization. This type 
of innovation especially is critical for patients with rare diseases 
because in some instances a few extra weeks or months can mean so much 
to those patients and their families. A concern is that the Medicare 
prospective payment systems, which have been the underlying Medicare 
payment structure since the early 1980s, is ill equipped to support our 
beneficiaries in this new era. My congressional colleagues previously 
have recognized this shortcoming, and now Medicare has some tools, 
including New Technology Add-On Payments and Pass-Through Payments for 
outpatient drugs. However, these programs are temporary fixes lasting 
only 2 or 3 years.

    How can Medicare better incentivize the utilization and remove 
patient access barriers of innovative treatments currently on the 
market for rare and ultra-rare diseases?

    Does Medicare's current under-reimbursement of innovative therapies 
for rare diseases send a signal to the patient and provider community 
that Medicare does not prioritize access and treatment of rare 
diseases?

    Answer. If confirmed, I will work closely with Congress, the FDA, 
and other entities to ensure that the Medicare program has clear 
pathways for innovations that benefit patients including the millions 
of Americans suffering from rare diseases. I appreciate that Medicare 
should be a partner when it comes to ensuring that beneficiaries have 
access to cutting-edge therapies. Making sure that Medicare provides 
access to innovative treatments will be a top priority for CMS if I am 
confirmed.

    Question. I have heard from rehabilitation hospital facilities in 
Georgia that are concerned about the impact that the implementation of 
ICD-10 coding is having on a regulation applicable to them called the 
60 percent rule. CMS has said there is monitoring of the issue, however 
there have been no changes made. I would appreciate if once confirmed, 
CMS review this more closely.

    Answer. If confirmed I will review this policy closely and look 
forward to working with you and your staff to better understand how 
this impacts health-care providers in Georgia and around the country.

                                 ______
                                 
              Question Submitted by Hon. Patrick J. Toomey
    Question. Since 2005, the Centers for Medicare and Medicaid 
Services have sought to restrict long-term care hospitals, known as 
LTCHs, from receiving more than 25 percent of their patients from a 
single acute care hospital. Worried that this arbitrary threshold would 
undermine access for very sick seniors to specialty hospitals, 
especially in non-urban communities, Congress has repeatedly intervened 
to block this proposal. Most recently, as part of the 21st Century 
Cures Act, Congress enacted legislation that I authored with Senator 
Bennet and Nelson to block the 25 percent rule through September.

    Beginning later this year, LTCHs will be paid on the basis of a 
patient's physical condition. This new patient-specific criteria 
obviates any need to restrict payment on the basis of where the patient 
came from.

    Will you commit to working with my office and other interested 
lawmakers to make sure that the implementation of the new payment 
criteria does not include a return to arbitrary thresholds like the 25 
percent rule?

    Answer. If I am confirmed, I look forward to working with you and 
your office as well as other members of Congress to develop and 
implement sound payment policies in accordance with the law. Patient 
access to quality care in the most appropriate setting for the patient 
and doctor must be a top priority for CMS.

                                 ______
                                 
                Questions Submitted by Hon. Dean Heller
             medicaid block grants and per capita allotment
    Question. Do you understand why States like Nevada are so concerned 
with the block grant approach?

    How would you design a block grant that would still protect access 
to care for the Medicaid expansion population?

    What is your opinion on reforming Medicaid, so funding is based on 
a per beneficiary allotment?

    Would you take into consideration population growth?

    Would you take into consideration the cost of care in rural areas?

    Answer. If confirmed, I look forward to working with your office to 
implement any reform, whether it involves Medicaid block grants, per 
beneficiary allotments or other innovative ideas, which empowers our 
most needy citizens with access to quality health care, while 
supporting innovation efforts at the State level. At the same time, 
States must be held accountable to standards that result in better 
health-care quality and access. Ultimately, Congress will decide on any 
proposals to strengthen the safety net for our most vulnerable 
citizens, and I look forward to providing any technical assistance that 
your office or other members of Congress seek in the development of 
legislative reforms to the Medicaid program.
                            medicaid waivers
    Question. What types of reforms have you worked on through the 
waiver process that you believe has increased coverage for those 
respective States?

    How would you make it easier for States, like Nevada, that did not 
originally seek a waiver to go through that process and approve the 
types of reforms needed to protect the 600,000 Nevadans on Medicaid--
including 200,000 Nevadans that were eligible through the expansion?

    Answer. Innovation starts locally, so if confirmed my job will be 
to work with Nevada and other States to tailor their Medicaid programs 
to the unique needs of their citizens. Working through the waiver 
process at the State level has provided me with the experience to know 
what works best and what doesn't work as well. I've also been able to 
learn what the Federal Government asks for and how they ask for it can 
slow or stop innovation. My experience at the State level reminds me 
that Washington often doesn't know best; in fact, Nevadans know better 
how to structure their programs and deliver care to their most needy 
citizens. I will make it a priority to ensure that Nevada is able to 
understand the process from beginning to end. Communication and 
collaboration with your office, other members of your delegation and 
stakeholders from around the State is crucial. I commit to working 
closely with you as early and often as needed.
                    questions from state legislature
    Question. What steps do you plan to take to ensure that the more 
than 88,000 Nevadans who have purchased health insurance through the 
Silver State Health Exchange continue to have the ability to purchase 
health insurance with adequate coverage in a transparent marketplace?

    What steps do you plan to take to ensure that the more than 77,000 
Nevadans who are eligible for Federal tax credits under the Affordable 
Care Act to help purchase private insurance will continue to have 
access to affordable health-insurance options with adequate coverage?

    What steps do you plan to take to ensure that the 217,000 Nevadans 
who are receiving health care under the Medicaid expansion remain 
covered?

    The Affordable Care Act guarantees coverage vital to preventative 
services for women, including cancer screenings and birth control. What 
steps do you plan to take to ensure that the Affordable Care Act's 
coverage guarantees remain intact for women's health?

    The Affordable Care Act guarantees that Nevadans with pre-existing 
conditions will not be denied health care and ends lifetime minimums on 
coverage. It also allows younger people, many of whom are saddled with 
college debt and cannot afford insurance, to stay on their parents' 
insurance until they are 26. What steps do you plan to take to preserve 
those coverage guarantees?

    Answer. If confirmed, I will work to ensure that any legislation 
enacted by Congress is implemented with the utmost care for Nevadans. I 
am fully committed to ensuring all Americans have access to affordable 
health care of the highest quality that meets the unique and important 
needs of their families.

                                 ______
                                 
                 Questions Submitted by Hon. Ron Wyden
                        corporate relationships
    Question. As discussed in the hearing and in news media accounts, 
you and your firm, SVC, Inc., contracted with the following firms: 
Electronic Data Systems (EDS), Hewlett Packard Enterprises (HP), 
Milliman, Inc., Highpoint Global, Roche Diagnostics, Health Management 
Associates (HMA), and Maximus, which provide health-program services 
and products to the State of Indiana, or represent that they have.\1\ 
Please provide the following for each of these corporate relationships:
---------------------------------------------------------------------------
    \1\ Inside Health Policy, February 10, 2017; IndyStar, August 26, 
2014; Associated Press, February 15, 2017.

    The dates you or your firm entered into contracts or subcontracts 
---------------------------------------------------------------------------
with each of these companies.

    The scope of work you or your firm performed for each contract or 
subcontract with these companies.

    The amount of money you or your firm were paid for work that was 
completed under each such contract or subcontract.
---------------------------------------------------------------------------
    \2\  Due to the age of this work, specific responsive information 
was not located.

    Answer.

------------------------------------------------------------------------
                                                           Approximate
      Firm            Dates               Scope              Revenue
------------------------------------------------------------------------
Electronic Data
 PSystems (EDS)
 \2\
------------------------------------------------------------------------
Hewlett Packard    2008-Present   Training,                    $725,000
 PEnterprises                      communications,       (invoices 2011
                                   analysis of Federal/      to present
                                   State actions                  only)
------------------------------------------------------------------------
Hewlett Packard    2015-Present   Communications               $100,000
 PEnterprises                      assistance specific
                                   to Federal/State
                                   regulations and
                                   compliance
------------------------------------------------------------------------
Milliman           2013-Present   Development of 1115        $1,500,000
 Actuaries                         and 1915c/b waivers
------------------------------------------------------------------------
Milliman           2012-Present   1915 waiver                    $5,000
 Actuaries                         development, ACA
                                   impact analysis, and
                                   policy
                                   implementation
                                   support
------------------------------------------------------------------------
Milliman           2015-Present   1115 waiver drafting         $150,000
 Actuaries                         and managed care
                                   regulation impact
                                   analysis
------------------------------------------------------------------------
Milliman              2013-2014   Technical assistance          $10,000
 Actuaries                         for waiver
                                   implementation
------------------------------------------------------------------------
Highpoint          2016-Present   Provide subject              $350,000
 Global                            matter expertise for
                                   training materials
                                   with CMS Assister
                                   Program
------------------------------------------------------------------------
Roche                 2010-2012   Development of launch         $30,000
 Diagnostics                       plan related to Accu-
                                   Chek platform
------------------------------------------------------------------------
Health                2006-2011   Development of               $300,000
 Management                        uninsured program
 Associates
 (HMA)
------------------------------------------------------------------------
Maximus            2016-Present   Provide curriculum            $10,000
                                   development support
                                   for Maximus Training
                                   Services
------------------------------------------------------------------------

                corporate ethics agreements/disclosures
    Question. For each of the corporate relationships identified in 
Question 1, please provide the following:

    Copies of any ethics agreements you entered into with these 
companies, or ethics guidelines or contract terms you received from 
these companies, governing conflicts of interest for your engagement 
with them.

    Answer. There were no separate ethics agreements entered into with 
these companies.

    Question. Any documentation showing the processes you were to 
follow if and when you were to recuse yourself with regard to conflicts 
of interest involving each company.

    Answer. None, and none was required.

    Question. Any documentation showing any situations in which you 
actually recused yourself from matters related to these companies 
pursuant to these policies, guidelines, or terms.

    Answer. None. Other than with respect to HP, there was not a 
situation for which my recusal was appropriate. I did not supervise any 
of the work performed by these other companies.
                  post-confirmation corporate recusals
    Question. In its annual report to the Securities and Exchange 
Commission, Maximus says they are the largest provider of Medicaid and 
CHIP enrollment services in the United States.\3\ In the same filing, 
Maximus states that HP is one of their major competitors in the health 
services sector. You have current contracts with both of them. As 
you've reported on OGE Form 278, you also have current contracts with 
HighPoint Global and Milliman, Inc. All four engage in activities 
funded through CMS. Your Ethics Agreement states you will need to get 
special approval to consider matters involving seven of the States for 
which you did consulting work, but it is completely silent on the 
question of what is required for you to consider matters involving your 
consulting work for these companies. The only specific corporate 
recusal in your Ethics Agreement relates to HMA, which is buying your 
consulting firm. Please describe your understanding of the extent to 
which you would need to recuse yourself from matters involving these 
other four companies.
---------------------------------------------------------------------------
    \3\  Maximus, Inc. SEC 10-K, November 21, 2016.

    Answer. My understanding is as stated in my Ethics Agreement and 
the Ethics Pledge. These documents are quite specific regarding my 
ethical obligations with respect to these four companies. My Ethics 
Agreement states: ``I will not participate personally and substantially 
in any particular matter involving specific parties in which I know a 
former client of mine is a party or represents a party, for a period of 
1 year after I last provided service to the client, unless I am first 
authorized to participate pursuant to 5 CFR Sec. 2635.502(d)'' 
(emphasis added). The Ethics Pledge states: ``I will not for a period 
of 2 years from the date of my appointment participate in any 
particular matter involving specific parties that is directly and 
substantially related to my former employer or former clients, 
including regulations and contracts.''
                       state of indiana contracts
    Question. Please identify, by contract number and date, each of 
your contracts with the State of Indiana and any related amendments 
thereto. Also, please provide the total award value of those contracts, 
to the present, and the total revenue amount from those contracts, to 
the present.

    Answer.


------------------------------------------------------------------------
   Contract
    Number         Date          Amendment(s)           Award Value
------------------------------------------------------------------------
57464-000      July 19,                57464-001             $2,978,527
                2011                   57464-002
                                       57464-003
                                       57464-004
                                       57464-005
                                       57464-006
------------------------------------------------------------------------
80287-000      July 23,                80287-001             $4,851,400
                2014                   80287-002
                                       80287-003
------------------------------------------------------------------------


    The approximate revenue from these contracts to date is $5.3 
million.
                  oversight of contractors in indiana
    Question. According to a recent press report, you were a member of 
a ``group of health officials'' that unsuccessfully pitched former 
Governor Mitch Daniels on health reform in 2006. You were also 
identified as ``leading'' that same group when it later successfully 
convinced Daniels to move forward with health-care reform.\4\ In your 
biographical materials, you have also discussed your role as the 
architect of the Healthy Indiana Plan (HIP). As discussed in the 
hearing, it appears that you were advising the State at the same time 
that you had contracts with other vendors, including HMA. You also 
provided the committee with a statement from then-
Secretary of the Indiana Family and Social Services Administration 
(FSSA) John J. Wernert, which included the sentence: ``Additionally, no 
consultant is allowed to oversee the work of a contractor with whom 
they have a separate professional relationship.''
---------------------------------------------------------------------------
    \4\ CNN, February 16, 2017.

    It appears that on or about May 1, 2006, you and your firm became a 
subcontractor to HMA on a contract HMA held with the State of Indiana 
to provide consulting services to FSSA. A May 1, 2008 amendment to a 
contract between Indiana and HMA shows that you received payments from 
the consulting firm for subcontract work beginning May 1, 2006.\5\ The 
original May 1, 2006 contract does not appear to be available in the 
State's public disclosure database. Please provide a copy of the 
original HMA contract with the State and a description of the scope of 
work HMA performed and that you performed under that contract, as well 
as under the subsequent contract amendment.
---------------------------------------------------------------------------
    \5\ Indiana SVC Contract (EDS: A129-6-49-06-XE-2020).

    Answer. A copy of the contract has been provided to the committee. 
Under that contract, HMA developed an uninsured program for the State 
of Indiana. The scope of work that SVC performed solely included 
provision to HMA of professional consulting services related to HMA's 
development of that uninsured program. I did not oversee HMA's work on 
---------------------------------------------------------------------------
this contract.

    Question. On or about January 22, 2007, your firm received a sole 
source FSSA contract for coordinating development of a Request for 
Proposal to procure the services of a vendor to administer the 
``Governor's Plan for a Healthier Indiana.'' \6\ That same day, HMA 
received a sole source FSSA contract to develop and draft the Request 
for Proposal for the ``Governor's Health Care Plan.'' \7\ It appears 
that the work scope in your contract required you to oversee the work 
of HMA contrary to FSSA policy. Please provide the following:
---------------------------------------------------------------------------
    \6\ Indiana SVC Contract (EDS: A129-7-49-07-XE-2730).
    \7\ Indiana Health Management Associates Contract (EDS: A129-7-49-
07-XE-2020).

    A description of the work you performed under your contract with 
---------------------------------------------------------------------------
the State.

    Answer. It is not correct that the scope of work in the SVC 
contract included oversight of the HMA work under its contract. SVC and 
HMA had parallel but distinct roles, both under the oversight of State 
officials. Through SVC, I provided consulting services regarding 
preparation of an RFP for a vendor to administer the Governor's Plan 
for a Healthier Indiana. I provided project management services, 
technical assistance to contractors and to FSSA, and other assistance 
to the State in its development of the RFP, including reviews of drafts 
of the RFP.

    Question. The justification provided for SVC, Inc. having been 
awarded a non-competitive contract.

    Answer. The justification, as drafted and approved by State 
officials, was: ``The contractor has been involved in the development 
of The Governor's Plan for a Healthier Indiana from its inception, and 
has intimate knowledge of its many parts. With the rapid timeframe 
required to develop the RFP, the State does not have the resources to 
bring another consultant up to speed. SeemaVerma Consulting is Indiana-
based and has keen knowledge of the Indiana health care market place, 
which will be critical to developing the RFP. We have worked with her 
over the past 2 years and feel very comfortable with the quality of her 
work product.''

    Question. A description of your understanding of the scope of work 
that HMA was to perform and an explanation of how you interacted with 
HMA on this task.

    Answer. As stated in HMA's contract, HMA was to ``[D]evelop the 
draft and final version of the `Request for Proposal' for the 
Governor's Health-Care Plan. The contractor will review current 
commercial carrier Health Savings Account Plan structures, propose 
alternatives and opinions, conduct research as necessary, assure 
compliance and coordination with existing FSSA regulations, and provide 
technical assistance as required by FSSA or its contractors.''

    Question. A description of any role you played, if any, in the 
award of this HMA contract, including any documentation of any recusals 
related to the award or performance of this contract.

    Answer. I had no role in the award of the HMA contract.

    Question. Please explain how you coordinated development of the 
State's RFP for HIP while HMA--with whom you had a prior financial 
relationship--drafted that RFP, without violating FSSA policy as 
described in Secretary Wernert's statement.

    Answer. As the contracts make clear, I worked in conjunction with 
HMA on this effort, but I did not oversee its work. When the State of 
Indiana develops RFPs for something as large and important as the 
Governor's Health-Care Plan, it often procures services from several 
vendors who are assigned distinct tasks; that was the case here, such 
as actuarial services, and procurement specialists.

    Question. A fourth amendment to the HMA contract, prepared on April 
20, 2012, appears to show that HMA billed Indiana for work with the 
Office of Medicaid Policy and Planning (OMPP) including for your firm's 
hourly rate from May 1, 2010 to June 30, 2011.\8\ Please provide the 
following:
---------------------------------------------------------------------------
    \8\ Indiana SVC Contract (EDS: A129-6-49-06-XE-2020).

    Question. A description of the consulting work performed under this 
---------------------------------------------------------------------------
contract by HMA for OMPP.

    Answer. HMA provided ``financial and/or business consulting 
services related to health-care services to four (4) divisions of 
FSSA.'' Full details of the scope of these services are provided in the 
amendment to the contract.

    Question. Confirmation of whether you and your firm were an active 
subcontractor on this contract during this period, or in the 
alternative, please provide the period of performance by you and your 
firm.

    Answer. Confirmed.

    Question. A detailed description of the scope of work SVC, Inc. 
performed under this contract, specifically with OMPP between May 2010 
and June 2011, and revenue received.

    Answer. HMA and its subcontractors provided consulting services to 
Indiana Family and Social Services Administration in four areas: 
Transformation of Aging Services and operational and programmatic work 
for the Division of Aging; operational and financial management 
services for the Division of Mental Health and Addiction; and waiver 
system administration for the Office of Medicaid Policy and Procedures. 
The revenue received by SVC, Inc. between May 2010 and June 2011 for 
this subcontract was approximately $500,000.

    Question. Any documentation showing if you recused yourself when 
potential conflicts arose under this contract.

    Answer. None. There was no potential conflict for which recusal was 
necessary or appropriate. SVC's separate work for FSSA did not involve 
oversight of this HMA contract, and SVC played no role in FSSA's 
decision to award the contract to HMA.

    Question. In December 2007, EDS was awarded a contract to ``provide 
fiscal agent services for the Medicaid program for FSSA.'' You were 
included in the EDS contract, and paid through this contract as a 
subcontractor.\9\ These contracts were subsequently continued through 
HP. On February 21, 2012, an existing 2011 SVC, Inc. contract was 
increased by $475,000 and amended to broadly increase the scope of 
SVC's work, including specifically overseeing ``MMIS (HP) technical 
changes.'' \10\ It appears that the scope of work in this expanded 
contract required you to oversee work performed by HP contrary to FSSA 
policy. Please provide the following:
---------------------------------------------------------------------------
    \9\ Id.
    \10\ IN Contract EDS: A129-1-29-11-ZN-1758 (first amendment).

    A description of the work, you performed under this contract with 
---------------------------------------------------------------------------
the State of Indiana with regard to MMIS.

    Answer. Regarding MMIS, SVC worked with the State of Indiana and 
its vendors, including HP, to design systems for implementation of the 
Healthy Indiana Plan. We helped vendors translate the policy and waiver 
language into system operations. We did not oversee HP or any other 
vendor in this regard, and did not negotiate or participate in change 
orders or contract amendments. To the best of my recollection, State 
officials participated in all meetings with HP regarding the Healthy 
Indiana Plan work at which SVC representatives were also present.

    Question. A description of your understanding of the scope of work 
that HP was to perform and an explanation of how you and your firm 
carried out your work regarding HP on this task.

    Answer. HP prepared systems for the implementation of the Healthy 
Indiana Plan and all Medicaid programs. My firm and I worked with HP 
and the State's other vendors on this task, helping them to understand 
the program so they could make the appropriate technical changes to the 
system. In addition, please see the previous answer.

    Question. A description of the work you and your firm performed 
under the EDS/HP contracts.

    Answer. My firm and I performed a substantial amount of work on a 
variety of subjects; a comprehensive description of the scope of work 
is contained in the contract.

    Question. Documentation of any recusals related to the performance 
of your State of Indiana contract with regard to EDS/HP.

    Answer. None, and none was required.
                   state of indiana ethics procedures
    Question. In response to Senator Wyden's question regarding 
conflicts of interest during your time working with the State of 
Indiana, you responded that you recused yourself from meetings in which 
a potential conflict could arise: ``I've been in meetings, where we 
were talking about contractors and talking about implementing a 
program. And when it came to a vendor that we had a relationship with, 
I would recuse myself. I would get up and leave the meeting so that 
there was never any issue.''

    In a written response--to the 2014 Indianapolis Star article 
regarding Hewlett Packard--provided to the committee, you similarly 
stated ``(i)f any issue between HP and the State presented a conflict 
between the two, I recused myself from the process.''

    Please describe the process for determining when a matter 
constituted a conflict. What agency official or officials determined 
such a conflict existed?

    Answer. Consistent with the ethics opinion that I received, I 
recused myself from any matters related to HP's contract, the scope of 
its work, any change orders, its compensation, etc. Agency officials 
were fully aware of and supported this approach. I do not recall any 
other formal determinations regarding potential conflicts.

    Question. Please provide any written policies, agreements, or other 
communications documenting the nature of this conflicts process.

    Answer. None.

    Question. Did this process apply to all of your clients, namely 
EDS, HP, Milliman, HMA, Roche Diagnostics, and Maximus? If not, which 
clients were not subject to this process and why?

    Answer. Yes, I was alert to potential conflicts regarding all of my 
clients.

    Question. You have stated that you did recuse yourself. In which 
instances did you do so? Were these recusals documented? And if so, 
please provide this documentation.

    Answer. I recused myself from any matters related to HP's contract, 
the scope of its work, management issues, any change orders, etc. If 
these issues arose during a meeting, I would remind the State employees 
of my relationship with HP and made clear that I would not be involved, 
and would leave the meeting.

    Question. In 2012, you requested an ethics opinion from the Indiana 
Ethics Commission with respect to your work for Hewlett Packard. Did 
you request ethics opinions for your work with EDS, Milliman, Inc., 
HMA, Roche Diagnostics, or Maximus? If so please provide copies of 
those opinions.

    Answer. No. The scope of SVC's work for those other companies was 
narrower than the work involving HP.

    Question. Please provide copies of any ethics agreements you 
entered into or ethics guidelines or contract terms you received from 
the State of Indiana for your work with the State governing conflicts 
of interest.

    Answer. None, other than that previously provided.
                  representation before state agencies
    Question. In two separate news articles, the former head of the 
FSSA in Indiana, Debra Minott, indicated that you represented Hewlett 
Packard in a billing dispute before a State agency--FSSA--for which you 
were a consultant. In an Indianapolis Star article, dated August 26, 
2014, which Senator Wyden quoted in the hearing, Ms. Minott is herself 
quoted:

    ``We had delayed paying an HP invoice because of an issue we were 
trying to resolve, and HP sent Seema to our CFO to resolve the issue on 
their behalf,'' Minott said. ``I was troubled because I thought Seema 
was our consultant.''

    That article was updated and republished on November 29, 2016. More 
recently, the Associated Press published a story on Feb. 14, 2017, in 
which Ms. Minott reiterated that you had represented HP in this 
dispute. The AP article states:

    ``It was never clear to me until that moment that she, in essence, 
was representing both the agency and one of our very key contractors,'' 
said Minot(t), who was removed as head of the agency by Pence over her 
disagreements with Verma. ``It was just shocking to me that she could 
play both sides.''

    Did you represent HP in a billing dispute with the FSSA as 
reported?

    Answer. No. The only source for this allegation is Ms. Minott, a 
disgruntled former employee; to my knowledge, no one else has provided 
support for her assertions. Indeed, HP has made clear, as stated in the 
same AP article, that ``it can find no one in its company with any 
recollection of such a meeting.'' \11\ Further, Ms. Minott participated 
in a tour and briefing at HP's facilities on November 21, 2013 in which 
the HP-SVC partnership was specifically discussed and written materials 
were provided that documented the relationship. With that knowledge, 
Minott approved increases in the amount of SVC's contracts with the 
State thereafter. At no time during her tenure at FSSA did Ms. Minott 
ever express any concerns to me about SVC's work for HP.
---------------------------------------------------------------------------
    \11\ http://www.indystar.com/story/news/politics/2014/08/25/
powerful-state-healthcare-consultant-serves-two-bosses/14468683/.

    Question. Did you ever represent HP in any other matter before any 
---------------------------------------------------------------------------
Indiana agency or office? If so, when and in what capacity?

    Answer. No.

    Question. Did you ever represent any other client, specifically 
EDS, HMA, Milliman, Roche Diagnostics, or Maximus, in any matter before 
FSSA or any other State agency or office? If so, when and in what 
capacity?

    Answer. No.
                          waiver transparency
    Question. The ACA required HHS to issue regulations that ensure the 
public has a meaningful opportunity to provide input on proposed 
section 1115 waivers, including new applications and applications for 
waiver extensions. The rule HHS promulgated in February 2012 requires 
States to provide a 30-day public notice and comment period, set up a 
website for their proposal, and hold public hearings around the State, 
among other provisions. States are also required to submit an annual 
report to HHS that includes an evaluation of the changes' impact.

    Do you believe that the details of a State's waiver request should 
be made available to the public in advance of the State submitting the 
waiver request to CMS?

    Do you support requirements for the State and CMS to obtain and 
respond to public comments prior to a State deciding on whether to 
submit or CMS to approve or deny the request?

    Will you maintain the section 1115 transparency provisions that 
seek to improve public accountability and bring waiver negotiations 
from behind closed doors?

    What additional steps will you take to ensure public participation 
in the waiver process and transparency in the negotiations between CMS 
and States seeking waivers?

    Will you continue CMS's current practice of timely posting of 
waiver applications, approvals, and all supporting documents on the CMS 
website?

    Will you require that every waiver application at a minimum provide 
a description of the demonstration and a specific listing of the waiver 
authorities requested and the intended use of the waiver requested?

    When issuing approvals, will you require that these approvals 
specifically list the waiver authorities that are approved and their 
approved use?

    Do you think amendments should be subject to the same transparency 
requirements?

    Answer. If confirmed, transparency and consistency in the waiver 
process will be priorities for CMS. It is imperative that States are 
able to partner with CMS in a joint effort to update and modify their 
Medicaid programs to better serve their citizens. Clear and fair rules 
of the road are crucial for States' planning purposes as well as for 
the longevity and success of their Medicaid programs. If States are 
mired in paperwork and forced to redirect resources to unnecessary 
Federal requirements, that means less resources are available to their 
most needy citizens. I pledge to work with States to make this process 
easier, more transparent and more efficient for both States and all 
impacted parties. Additionally, it is crucial that stakeholders receive 
an opportunity to provide input, so I look forward to communicating and 
collaborating with them, whenever appropriate.
                president's january 20th executive order
    Question. On January 20th, the President issued an executive order 
instructing the Secretary of Health and Human Services and the heads of 
all agencies--which includes the CMS Administrator--to do everything 
possible to roll back the Affordable Care Act (ACA). If confirmed as 
CMS Administrator, you will be responsible for carrying out this 
executive order.

    Based on your understanding, what are the specific actions that the 
CMS Administrator could take to carry out the President's January 20th 
executive order regarding the ACA?

    If confirmed, which of those actions would you take as CMS 
Administrator to carry out the President's order?

    Answer. If I am confirmed, I plan to review prospective options 
with CMS staff and others within HHS and the administration to better 
determine what can be done to undo or mitigate the harms created by the 
ACA. Once I evaluate the options, we will act accordingly to help 
Americans suffering from higher costs, fewer choices, and less access 
to quality care.
                        prescription drug prices
    Question. Ms. Verma, during your nomination hearing I asked for one 
specific action you would take as CMS Administrator to curb the rising 
prices of prescription drugs, but you did not provide one specific 
idea.

    As CMS Administrator you will have broad power, independent of 
Congress, to impact the cost of prescription drugs. For example, each 
year CMS publishes the Part D Call Letter and Rate Notice and also is 
able to propose changes to regulations regarding payment for physician 
administered drugs. Within CMS, the Center for Medicare and Medicaid 
Innovation also has broad authority to test new payment models that 
could involve prescription drugs.

    Please provide one specific action you would take as Administer to 
address the rising costs of prescription drugs.

    Answer. I appreciate that drug costs are an important pocket-book 
issue for many Americans. If confirmed, I will work with the CMS staff 
to evaluate potential options and ensure that beneficiaries' access to 
high quality and affordable drugs is a top priority for CMS. I look 
forward to reviewing relevant implementation issues, including items 
such as PBM contracts, when appropriate.
                    medicaid reform and opioids/suds
    Question. Opioid abuse (including heroin and prescription pain 
relievers) is contributing to a public health epidemic of significant 
consequence. In 2015, there were 20,101 prescription drug-related 
overdose deaths and 12,990 heroin-related overdose deaths. Medicaid is 
the primary payer for all substance use disorder services in the 
country and will be critical in the fight against the opioid epidemic.

    Thanks to Medicaid expansion under the Affordable Care Act (ACA), 
an additional 11 million adults now have access to Medicaid. Over one 
million of these adults gained access to treatment for opioid abuse and 
other substance use disorders (SUDs). In States that expanded Medicaid, 
there are more physicians who can prescribe the drugs needed (e.g., 
buprenorphine) to help individuals overcome their addiction to opioids. 
Without the Medicaid expansion, fewer people would have access to 
Medication-Assisted Treatment (MAT) for opioid abuse and other 
substance abuse treatment. Furthermore, the ACA included addiction 
treatment as an essential health benefit that must be covered in all 
health plans.

    Will you commit to advising against repeal of the Medicaid 
expansion resulting in over a million Americans with SUDs losing access 
to essential addiction treatment services?

    Answer. It is critical that all Americans suffering from mental 
health and substance abuse disorders have access to the care they need. 
If confirmed, to the extent I am not required to recuse from a 
particular matter under the terms of my Ethics Agreement, I am 
committed to ensuring that access is not diminished.

    Question. Will you commit to advising against cuts to State 
Medicaid programs through block grants and per capita caps that put 
individuals struggling with SUDs at risk of losing access to their 
Medicaid coverage or benefits?

    Answer. I support ensuring Americans have access to quality health 
care. It is critical that all Americans suffering from substance abuse 
disorders have access to the care they need. If confirmed, to the 
extent I am not required to recuse from a particular matter under the 
terms of my Ethics Agreement, I am committed to ensuring that access is 
not diminished.

    Question. Will you commit to ensuring States are required to cover 
behavioral health benefits such as treatment for SUDs as they cover 
services for physical health conditions?

    Answer. If confirmed, I will implement the law as designed by 
Congress and I look forward to realizing reforms that put patients and 
their doctors in charge of their health care decisions, whether they 
involve physical or mental health conditions. As noted in my Ethics 
Agreement, referenced above, because of my husband's practice as a 
psychiatrist with the Indiana Health Group, Indianapolis, IN, and his 
financial interest in the Indiana Health Group, I have agreed not to 
participate personally and substantially in any particular matter that 
to my knowledge has a direct and predictable effect on the financial 
interests of the Indiana Health Group, unless I first obtain a written 
waiver, pursuant to 18 U.S.C. Sec. 208(b)(1). Under the Federal ethics 
regulations, I am not required to recuse from consideration or adoption 
of broad policy options that are directed to a large and diverse group 
of persons. I will be required to recuse myself from matters that 
involve deliberation, decision or action that is focused upon the 
interests of the Indiana Health Group, or the discrete and identifiable 
class of persons or entities that includes the Indiana Health Group. To 
the extent that I have questions on how to apply my recusal obligations 
to a particular matter, I will consult with the HHS Ethics Office for 
guidance on the scope of my recusal obligations.

    Question. What are your specific plans to address the opioid 
epidemic? What role should CMS play in this fight?

    Answer. If confirmed, I will work with CMS to ensure that Americans 
suffering from mental health and substance abuse disorders have access 
to the care they need. Americans in CMS programs should have access to 
high quality health care and I look forward to partnering with HHS and 
other departments and agencies to address the opioid epidemic.
                           medicaid lock-out
    Question. During your nominations hearing, I asked about your 
Healthy Indiana Plan (HIP) 2.0.

    Will Indiana be able to maintain eligibility under HIP 2.0 if the 
Medicaid expansion is repealed or if Federal financial support of the 
expansion population is drastically reduced?

    Answer. I cannot speculate as to what impact legislative changes 
that Congress has yet to make will have on Indiana's Medicaid program.

    Question. To clarify for the record, does your Healthy Indiana Plan 
2.0 lock out an individual making $12,000 a year from coverage if they 
cannot pay their premium for 2 months?

    Answer. The State of Indiana's Healthy Indiana Plan's contribution 
requirements are not designed as a punitive measure but as a way to 
promote personal responsibility among members which has resulted in 
better health outcomes than traditional Medicaid. Only members above 
the poverty line are at risk of losing coverage for non-payment. Where 
HIP members are locked out of coverage for 6 months for non-payment, 
those who fail to pay Marketplace premiums may have to wait until the 
next open enrollment period to regain coverage, which can be up to 9 
months, unless they have a change in circumstance that makes them 
eligible for a special enrollment period. On whole, HIP's non-payment 
policies for individuals above the poverty line are at least comparable 
to, if not more lenient than, the policies governing the Marketplace. 
Moreover, only 5 percent of former HIP members indicated they left the 
program due to affordability issues. Additionally, more than 80% of HIP 
members have indicated they would be willing to pay more to stay in the 
program, while more than half of those who left the program due to non-
payment successfully transitioned to private health insurance coverage.
                            family planning
    Question. Medicaid is the largest payer of reproductive health care 
and provides coverage to approximately one in five women of 
reproductive age. Family planning services and supplies, in particular, 
are provided special protections under the law. Not only are family 
planning services and supplies a mandatory covered service for both 
traditional and expansion populations, but Federal law also protects 
the ability of Medicaid beneficiaries to choose any qualified family 
planning provider who participates in the Medicaid program, even if 
they are not in a health plan's network. The Federal Government matches 
family planning services at a rate of 90 percent to ensure that States 
provide robust coverage of birth control methods and related services.

    Do you commit to maintaining the requirement that Medicaid 
beneficiaries have the freedom to choose their family planning service 
provider?

    Answer. As a woman, I support ensuring access to health care for 
both women and men and a health-care system that will provide access to 
quality care while ensuring patients are able to make decisions that 
work best for them.

    Question. Do you commit to ensuring that family planning services, 
including access to a person's preferred contraceptive methods, 
including IUDs, birth control pills, and implants, will remain 
available to all women?

    Answer. I support a health-care system that will allow women to 
make the decisions about what works best for them.

    Question. Do you commit to maintain the 90-percent Federal matching 
rate for family planning services?

    Answer. Changes in the Federal matching rate are determined by 
Congress, so I look forward to enforcing the law as written by 
Congress.
                           behavioral health
    Question. Ms. Verma, during your nomination hearing you did not 
answer Senator Menendez's question regarding essential health benefits 
and children with autism because you are recusing yourself from the 
topic of behavioral health due to your husband's profession as a 
psychiatrist, pursuant to your Ethics Agreement. In order to clarify 
the issue, please answer the following:

    What specific actions as Administrator will you be required to 
recuse yourself from that involve behavioral health? For example, 
implementation of MACRA involves physicians treating patients with 
behavioral health. How would you separate behavioral health issues from 
other patient groups while working on physician payment issues?

    Answer. As noted in my Ethics Agreement, which was previously 
provided to the Senate, because of my husband's practice as a 
psychiatrist with the Indiana Health Group, Indianapolis, IN, and his 
financial interest in the Indiana Health Group, I have agreed not to 
participate personally and substantially in any particular matter that 
to my knowledge has a direct and predictable effect on the financial 
interests of the Indiana Health Group, unless I first obtain a written 
waiver, pursuant to 18 U.S.C. Sec. 208(b)(1). Under the Federal ethics 
regulations, I am not required to recuse from consideration or adoption 
of broad policy options that are directed to a large and diverse group 
of persons. I will be required to recuse from matters that involve 
deliberation, decision or action that is focused upon the interests of 
the Indiana Health Group, or the discrete and identifiable class of 
persons or entities that includes Indiana Health Group. To the extent 
that I have questions on how to apply my recusal obligations to a 
particular matter, I will consult with the HHS Ethics Office for 
guidance on the scope of my recusal obligations.

    Question. Will you meet with advocates for and providers of 
behavioral health care?

    Answer. If confirmed, there will be certain situations where I 
would be able to meet with a particular provider of behavioral health 
care (or its advocates) and certain situations where I will be required 
to recuse. For example, if one specific provider of behavioral health-
care services, that is not the Indiana Health Group, requests a meeting 
to discuss settlement of litigation against that provider, I would be 
able to meet and listen to that provider's concerns. On the other hand, 
if a group of behavioral health-care providers, requests a meeting with 
me to discuss health insurance coverage in the small group market for 
mental health services as an essential health benefit (EHB), I would 
recuse from this meeting. If I have questions on how to apply my 
recusal obligations to a particular matter, I will consult with the HHS 
Ethics Office for guidance on the scope of my recusal obligations.

    Question. Behavioral health also includes substance abuse, 
including addiction to opioids. Are you recusing yourself from any 
issue related to opioid abuse?

    Answer. As noted above, under the Federal ethics regulations, I am 
not required to recuse from consideration or adoption of broad policy 
options that are directed to a large and diverse group of persons. I 
will be required to recuse from matters that involve deliberation, 
decision or action that is focused upon the interests of the Indiana 
Health Group, or the discrete and identifiable class of persons or 
entities that includes Indiana Health Group. There will be certain 
situations where I would be able to participate in substance abuse 
matters and certain situations where I will be required to recuse. The 
analysis of my recusal obligation for a particular matter will be made 
on a case by case basis. To the extent that I have questions on how to 
apply my recusal obligations to a particular matter, I will consult 
with the HHS Ethics Office for guidance on the scope of my recusal 
obligations.

    Question. What other specific patient types and/or issues will you 
recuse yourself from because of your husband's medical practice?

    Answer. If confirmed, because of my husband's practice as a 
psychiatrist with the Indiana Health Group, Indianapolis, IN, and his 
financial interest in the Indiana Health Group, I have agreed not to 
participate personally and substantially in any particular matter that 
to my knowledge has a direct and predictable effect on the financial 
interests of the Indiana Health Group, unless I first obtain a written 
waiver, pursuant to 18 U.S.C. Sec. 208(b)(1). Under the Federal ethics 
regulations, I am not required to recuse from consideration or adoption 
of broad policy options that are directed to a large and diverse group 
of persons. I will be required to recuse from matters that involve 
deliberation, decision or action that is focused upon the interests of 
the Indiana Health Group, or the discrete and identifiable class of 
persons or entities that includes Indiana Health Group. To the extent 
that I have questions on how to apply my recusal obligations to a 
particular matter, I will consult with the HHS Ethics Office for 
guidance on the scope of my recusal obligations.

    Question. For each area you are recusing yourself, please provide 
the names and/or positions of the individual to whom you expect to 
delegate responsibility for such issue on behalf of CMS, or do you 
intend to seek waivers from the recusal requirement?

    Answer. If confirmed, matters from which I am recused will be 
elevated to the HHS Deputy Secretary or the HHS Chief of Staff, as 
appropriate, for disposition without my input or recommendation. 
Additionally, once they are appointed I would designate certain members 
of my administrative staff and other appropriate CMS officials within 
my immediate office to screen matters that are covered by my recusal 
obligation, so that these matters are not given to me for action.
                 alternative payment models in medicare
    Question. The previous administration set a goal of tying 30 
percent of traditional, or fee-for-service, Medicare payments to 
quality or value through alternative payment models, such as 
Accountable Care Organizations (ACOs) or bundled payments by the end of 
2016 and tying 50 percent of those payments to alternative payment 
models by the end of 2018. CMS achieved its goal to alternative payment 
models into 30 percent of Medicare payments in March 2016--9 months 
earlier than expected.

    Will you commit to supporting the previous administration's goal of 
making 50 percent of Medicare payments through alternative payment 
models by 2018?

    If so, what specific actions will you take--if confirmed as CMS 
Administrator--to reach that goal?

    Answer. I look forward to reviewing the actions taken by health-
care providers and CMS to achieve this goal in order to determine what 
has worked and what we can improve upon going forward. Additionally, it 
is crucial that we communicate with providers and stakeholders and seek 
their input as early in the process as appropriate.
   actuarial soundness and network adequacy in medicaid managed care
    Question. In the final Medicaid Managed Care rule, released in May 
2016, CMS strengthened actuarial soundness requirements for plans that 
contract with State Medicaid programs to provide health-care services. 
The actuarial soundness provision requires States to pay health plans 
at a rate that is sufficient to provide, ``for all reasonable, 
appropriate, and attainable costs,'' that are required under the terms 
of the contract and for successful operation of a managed care entity 
providing services to Medicaid beneficiaries. The final Medicaid 
Managed Care rule included provisions to increase the transparency and 
accountability in the development of health plans' capitation rates.

    The final rule also includes important beneficiary protections. The 
new rule proposes important changes to increase the adequacy of 
provider networks in Medicaid managed care. States are required to set 
``time and distance'' standards to limit how long or how far a Medicaid 
beneficiary has to travel in order to receive services from all types 
of providers. For long-term services and supports (LTSS) providers, who 
travel to beneficiaries, States must set similar time and distance 
standards. In addition, States must establish continuity of care 
policies for beneficiary transitions into or between managed care 
plans.

    Do you commit to maintaining the actuarial soundness requirements 
in the provision of Medicaid managed care?

    Do you commit to maintaining the increase in transparency and 
accountability in the capitation rate development process?

    Do you commit to maintaining time and distance standards to 
strengthen network adequacy for Medicaid managed care enrollees?

    Do you commit to maintaining the requirement for time and distance 
standards to be applicable to the 11 categories of providers specified 
in the final rule?

    Do you commit to maintain the requirement for States to consider 
the number of network providers who are not accepting new patients, the 
geographic location of network providers, the ability of network 
providers to communicate in non-English languages, and the ability of 
network providers to ensure accessible, culturally competent care to 
people with disabilities when setting their time and distance 
standards?

    What specific actions will you take to assure proper oversight of 
the implementation of the final Medicaid Managed Care rule?

    Answer. If confirmed, I commit to thoroughly reviewing the rule 
with the utmost regard for the accessibility of high-quality health 
care for all impacted Medicaid beneficiaries as well as State 
flexibility, efficiency, and cost effectiveness.
 periodic updates regarding affordable care act outreach and enrollment
    Question. At Marilyn Tavenner's confirmation hearing for CMS 
Administrator, Chairman Hatch asked her to commit to providing bi-
weekly updates on the establishment of the Affordable Care Act (ACA)'s 
Exchanges and on enrollment. I request that you make a similar 
commitment to provide periodic updates to the Finance Committee.

    Will you commit to providing the members of the Finance Committee 
with periodic updates--both written progress reports and briefings--in 
the months leading up to and during ACA open enrollment periods?

    In addition to any available enrollment numbers, I would ask that 
those updates address technology functioning; marketing and outreach 
plans; operation of the call center, in-person assistance and staff 
working with the States; and any improvements or changes being made to 
the enrollment process. Do you agree?

    Answer. If confirmed, I am committed to working with Congress to 
ensure you are updated on CMS activities. If I am confirmed, 
communication and collaboration with Congress will be a major priority 
for me and the agency.
                              1115 waivers
    Question. Under section 1115 of the Social Security Act, the 
Secretary of Health and Human Services may waive certain statutory 
requirements of major health programs such as Medicaid as long as they 
further the purposes of the program. States have historically used 
waivers to expand coverage, strengthen benefits, and innovate in 
payment and delivery systems.

    Do you agree that section 1115 experimental projects must ``promote 
the objectives of the Medicaid Act?''

    Do you agree that the objective of the Medicaid Act is to furnish 
medical assistance to low-income people and to furnish ``rehabilitation 
and other services to help such . . . individuals attain or retain 
capability for independence or self-care?'' (42 U.S.C. Sec. 1396-1).

    Do you agree that a proposal that will clearly reduce access to 
medical assistance is inconsistent with the objectives of Medicaid?

    Do you agree with the criteria the Centers for Medicare and 
Medicaid Services (CMS) currently uses to evaluate when a demonstration 
project promotes the objectives of Medicaid--that the demonstration 
will: increase and strengthen overall coverage of low-income 
individuals in the State; increase access to, stabilize, and strengthen 
providers and provider networks available to serve Medicaid and low-
income populations in the State; improve health outcomes for Medicaid 
and other low-income populations in the State; or increase the 
efficiency and quality of care for Medicaid and other low-income 
populations through initiatives to transform service delivery networks?

    Answer. I agree that experimental projects and demonstrations 
within the Medicaid program should reflect the overall objectives of 
the program, as defined by Congress. If confirmed, I look forward to 
reviewing any proposal put before me to determine whether and how it 
could impact beneficiaries in addition to ensuring the demonstration 
project is budget neutral to the Federal Government.
                president's january 30th executive order
    Question. On January 30th, the President signed an executive order 
requiring the Federal agencies revoke two existing regulations during 
fiscal year 2017 for every new rule they issue.

    On Wednesday, February 15th, CMS released a proposed rule regarding 
the individual and small group health insurance markets.

    If confirmed as CMS Administrator, which two existing CMS rules or 
regulations would you repeal to account for the release of this 
proposed rule?

    For additional rules that CMS is statutorily required to publish 
this year, if confirmed as CMS Administrator, would you require that 
CMS publicly identify which two regulations it plans to repeal at the 
same time as the new rule is proposed? If not, within what timeframe 
will those two regulations be identified?

    What are some examples of current rules you would eliminate to 
comply with the arbitrary two for one rule reduction requirement? Would 
you rescind rules to comply with the executive order that protect 
public health or patient safety? How would you determine which rules 
would be rescinded when new rules are issued?

    Answer. If confirmed, I will work with HHS and CMS staff to review 
all rules and regulations and ensure compliance with the President's 
executive order.
                   home- and community-based services
    Question. Federal Medicaid law provides States with flexibility to 
provide long-term services and supports (LTSS) through home- and 
community-based services (HCBS) rather than in nursing homes or other 
long-term care facilities. To date, almost every State offers HCBS 
services to older adults and people with disabilities through waivers. 
HCBS waiver programs have helped 1.5 million Americans stay at home 
rather than move into a nursing home.

    Section 2401 of the Affordable Care Act also authorized the 
Community First Choice Option to provide home- and community-based 
services for people who otherwise would have to move into a nursing 
home. To encourage States to adopt the program, Federal financial 
participation is increased by 6 percent. Today, 8 States, including 
Oregon, and over 300,000 people are served by the program.

    Baby boomers are reaching retirement age, and Americans are living 
longer. By 2030, older Americans will account for 20 percent of the 
Nation's population. As a result, the demand for long-term services and 
supports including those offered at home and in the community is 
expected to increase dramatically.

    Do you think the Federal Government should help States address the 
needs of a high-cost, aging population?

    How do you think HCBS wait lists will fair with a 30-plus-percent 
cut to Medicaid funding through block grants or per capita caps, which 
HHS Secretary Price proposed in his 2017 budget proposal as House 
Budget Committee chairman?

    Do you support extending the Money Follows the Person program at 
current funding levels?

    Do you support the Community First Choice State option with the 
current Federal matching levels?

    Answer. Long-term services and supports are a vital part of the 
Medicaid program and will increase with the aging baby boomer 
population. I look forward to reviewing CMS's previous actions and 
prospective options to ensure our commitment to Americans with long-
term care needs is met and that States have the flexibility to 
implement innovative programs that work best for the populations they 
serve.

                                 ______
                                 
              Questions Submitted by Hon. Debbie Stabenow
    Question. Because of Medicaid expansion in Michigan, 650,000 people 
have insurance, and uncompensated care has been cut by at least 50%. 
Thirty thousand jobs have been created, and the State will end the year 
with $432 million more than it invested in the program. Unfortunately, 
the one thing in common about every Republican proposal in front of 
Congress right now is cuts to Medicaid funding.

    Do you support cutting funding to States to run Medicaid programs?

    Answer. I support ensuring all Americans have access to quality 
health care. Medicaid's financing structure is determined by Congress, 
so I look forward to collaborating with Congress and implementing the 
law as written.

    Question. A repeal of Medicaid expansion in addition to the block 
grant proposal supported by Speaker Ryan, Secretary Price, and many 
others would cut about $2 trillion from the Medicaid program over the 
next 10 years.

    Having worked closely with States and State budgets, including 
working with Michigan during implementation, if the Medicaid program 
was cut by $2 trillion how would you advise Michigan absorb the loss?

    Do you think it is possible to do without dropping eligibility, 
cutting services and providers, or raising State taxes?

    Waivers are used to promote innovation--how do you innovate without 
harming people if your budget is being decimated?

    When you talked about State flexibility from Federal regulations, 
should that include the ability to not follow Federal mental health 
parity law?

    Can you commit that you would not approve any waiver or regulation 
that reduces mental health protections under the Medicaid program?

    Answer. If confirmed, to the extent that I am not required to 
recuse from a specific waiver or regulation under the Ethics Agreement 
I signed on January 31, 2017, I would evaluate each waiver that is 
elevated to the level of the CMS Administrator to ensure it meets the 
requirements set out by law and to evaluate its impact on beneficiary 
access as well as budget neutrality requirements.

    Question. During the ACA debate, I was the lead sponsor of a 
provision that ensured maternity and newborn coverage would be 
guaranteed for women and their babies. Last Congress I led a bill with 
Senator Grassley called the Quality Care for Moms and Babies Act, which 
passed the Finance Committee. The bill would address performance 
measurement gaps in Medicaid and CHIP and create maternity care quality 
collaborates to share and adopt best practices.

    Can you commit to work with me on this legislation, and work on 
driving down the maternal mortality rate?

    Answer. If confirmed, CMS will be happy to provide technical 
assistance related to this legislation as well as other priorities of 
yours. Improving maternal and child health outcomes has been something 
I have focused on in my career, so I look forward to working closely 
with your office on matters of great importance, such as the maternal 
mortality rate.

    Question. More generally, do you agree that it is critical to 
continue investing in health-care-quality improvement and measurement? 
How would you engage stakeholders from across the health-care system to 
participate in the effort?

    Answer. I believe that we should constantly be monitoring data and 
outcomes to ensure that patients are receiving quality care that 
improves health-care outcomes.

    Question. One of the greatest threats to the Medicare program is 
Alzheimer's disease. We need a cure and research dollars to help us get 
there, but we also need the Medicare program to provide coordinated, 
thoughtful care to people living with Alzheimer's disease and their 
caregivers who shoulder so much of the burden. We made progress last 
year, as I was able to get a care planning benefit included in the 
program, which will help ensure better delivery of care.

    Do you agree we could help shore up Medicare financing by tackling 
Alzheimer's disease care?

    What steps would you take as CMS Administrator to help families 
struggling with the diagnosis of Alzheimer's disease?

    Answer. If confirmed, I stand ready to partner with Congress, the 
FDA, NIH, and stakeholders to ensure that Medicare beneficiaries 
suffering from Alzheimer's are treated with dignity and compassion. 
Curing Alzheimer's would revolutionize the American health-care system 
for the millions of families impacted by this disease.

    Question. The Patient Access and Medicare Protection Act helped 
stabilize patient access to radiation oncology services delivered in 
community-based clinics. The legislation also requested a report from 
CMS on the development of alternative payment models in radiation 
oncology by this summer. Radiation oncologists in my State are 
currently working to develop alternative payment models that 
incentivize high-
quality care for cancer patients.

    As Administrator, how would you consult with radiation oncology 
stakeholders, and others, on the development of APMs to ensure 
stability, patient access, and appropriate reimbursement?

    Answer. If confirmed, I would ensure that CMS is consistently 
engaging stakeholders as policies and programs are developed and 
implemented to ensure we are achieving the best outcomes for patients. 
It is critical that we have open communication to understand their 
perspective, what they are going through, and what their challenges 
are.

    Question. How would changes to the Medicaid financing structure, 
such as a block grant system, affect Indian health programs?

    Answer. Every State is unique with a different population and 
different needs. Congress ultimately decides how to reform Medicaid's 
financing structure, and I look forward to implementing whichever 
reforms they enact with the utmost care for those affected by those 
changes, including families in Indian health programs.

    Question. Would you protect the 100% FMAP for services provided 
through an IHS/Tribal facility?

    Answer. If confirmed, I look forward to implementing the law as 
written by Congress. Questions related to the percentage of Federal 
assistance are determined by Congress, so I stand ready to work with 
you and the rest of Congress to ensure the law is implemented 
appropriately.

    Question. In 2010, then-Secretary Sebelius established the 
``Secretary's Tribal Advisory Committee'' for HHS to hear directly from 
tribes on departmental policy development and budget proposals.

    What, if any, input would you seek from tribes and urban Indian 
health organizations about proposed administrative changes to the 
Medicaid and Medicare programs?

    As CMS Administrator, what methods would you employ to ensure 
proper consultation occurs?

    Answer. If confirmed, I will proactively engage stakeholders, 
including tribes and urban Indian health organizations, on the front-
end regarding proposed administrative changes to the Medicaid and 
Medicare programs. Additional perspective on how CMS policy could 
impact their beneficiaries and families is of great value to CMS. 
Communication and collaboration early on in the process ensures that 
caregivers and families have an opportunity to discuss their 
priorities, questions or concerns.

    Question. In November 2016, the IHS released the outline of its 
plan to improve care at its facilities. The framework includes 5 
priorities--strengthening organizational capacity, maintaining facility 
accreditation, improving patient experiences, ensuring patient safety, 
and identifying potential risks earlier.

    What role do you see CMS having in these efforts as the framework 
moves forward?

    Answer. If confirmed as Administrator of CMS, I will diligently 
collaborate and coordinate with all HHS sister agencies, including the 
Indian Health Service. CMS will continue to conduct Medicare 
certification surveys for IHS hospitals, and will stand ready to 
provide technical assistance or other support whenever appropriate.

                                 ______
                                 
              Question Submitted by Hon. Debbie Stabenow 
                       and Hon. Michael F. Bennet
    Question. The Protecting Access to Medicare Act (PAMA) included 
requirements that ordering physicians consult appropriate use criteria 
prior to referring Medicare patients for advanced diagnostic imaging 
services.

    If confirmed, do you intend to implement the appropriate use 
criteria provisions according to existing statute? Would you start the 
program on January 1, 2018?

    Answer. If confirmed, I will follow the laws as passed by Congress 
and implement them accordingly. I look forward to closely monitoring 
challenges associated with this implementation process, while 
identifying and evaluating specific burdens that have the potential to 
limit patient access.

                                 ______
                                 
               Questions Submitted by Hon. Maria Cantwell
                                medicaid
    Question. You have worked extensively on State Medicaid policy and 
financing issues. In your view, when States face budget shortfalls, 
what do they typically do to reduce costs in their Medicaid programs, 
in the absence of additional Federal or State revenue? In other words, 
what are the ``levers'' available to States to reduce Medicaid costs? 
Moreover, which of these levers are most frequently used?

    Answer. The current system is inflexible, with States required to 
receive CMS approval for routine changes. We need to allow States to be 
innovative and deliver better outcomes while holding States 
accountable. If confirmed as Administrator of CMS, I will work to allow 
more flexibility to the States, allowing for innovation in the Medicaid 
waiver process.

    Question. You have stated that Medicaid does not always produce 
good outcomes for patients. In your view, what specific outcomes--
clinical, financial, or otherwise--should States strive for in their 
Medicaid programs?

    Answer. I support State innovations to increase coordination of 
care, improve access to preventative care, improve drug adherence and 
lower emergency room usage, all with the goal of improving access to 
high quality health care and improving patients' outcomes. Outcomes can 
be measured in a variety of ways but should focus on the patient 
experience and impact of the program on beneficiaries. I look forward 
to working with you to reach these goals, if confirmed as Administrator 
of CMS.

    Question. Does the Federal Government have a role to play in 
encouraging those outcomes, and if so, what is that role?

    Answer. We can do better to improve health outcomes. Our goal is to 
ensure that all Americans have access to high-quality health care with 
choices that fit their needs and the needs of their family. If 
confirmed, I look forward to working with you to realize better health 
outcomes through encouraging innovation, reducing redundant paperwork, 
and allowing for providers to spend more of their time on their 
patients while also holding States and providers accountable.
                             long-term care
    Question. Do you support Federal ``rebalancing'' initiatives, such 
as the Balancing Incentives and Money Follows the Person programs in 
the Affordable Care Act?

    Answer. I support Americans being in charge of their health care 
and choosing what works best for themselves and their family. Every 
State is unique with a different population, different needs and 
different challenges. If confirmed, I am committed to working to 
provide States more flexibility to pursue measures that fit the needs 
of their citizens.

    Question. Do you believe that, if well-implemented, ``rebalancing'' 
programs such as the Balancing Incentives Program can improve the care 
experience for patients and reduce State Medicaid costs?

    Answer. Every State is unique, and design flexibility is an 
important component. What works in one State may not work as well in 
other parts of the country, so if confirmed, I am committed to working 
to provide States more flexibility to pursue innovative measures that 
allow States to make the most of available resources and serve their 
citizens with the highest quality of care.
                          basic health program
    Question. The Basic Health Program (section 1331 of the Affordable 
Care Act) is a State option that is providing health insurance and 
access to care to more than 750,000 working low-income individuals in 
New York and Minnesota. States that have taken advantage of this 
voluntary program are seeing lower costs for beneficiaries, higher 
enrollment, and net State budget savings, compared to not implementing 
the program. Through the Basic Health Program, States are price-makers, 
not price-takers. Do you support the Basic Health Program as a way to 
empower States to negotiate a better deal on health insurance for their 
citizens?

    Answer. I support State innovation to make the most of available 
resources and serve their citizens with the highest quality of care. 
Programs that work well in one State might not translate to other parts 
of the country. From my experience working with States, I learned that 
one-size-fits-all solutions won't work so I am committed to increased 
State innovation and accountability to the citizens they represent.

    Question. If confirmed, will you commit to funding and 
administering the Basic Health Program as required under current 
Federal law?

    Answer. If confirmed, I will follow the laws as passed by Congress 
and implement them accordingly.

    Question. If Congress repeals parts of the Affordable Care Act, 
will you commit to ``not pulling the rug out'' from the 750,000 low-
income individuals who are benefiting from the Basic Health Program?

    Answer. I support Americans being in charge of their health care 
and choosing what works best for themselves and their family. Our goal 
is to ensure that all Americans have access to high-quality health care 
with choices that fit their needs and the needs of their family. I am 
committed to implementing the law as written and I am committed to 
implementing it with careful attention to those Americans who may be 
impacted.

    Question. Will you use your administrative discretion as CMS 
Administrator to not rescind funding for State Basic Health Programs, 
unless a rescission of that funding is explicitly required by a change 
to the statute?

    Answer. If confirmed as Administrator of CMS, I will follow the 
laws as passed by Congress and implement them accordingly, including 
the directions from Congress related to appropriations measures and 
other sources of funding for health care programs.
                         delivery system reform
    Question. Washington State and the Pacific Northwest have led the 
way in pioneering nationally recognized innovations in the delivery of 
health care--whether it is the Qliance Direct Primary Care medical home 
model, Group Health Cooperative's highly popular integrated coverage 
and care model, the Everett Clinic's price transparency initiatives, 
Boeing's Accountable Care Organizations, or Virginia Mason's team-based 
care. Despite their innovations, health-care providers in my State are 
paid nearly $2,000 less (per Medicare enrollee, per year) than the 
national average, based on CMS spending data compiled by the Kaiser 
Family Foundation. I would argue that, due to our current volume-based 
system, my constituents are paid less specifically because they are 
efficient and because they do a good job of keeping patients healthy. 
Should the Federal Government reward such high-value health-care 
providers, as long as we clearly define and agree upon metrics for what 
constitutes ``high-value'' care?

    Answer. If confirmed as Administrator of CMS, I will follow and 
implement laws, such as MACRA, related to payment to high-value health-
care providers.

    Question. Does the current fee-for-service system encourage 
unnecessary health-care spending? If so, can you please explain 
specifically how this system encourages unnecessary health-care 
spending, including in which specialties of medicine, and in which 
settings of care?

    Answer. The current system can encourage unnecessary spending by 
putting too many health-care decisions in the hands of a distant 
Federal bureaucracy rather than in the hands of doctors and their 
patients. All health-care providers, from primary care providers to 
specialists, should be encouraged to provide value to their patients.

    Question. Under the Obama administration, HHS Secretary Burwell and 
CMS Administrator Slavitt set a goal of providing 50 percent of 
Medicare fee-for-service spending through alternative payment models. 
If confirmed, will you continue, rescind, or modify that goal?

    Answer. If confirmed, I look forward to reviewing the actions taken 
by health-care providers and CMS to achieve the initial goal to better 
understand what has worked and what we can improve upon in the 
implementation of laws such as MACRA. Additionally, it is crucial to 
communicate and collaborate with providers and stakeholders throughout 
the process.

    Question. In 2015 Congress passed and President Obama signed into 
law the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA 
incorporated the Value-Based Payment Modifier, which I authored in the 
Affordable Care Act, into Medicare's new physician payment system, the 
Quality Payment Program. Will you commit to working with Washington 
State health-care providers to help them succeed in Medicare's Quality 
Payment Program, as outlined in regulations by CMS, including Advanced 
Alternative Payment Models?

    Answer. If confirmed, I am committed to working closely with the 
Secretary of HHS to ensure MACRA is implemented fairly and so that it 
is easy to understand and minimizes burdens, especially on smaller and 
rural providers.

    Question. Will you commit to fund and administer Medicare's 
Accountable Care Organizations, including the Medicare Shared Savings 
Program under section 3022 of the Affordable Care Act, and will you 
commit to helping health-care providers participate in these models, 
should they choose to do so? Will you commit to not taking any 
administrative action that would make it more difficult for Medicare 
beneficiaries or health-care providers to participate in this voluntary 
program?

    Answer. If confirmed, I will follow the laws set forth by Congress 
related to Medicare's ACOs, and I intend to work with the Secretary of 
HHS to ensure, as we move forward, that we learn from the results of 
ACOs and chart a path forward based on an understanding of what is and 
what is not working.

    Question. Will you commit to fully fund approved grants under the 
Center for Medicare and Medicaid Innovation (CMMI), and will you 
continue to fund and administer future payment initiatives under CMMI, 
consistent with the legislative intent of Congress in the Affordable 
Care Act?

    Answer. I look forward to reviewing current CMMI projects, 
consistent with congressional actions.

    Question. Health-care researchers and providers in Washington 
State, such as the AIMS Center at the University of Washington and Iora 
Health, are working to integrate behavioral health services into the 
primary care experience in order to provide a more seamless care 
experience, reduce the stigma of behavioral health conditions, and fill 
historical gaps in access to care. Do you support the integration of 
primary care and behavioral health into the same care setting?

    Answer. If confirmed, to the extent I am not required to recuse 
from a particular matter under the terms of my Ethics Agreement, I will 
work to implement the laws passed by Congress. I support flexibility 
for States to design innovative care programs that improve health 
outcomes. Both primary and behavioral health care are key components to 
providing comprehensive care to patients and I support innovative 
approaches that drive better health care.
                    specific health care legislation
    Question. I have authored bipartisan legislation (S. 2259 in the 
114th Congress) to make it easier for rural health-care providers to 
participate in the Medicare Shared Savings Program by allowing CMS to 
adopt a broader beneficiary assignment method than is provided under 
current law. Will you commit to providing me and my office responsive 
and accurate technical assistance on this legislation?

    Answer. I am committed to open communication, collaboration, and 
bipartisanship. If confirmed, I will work with you and be responsive to 
your inquiries and concerns and provide information on the beneficiary 
assignment for the Medicare Shared Savings Program.

    Question. I have authored bipartisan legislation (S. 2373 in the 
114th Congress) to require CMS to cover an essential preventive 
product, compression therapy items, for Medicare beneficiaries who 
experience swelling from lymphedema. Will you commit to providing me 
and my office responsive and accurate technical assistance on this 
legislation?

    Answer. I am committed to open communication, collaboration, and 
bipartisanship. If confirmed, I will work with you and be responsive to 
your inquiries and concerns and provide information on the Medicare 
coverage and payment process.

    Question. I have cosponsored bipartisan legislation (S. 3129 in the 
114th Congress) to preserve patient access to outpatient therapeutic 
services in Critical Access Hospitals and other rural hospitals. 
Similar legislation has been signed into law the last 3 years. Will you 
commit to working with me, my staff, and bill sponsors and cosponsors, 
on this issue?

    Answer. I am committed to open communication, collaboration, and 
bipartisanship. If confirmed, I will work with you and be responsive to 
your inquiries and concerns to ensure that critical access hospitals 
continue to provide quality health care to rural populations.

    Question. Will you commit to providing me and my office responsive 
and accurate technical assistance on any future legislation I author or 
on which I seek assistance?

    Answer. I am committed to open communication, collaboration, and 
bipartisanship. If confirmed, I will work with you and be responsive to 
your inquiries and concerns.
            washington state's section 1115 medicaid waiver
    Question. On January 9, 2017, CMS approved Washington State's 
proposed Medicaid waiver (``Medicaid Transformation Project, No. 11-W-
00304/0) under section 1115(a) of the Social Security Act. In securing 
agreement on this waiver, Washington State health officials and CMS 
spent countless hours over more than a year in good-faith negotiations. 
This approved waiver will help Washington State pursue a smarter and 
more innovative Medicaid program that reflects changes in health-care 
delivery, technology, and the preferences of patients. Specifically, 
the waiver will help my State integrate behavioral health and primary 
care services, and re-orient the care experience away from higher-cost 
institutional settings to lower-cost community based settings. Will you 
commit to honor this approved waiver and not take any administrative 
action to rescind, weaken, or de-fund its components?

    Answer. If confirmed, I am committed to working to provide States 
more flexibility to pursue innovative waivers that fit the needs of 
their citizens. Our goal is ensure that all Americans have access to 
have high quality health care with choices that fit their needs and the 
needs of their family.
                       graduate medical education
    Question. The vast majority of Washington State counties are Health 
Professional Shortage Areas (HPSAs) according to HHS's HRSA. In 
response to an aging population and impending physician shortages, two 
new medical schools have opened in Washington, each focused on training 
more physicians to practice in shortage specialties and in medically-
underserved communities. Do you agree with an established body of 
research illustrating that there are physician shortages in the United 
States, especially in primary care specialties and in rural 
communities?

    Answer. Coverage doesn't always translate to access, and access to 
care is a critical issue in many areas of our country, especially in 
our rural areas where there are challenges in attracting workforce. If 
confirmed, I will work with the Congress, the Secretary of HHS, and the 
Health Resources and Services Administration (HRSA) to address 
physician shortages as they relate to Medicare and Medicaid programs.

    Question. Given your experience in health-care policy, what is your 
view of the role the Federal Government should play to promote an 
adequate and balanced physician workforce in the United States? Or 
should that role be left to the States?

    Answer. When considering new rules and regulations, we all (Federal 
and State) should be mindful of the workforce shortage, particularly in 
our rural areas where there are unique challenges in attracting medical 
providers. We all should proactively engage providers on the front end 
for valuable feedback and take into account the fact that they may have 
limited time and resources to implement regulations.

    Question. As the practice of medicine transforms, how should 
Medicare's financial support for graduate medical education (GME) 
adapt, or should it remain the same?

    Answer. If confirmed, I look forward to working with you and other 
members of Congress on your priorities to see that our GME programs 
work well for a 21st-
century medical work force.
                         medicare reimbursement
    Question. CMS recently finalized a regulation implementing section 
603 of the Bipartisan Budget Act, which effectively reduces Medicare 
payment rates for certain newly established, off-campus hospital 
outpatient departments to the payment level under the physician fee 
schedule or ambulatory surgery center fee schedule. If confirmed, how 
will you approach implementation and interpretation of section 603 of 
the Bipartisan Budget Act?

    What exceptions, if any, are appropriate to ``site-neutral'' 
payment reductions?

    Do you support ``site-neutral'' payment policies in Medicare? If 
you do in part, could you explain in what settings they are 
appropriate, and in what settings they are not?

    Answer. If confirmed, I will support the implementation of the 
site-neutral payment rules that Congress has enacted or will enact. 
Ensuring that patients can access quality care in all kinds of health-
care settings is a priority for Congress, CMS and the American people. 
It is essential that beneficiaries have robust choices in their 
providers and I look forward to implementing policies that ensure we 
attract providers to deliver quality care.

                                 ______
                                 
                Questions Submitted by Hon. Bill Nelson
    Question. On January 30th, President Trump issued an executive 
order that requires some Federal agencies to repeal two regulations for 
every new one issued. Given the sheer number of rules and regulations 
that CMS must issue every year, how do you envision this executive 
order functioning so that CMS can continue to do its job? Can you give 
me examples of two specific regulations that you would repeal as CMS 
Administrator?

    Answer. If confirmed as Administrator of CMS, I look forward to 
reviewing existing regulations and any new proposed regulations to 
determine applicability to the President's Executive order.

    Question. Over 4 million seniors in Florida rely on the health and 
financial security provided by the Medicare program. I've consistently 
opposed efforts to convert Medicare to voucher program, which would 
fundamentally change the program and leave seniors exposed to higher 
out-of-pocket costs. How would you propose to help people on Medicare 
and their families with the rising cost of medical care and long-term 
care?

    Answer. I support offering choices for seniors and opportunities 
for additional benefits. Ultimately, the direction of Medicare is up to 
Congress and if confirmed as Administrator of CMS, I will follow the 
laws as passed by Congress and implement them accordingly. I hope we 
can work together to make the program more sustainable.

    Question. Then-Congressman Price introduced a bill (the Medicare 
Patient Empowerment Act) to allow practitioners to enter into private 
contracts with their Medicare patients and charge higher fees than what 
is currently allowed under the Medicare program. Currently, when 
seniors in Medicare see their doctors they are responsible for a set 
amount of costs and physicians participating in Medicare cannot bill 
their patients for any outstanding costs. Do you support this change in 
policy?

    Answer. I support offering choices for seniors and putting 
Americans in charge of their health care and choosing what works best 
for them and their family. Medicare policy-making is in large part done 
by Congress, so I look forward to working with you on Medicare issues.

    Question. The ACA includes provisions designed to improve 
treatments for people with substance use disorders, including opioid 
addiction. It included mental health and substance use disorder 
treatment as essential health benefits; it expanded access to treatment 
services; it eliminated lifetime limits on behavioral health services; 
and ended discrimination by insurers based upon pre-existing 
conditions.

    According to the CBPP, 1.3 million people with serious mental 
illness and 2.8 million people with substance use disorders would lose 
health coverage under ACA repeal. Would you recommend that President 
Trump and congressional Republicans maintain the provisions listed 
above in any replacement plan? Beyond keeping the ban on discriminating 
against people with pre-existing conditions, what are the elements that 
any replacement plan must include?

    Answer. My goal is to ensure that all Americans have access to high 
quality health care with choices that fit their needs and the needs of 
their family. If confirmed, I will follow the laws as passed by 
Congress and implement them accordingly.

    Question. As CMS Administrator, what administrative actions would 
you take to address the opioid epidemic?

    Answer. If confirmed as Administrator of CMS, to the extent I am 
not required to recuse from a particular matter under the terms of my 
Ethics agreement, I will work closely with the Secretary and the 
Substance Abuse and Mental Health Services Administration (SAMHSA) 
whose duty is to advance behavioral health and reduce the impact of 
substance abuse and mental illness on America's communities. It is 
critical that all Americans suffering from mental health and substance 
abuse disorders have access to the care they need.

    Question. The Medicare Advantage program is an affordable option 
offering out-of-pocket spending caps, additional benefits like vision 
and dental, and often prescription drug coverage at no additional cost 
for many of my constituents. As Administrator, what specific actions 
would you take to strengthen and build upon this vital part of the 
Medicare program? How will you ensure that the 1.6 million seniors in 
Florida, and the 18 million that enrolled across the Nation are 
protected?

    Answer. I am committed to preserving and strengthening the Medicare 
Advantage program as it offers additional benefits and provides 
additional choices to seniors. If confirmed, I look forward to working 
with you and other members of Congress to support the program.

    Question. A CMS Medicare Graduate Medical Education (GME) rule 
prevents a number of hospitals that hosted--for a very brief period of 
time--medical residents from another facility's teaching program from 
establishing their own full-time Medicare support residency programs. 
Under current CMS policy, hospitals considered by CMS as ``new'' 
teaching hospitals are permitted to establish a permanent full-time 
(FTE) resident cap and per resident amount (PRA), which allows for 
reimbursement by CMS for Medicare's share of the hospital's training 
costs. I have heard from a small number of community hospitals in my 
State that inadvertently triggered a very low resident and/or PRA 
though hosting resident rotators for short periods of time. Do you 
commit to working with me to fix this glitch? Does CMS have the 
authority to fix this problem without congressional action?

    Answer. If confirmed, I commit to looking into this issue with you 
and helping you evaluate the options at both the legislative and 
executive level.

    Question. In 2016, CMS announced a new pre-claim review 
demonstration (PCRD) for home health services in five States. The 
demonstration began in Illinois in August, with plans to expand to 
Florida, Texas, Michigan and Massachusetts. Because of problems 
experienced by beneficiaries and providers in Illinois, program 
expansion was delayed. It is now scheduled to be implemented in Florida 
on April 1st, without any changes. Do you plan to continue this 
demonstration in Illinois? Do you plan to move forward with the 
demonstration in Florida? If so, will you amend the scale of the 
demonstration and provide additional safeguards for providers?

    Answer. If confirmed, I would review current demonstrations as well 
as the results of other similar demonstrations to understand the 
challenges and any lessons learned that may be applied to the Pre-
Claims Review Demonstration. I look forward to working with you to 
address your concerns.

    Question. When the Medicaid program was created in 1965, there were 
fewer service delivery settings and options available for consumers. As 
a result, nursing home care was made a mandatory benefit within the 
program. Since then, service innovations and technologies have enabled 
care to be safely and effectively delivered in home and community-based 
settings, yet the Medicaid program still retains the mandate for 
nursing home placement. States must seek a waiver in order to enable 
consumers to receive home and community-based care. How do you intend 
to use administrative power to facilitate beneficiaries have access to 
high-quality, cost-
effective home and community-based services? How would cuts to State 
Medicaid programs through block grants and per capita caps impact the 
ability of States to deliver high quality home and community-based 
services to an aging baby boomer population that wants to receive long-
term services and supports at home and in their communities?

    Answer. I support Americans being in charge of their health care 
and choosing what works best for themselves and their family. Every 
State is unique with a different population and different needs and the 
Medicaid program should be more flexible to address the changing 
health-care landscape and population needs with the goal of improving 
health outcomes. If confirmed, I am committed to working with States, 
in accordance with the laws passed by Congress, to provide more 
flexibility to pursue innovative measures that fit the needs of their 
citizens. At the same time, States must be held accountable to 
standards that result in better health-care quality and access. Our 
goal is to ensure that all Americans have access to high quality health 
care with choices that fit their needs and the needs of their family.
                                 ______
                                 

                Questions Submitted by Hon. Bill Nelson 
                        and Hon. Robert Menendez
    Question. Puerto Rico's economic recession has caused the number of 
Puerto Rico residents migrating to the States to reach staggering 
levels. The situation is made worse by physician shortages, a Medicaid 
program facing chronic funding shortfalls, and across-the-board 
disparities in Federal health programs.

    Puerto Rico's Medicaid program serves about 1.4 million residents--
over 40 percent of the island's population. The Affordable Care Act 
provided Puerto Rico with a one-time funding boost of $6.4 billion set 
to expire at the end of fiscal year 2019. This funding will be depleted 
in 2017. Once this money is gone, Puerto Rico will go back to receiving 
its annual set Medicaid allotment, about $350 million in FY 2018.

    Do you believe Puerto Rico should be treated the same as States 
under Federal Medicaid laws?

    Answer. As you acknowledge in your question, Puerto Rico's fiscal 
challenges are much broader than those pertaining to their Medicaid 
program. It is my hope that leaders in the Commonwealth and in Congress 
will be able to adequately fund Puerto Rico's Medicaid program while 
addressing their overall fiscal situation. If confirmed, I will follow 
the laws as passed by Congress and implement the law accordingly.

    Question. Do you support extending the Medicare Part D LIS program 
to seniors residing in Puerto Rico and the other territories? If you do 
not believe low-income seniors in Puerto Rico should have access to the 
LIS program, why?

    Answer. Extending the Medicare Part D LIS program to seniors 
residing in Puerto Rico and other territories would require a change in 
statute. Therefore, this is a legislative matter and I defer to 
Congress to address this issue. I will faithfully administer the 
Medicare Part D program as written in statute.

    Question. In order to use their supplemental allotment, the Puerto 
Rico Government must pay a 45 percent local match. During the last 3 
years, the Puerto Rico Government drew down only half of its Federal 
allotment funds because it could not generate its match. Do you believe 
CMS should remove or waive the local matching requirement so that 
Puerto Rico can fully access the allotment funding? If you do not 
believe this matching requirement should not be waived, why?

    Answer. Access to quality health care for the people of Puerto Rico 
is an important issue that I look forward to working with Congress and 
the Commonwealth to appropriately address in accordance with the law. 
Puerto Rico's broader economic challenges impact the Commonwealth's 
health care financing capabilities, so I am hopeful that these issues 
can be addressed in order to make Puerto Rico fiscally sound and 
healthy.

    Question. Last year, we had the honor of serving on the bipartisan, 
bicameral congressional Task Force on Economic Growth in Puerto Rico. 
The Task Force was responsible for identifying steps to help stabilize 
and grow Puerto Rico's economy. The Task Force recommended that 
Congress enact fiscally-responsible legislation to address the Medicaid 
cliff established by the ACA. Will you commit to taking up the Task 
Force's recommendation to ensure that going forward Federal financing 
of the Medicaid program in Puerto Rico should be more closely tied to 
the size and needs of the territory's low-income population? What 
specific actions would you take to help achieve this goal?

    Answer. I look forward to reviewing the Task Force's 
recommendations and implementing the laws as designed by Congress 
related to the financing of Puerto Rico's Medicaid program.

    Question. Will you commit to enacting the Task Force's 
recommendation that CMS undertake any additional administrative steps 
necessary to ensure that Medicare Advantage plans in Puerto Rico are 
being fairly and properly compensated for the services they provide to 
beneficiaries? What specific administrative steps will you recommend 
CMS take?

    Answer. Every effort should be made to ensure that Medicare 
Advantage plans in Puerto Rico are being fairly and properly 
compensated for the services they provide. If confirmed, I will 
carefully study and consider the Task Force's recommendations, and work 
closely with members of Congress in order to determine how best to 
proceed on this important matter.

    Question. The Obama administration established a working group that 
included HHS and CMS officials and Puerto Rico health-care stakeholders 
to jointly propose solutions to the ways in which the funding crisis is 
manifested. This includes, among other critical policies, dealing with 
the statutory cap on Medicaid expenditures and the lack of a low-income 
drug subsidy. Do you commit to ensuring CMS continues its focused and 
meaningful participation in this working group to ensure that we 
address Puerto Rico's disparate treatment under Federal health 
programs?

    Answer. I commit to working with you and all parties involved to 
ensure that the people of Puerto Rico are able to access high quality 
health-care plans and receive the proper attention of CMS as we 
evaluate our options and provide technical assistance for legislative 
matters as appropriate.

                                 ______
                                 
              Questions Submitted by Hon. Robert Menendez
                   recusal from mental health issues
    Question. In the hearing I asked you a question about the ACA's 
Essential Health Benefit package as it pertains to coverage of 
behavioral health services, specifically for autism services. In your 
response you mentioned that you were recusing yourself from mental 
health policy in light of your husband's work as a psychiatrist.

    According to your letter to the Associate General Counsel for 
Ethics at the Department of Health and Human Services, you say that you 
``will not participate personally and substantially in any particular 
matter that to (your) knowledge has a direct and predictable effect on 
the financial interest of the Indian Health Group'' at which your 
husband practices.

    Can you provide more detail about exactly what you plan to recuse 
yourself from, if confirmed?

    Answer. As noted in my Ethics Agreement, which you reference above, 
because of my husband's practice as a psychiatrist with the Indiana 
Health Group, Indianapolis, IN, and his financial interest in the 
Indiana Health Group, I have agreed not to participate personally and 
substantially in any particular matter that to my knowledge has a 
direct and predictable effect on the financial interests of the Indiana 
Health Group, unless I first obtain a written waiver, pursuant to 18 
U.S.C. Sec. 208(b)(1). Under the Federal ethics regulations, I am not 
required to recuse from consideration or adoption of broad policy 
options that are directed to a large and diverse group of persons. I 
will be required to recuse from matters that involve deliberation, 
decision or action that is focused upon the interests of the Indiana 
Health Group, or the discrete and identifiable class of persons or 
entities that includes the Indiana Health Group. To the extent that I 
have questions on how to apply my recusal obligations to a particular 
matter, I will consult with the HHS Ethics Office for guidance on the 
scope of my recusal obligations.

    Question. Does this recusal include your work on any/all work to 
oversee and enforce Federal mental health parity laws?

    Answer. Although I will consult with the HHS Ethics Office as 
needed for guidance, the mental health parity rules are focused on 
insurance coverage for mental health services and/or substance use 
disorder services, these rules may impact entities such as the Indiana 
Health Group and service providers in the Group, including my husband, 
that receive insurance reimbursement for mental health and substance 
use disorder services. Accordingly, I will recuse from this work.

    Question. Will you recuse yourself from dealing with any Medicaid 
waiver applications that include mental health components, such as the 
Comprehensive 1115 Waiver in New Jersey which is largely about the ID/
DD population?

    This is of particular importance given the massive changes to the 
Medicaid program you have previously championed and will, presumably, 
continue promoting. Seeing as the Indiana Health Group refuses to treat 
individuals enrolled in Medicare, Medicaid and CHIP, can you confirm 
your recusal from these issues?

    Answer. The 1115 Medicaid Waiver application for New Jersey is a 
particular matter involving New Jersey as a specific party. Resolution 
of that waiver will be State-specific. Accordingly, under the ethics 
regulations, my ethics obligation will not require my recusal from this 
waiver.

    Question. Since my question during the hearing was actually about 
insurance benefit design generally, not about anything specific to do 
with payment to providers of any kind, can you clarify your views on 
whether or not a child's access to insurance coverage (not only for 
behavioral health and autism services, but any health service) should 
be based on the State in which they live?

    Answer. Children are some of our most vulnerable citizens and I 
support ensuring that they receive quality health care through the most 
effective means available.
                   medicare packaged payment policies
    Question. As you may be aware, Medicare Part B hospital and 
ambulatory surgery center payments account for medications which cost 
more than a nominal amount to be reimbursed ``at cost'' rather than 
getting ``packaged'' into the procedure code payment. This is because, 
according to CMS, because packaging certain types of drugs ``might 
result in inadequate payments to hospitals, which could adversely 
affect Medicare beneficiary access to medically necessary services.''

    However, in recent years, CMS seemed to forget this rationale and 
finalized a series of rules to package certain ``drugs that function as 
a supply when used in a surgical procedure'' and that ``function as a 
supply in a diagnostic procedure.'' This package payment policy, which 
has nothing to do with the actual price of the drug or the amount 
Medicare pays for the drug, has made several critical treatment options 
out of reach for beneficiaries due to the sharp decrease in 
reimbursement resulting from the packaging policy.

    If confirmed as Administrator, will you commit to revisiting this 
policy in the upcoming rulemaking cycle and conduct an in-depth 
evaluation of the impact this packaging payment policy has had on 
beneficiary access to the services the current regulations single-out 
for packaged reimbursement?

    Additionally, if this evaluation demonstrates decreased access to 
care for Medicare beneficiaries or an increased burden on providers 
that make providing these services more difficult, will you commit to 
make changes to ensure access is restored?

    Answer. If confirmed, I commit to thoroughly reviewing the rules to 
ensure they are implemented consistently with the law and with the 
utmost regard for the accessibility of high quality health care for all 
impacted Medicare beneficiaries.
                proper oversight of medicare contractors
    Question. As you might know, CMS contracts out several 
administrative activities, such as processing Fee for Service claims, 
medical record review, provider enrollment and the establishment of 
local coverage determinations (LCDs), to Medicare Administrative 
Contractors (MACs). MACs are divided up by region and serve as the 
agency's primary contact agent with Medicare providers. It has recently 
come to my attention that the MAC covering New Jersey is implementing a 
prior-authorization requirement for certain services, specifically 
hyperbaric oxygen therapy (HOBT). While I generally support the idea of 
prior-authorization in certain cases, the New Jersey MAC has issued an 
LCD, and further guidance on its website through a Frequently Asked 
Questions page, that is having a significant impact on beneficiaries' 
ability to receive this important therapy and that contradicts well-
established medical and scientific practices. Additionally, it appears 
that the MAC is implementing this prior-authorization differently in 
New Jersey than other MACs in other States, causing provider confusion 
and unequal access to care across the country.

    If confirmed as Administrator, will you work to provide the 
necessary oversight of MACs and other contractors to ensure the 
policies they implement are both consistent across the country and 
consistent with medical best practices?

    Answer. I will strive to do so. If confirmed, I would be pleased to 
work with you on this issue. Our goal is to offer seniors access to the 
care they need. I appreciate the need to engage in oversight to 
identify and evaluate challenges associated with MACs and LCDs more 
generally.
               children's health insurance program (chip)
    Question. Since 1997, the Children's Health Insurance Program 
(CHIP) has been essential for children and pregnant women in working 
families who cannot afford private health insurance. Today, CHIP 
provides affordable health coverage to over 8 million children and 
hundreds of thousands of pregnant women across the country. Taken 
together, CHIP and Medicaid have combined to reduce the number of low-
income, uninsured children across the country by half. At the same 
time, the program has improved health outcomes and access to care.

    As was mentioned during your hearing, the CHIP program needs to be 
reauthorized by Congress this year, and now-Secretary Tom Price stated 
that he supported an extension of up to 8 years.

    If confirmed as Administrator, will you commit to working with 
Congress to enact a long-term reauthorization of the CHIP program and 
to do so in a manner that maintains the program's success at providing 
comprehensive coverage to pregnant women and children and does not 
limit funding, coverage, access or quality?

    Answer: It is important that every child has access to high-quality 
health coverage, and CHIP plays an important role in accomplishing this 
objective. CHIP plays a major role in this, but there is also a need to 
focus on family coverage in the private market and employer plans, and 
on giving States needed flexibility. Each State has different needs, 
and I believe CMS needs to work with States to ensure that, consistent 
with those needs, the CHIP program provide possible coverage to their 
residents. If confirmed, I would work with Congress on CHIP 
reauthorization with these principles in mind.
                         home visiting programs
    Question. As you may know, evidence-based home visiting programs, 
working in conjunction with FQHCs, promote support and expand access to 
children and families, specifically those eligible for, or enrolled in, 
Medicaid. One such program is the Maternal, Infant, and Early Childhood 
Home Visitation (MIECHV) program. In 2015 alone, MIECHV provided 
services to nearly 150,000 parents and children in more than 800 
counties in all 50 States, all five territories, and the District of 
Columbia. However, coordination between MIECHV grantees and Medicaid is 
often difficult given that Medicaid is the payer of last resort in all 
cases except those with a specific exemption in law, such as what 
exists under the Maternal and Child Health Services Block Grant, 
Special Supplemental Nutrition Program for Women, Infants and Children 
and services provided as part of an Individualized Education Program or 
Individualized Family Service plan under the IDEA. Currently, MIECHV 
services do not have that explicit exemption, despite being focused on 
maternal and child health as the other exempted programs are. There has 
been no effort on the part of CMS to meaningfully address the issue of 
benefit coordination, causing confusion among service providers and 
impeding access for beneficiaries.

    If confirmed as Administrator, will you commit to clarifying the 
funding relationship between the MIECHV and Medicaid programs?

    Answer. If confirmed, I commit to working with you to better 
understand this relationship and to evaluate all options to address 
MIECHV and Medicaid issues at both the legislative and executive level 
with the goal of improving the health and well-being of mothers and 
their children.

                                 ______
                                 
   Questions Submitted by Hon. Robert Menendez, Hon. Sherrod Brown, 
 Hon. Ron Wyden, Hon. Michael F. Bennet, and Hon. Robert P. Casey, Jr.
    Question. Congress passed the Protecting Access to Medicare Act 
(PAMA) in 2014. This bipartisan law included policies to update and 
change the way Medicare reimburses clinical laboratories under the 
Clinical Laboratory Fee Schedule (CLFS), moving the reimbursements 
towards a market-based payment methodology. Under the law, all 
``applicable'' laboratories are required to report to CMS the payment 
rates and test volumes for their private payers.

    CMS finalized PAMA regulations in June 2016, and released further 
guidance in September 2016, which impose an unrealistic reporting 
timeline for laboratories. Additionally, we have heard from our 
regional and community-based laboratories about significant concerns 
they have about their ability to report accurate data and how the 
current rules' exclusion of market data from hospital outreach labs and 
definition of ``applicable laboratory'' will impact the accuracy of 
CMS's data.

    If confirmed, will you commit to looking at the current PAMA 
regulations and reporting requirements to ensure that independent, 
physician and hospital laboratories are appropriately and accurately 
accounted for in the market price data?

    Answer. I appreciate your concerns regarding the implementation of 
PAMA. Certainly, we should strive for accuracy in this market data 
collection process. It is important that patients have access to 
community-based labs. Accordingly, I look forward to closely monitoring 
challenges associated with this implementation process, while 
identifying and evaluating specific burdens that have the potential to 
limit patient access.

    Question. Further, will you commit to evaluating the need to extend 
the March 31, 2017, reporting deadline to ensure that laboratories--
especially smaller, community laboratories--are able to successfully 
collect and report the data required under the regulations?

    Answer. I look forward to following up with CMS staff and regional 
and community-based laboratories to discuss workable solutions.

                                 ______
                                 
              Questions Submitted by Hon. Thomas R. Carper
            experience with private health insurance markets
    Question. As you know, the House and the Senate recently passed 
budget resolutions to repeal the Affordable Care Act and cut Medicaid 
funding by more than $1 trillion. More than 20 million Americans gained 
health insurance as a result of the Affordable Care Act. Can you share 
your experience and background working with the individual and small 
group health insurance markets? If confirmed as Administrator of the 
Centers of Medicare and Medicaid Services (CMS), what specific actions 
will you take to ``fix'' our State insurance markets and ensure access 
to health insurance for the millions of Americans who gained coverage 
under the ACA?

    Answer. I worked with States in preparing for the changes brought 
about by the ACA including working with State insurance departments and 
reviewing and implementing ACA regulations. If confirmed as CMS 
Administrator, I will work to ensure that every State insurance 
commissioner has as much flexibility as possible to repair their 
respective insurance markets.
                                medicare
    Question. Ms. Verma, you noted in your testimony that the American 
people are tired of politics and just want their health-care system 
fixed. As you already know, we recently passed bipartisan legislation 
to reform the way Medicare reimburses physicians, moving from a fee-
for-service system to payment based on better quality and improved 
outcomes. In your experience, what kinds of reimbursement systems do 
you believe are best suited to improving health outcomes and driving 
down costs? In your opinion, what are the strengths and weaknesses of 
accountable care organizations, bundled payments, and patient-centered 
medical homes? What other types of payment reforms should be 
implemented in Medicare to improve the quality of health care while 
reducing unnecessary costs?

    Answer. We share the goal of improving Medicare by empowering 
providers to be creative and developing payment models that best suit 
the unique needs of their patients to ultimately improve patient care. 
For instance, the Medicare Access and CHIP Reauthorization Act of 2015 
(MACRA) establishes the Physician-Focused Payment Model Technical 
Advisory Committee to review proposals for physician-focused payment 
models that can ultimately be adopted by CMS. More generally, a 
fundamental principle for payment reforms is the centrality of the 
patient in the system and their ability to make choices about their 
care in consultation with their doctor and that we drive toward better 
coordination and improving quality and health outcomes.
                                medicaid
    Question. In the Healthy Indiana program, you strongly promoted the 
use of personal responsibility such as the use of co-pays and cost-
sharing for Medicaid beneficiaries. For some extremely poor Medicaid 
beneficiaries, the premiums and co-pays are just $1, which does not 
seem unreasonable. When one of these beneficiaries fails to pay their 
$1 premium, how much does Indiana spend to collect this bad debt? Do 
beneficiaries with no income through no fault of their own, for example 
if their employer goes out of business, still have to pay premiums for 
their Medicaid benefits? When Medicaid beneficiaries lose their 
Medicaid benefits because of their inability to pay their premiums and 
goes to the hospital emergency room for care, what does it cost Indiana 
and American taxpayers? Does Indiana's Medicaid program fully recoup 
the dollars spent on managing this program?

    Answer. The Healthy Indiana Plan's contribution requirements are 
not designed as a punitive measure but as a way to promote personal 
responsibility in members which has resulted in better health outcomes, 
including lower ER use, higher patient satisfaction, drug adherence and 
more primary and preventative care. Only members above the poverty line 
are at risk of losing coverage for non-payment. Where HIP members are 
locked out of coverage for 6 months for non-payment, those who fail to 
pay Marketplace premiums may have to wait until the next open 
enrollment period to regain coverage, which can be up to 9 months, 
unless they have a change in circumstance that makes them eligible for 
a special enrollment period. On the whole, HIP's non-payment policies 
for individuals above the poverty line are at least comparable, if not 
more lenient, than the policies governing the Marketplace. Moreover, 
only 5 percent of former HIP members indicated they left the program 
due to affordability issues. Additionally, more than 80% of HIP members 
have indicated they would be willing to pay more to stay in the 
program, while more than half of those who left the program due to non-
payment successfully transitioned to private health insurance coverage.
                                obesity
    Question. We know that the disease of obesity costs the health-care 
system hundreds of billions of dollars a year in needless and 
potentially unnecessary treatments. The States you have worked with, 
such as Indiana, Kentucky, Tennessee and Iowa, have some of the highest 
rates of obesity in the country. It is long past the time that CMS 
adopt an ``all-in'' approach to fighting obesity. As CMS Administrator, 
how will you seek to maximize current obesity treatment programs and 
increase the treatments available to overweight or obese patients? 
Specifically, how would you increase access to nutritional counseling 
for overweight and obese individuals in the Medicare and Medicaid 
programs?

    Answer. Obesity is a chronic condition, and I agree that it is an 
important priority for our health-care system to address this condition 
for both children and adults. We need to strengthen the relationship 
between patient and doctor in order to address this disease on the 
front end and support providers in identifying best practices as well 
as supplying technical assistance as providers address this critical 
issue.
          program of all-inclusive care for the elderly (pace)
    Question. In Medicare, Medicaid, and the private sector, we are 
seeing significant and accelerating change towards value-based care and 
reimbursement based on better quality and outcomes. Yet the Program of 
All-Inclusive Care for the Elderly (or PACE), which pioneered so many 
of the features we now seek to build into our health-care system, is 
being constrained by outdated regulations. If confirmed, what will do 
you do to ensure that CMS updates these regulations quickly to provide 
more flexibility to PACE and to expand access to this program for 
medically frail seniors?

    Answer. I look forward to reviewing the regulations currently in 
place and changes outlined in the proposed rule and working with 
Congress to eliminate any regulations that hinder efficiency or access 
to quality care.

    Question. It is important for CMS to issue a final rule that would 
update and improve the Program of All-Inclusive Care for the Elderly 
(PACE). A proposed rule to update PACE was issued in August 2016 to 
increase access to care, remove inefficiencies in the system and assure 
continuous care to many of the most vulnerable patients. An important 
change in the proposed rule would explicitly allow physician assistants 
(PAs) to be employees or contracted providers for PACE programs. While 
PAs currently provide high quality medical care and chronic care 
management to Medicare and Medicaid beneficiaries throughout the 
country, current CMS rules exclude PAs from being an employee or 
contracted provider in the PACE program. Will you continue work to 
strengthen the PACE program and ensure it is modernized in a way that 
effectively uses PAs and other health-care providers, who provide high 
quality, affordable health-care services?

    Answer. I look forward to reviewing the changes outlined in the 
proposed rule, and I agree that PAs are a vital part of our health-care 
system and should be used to provide high quality, affordable health-
care services.
                   improving the value of health care
    Question. Improving the value of health care has been a shared 
bipartisan priority for several decades, as the share of our economy 
dedicated to health care has continued to rise, but not necessarily in 
sync with the overall quality of health care and health outcomes. 
Implementation of the quality reporting and performance programs is an 
important tool for increasing the quality of health care, improving 
health outcomes and lower unnecessary costs. How will you advance 
health care quality reporting and value-based purchasing programs in 
Medicare, Medicaid, and in private health insurance plans?

    Answer. I look forward to reviewing our current quality reporting 
and performance programs to ensure that they provide the data needed to 
improve patient outcomes while not becoming so burdensome that they 
reduce providers' ability to give quality care. Ensuring transparency 
so that patients can make informed decisions about the care they 
receive is a crucial component of this and I look forward to working 
with Congress on this issue.
                     health-care costs and quality
    Question. The United States spends nearly twice as much on health 
care as other developed countries, such as Japan, but fails to provide 
insurance coverage for all Americans. Health outcomes and quality, such 
as infant mortality, preventive care, and overall lifespans, often lag 
behind other countries as well. What are three specific health-care 
programs or public health strategies utilized by other countries' 
health-care systems that you would seek to emulate in the Medicare, 
Medicaid, and private health insurance programs and how would you adapt 
them to fit demographic trends, cultural norms, and logistical 
challenges unique to the United States.

    Answer. The United States is a world leader in medical research and 
medical innovation and performs well in key health indicators, such as 
cancer survival rates. We should focus on how we can provide access to 
quality health care for all Americans with local solutions that work 
best for individual patients and their families. Data-driven decisions 
based on price and quality transparency should be afforded to American 
patients as we learn from other countries and their efforts in those 
areas.
                             affordability
    Question. For many Americans, the affordability of health insurance 
continues to be a significant barrier to accessing basic health care. 
How would you seek to increase the affordability of health insurance, 
lower insurance premiums, and reduce deductibles and co-pays, while 
also ensuring that all Americans have comprehensive, high quality, and 
dependable health insurance plans? Do you think that health insurance 
plans should be able to apply annual and lifetime limits on health 
insurance coverage?

    Answer. As this is a matter for Congress, I look forward to working 
with Congress to make sure that every American has access to affordable 
health care.
                   federally-qualified health centers
    Question. Federally-qualified health centers (FQHCs) play 
fundamental roles in communities across the United States providing 
individuals and families with access to high quality health care who 
might otherwise find access to health care to be unaffordable. How will 
you work to protect reimbursement rates to FQHCs in Medicare, Medicaid, 
and private health insurance plans? How will you work to increase the 
number of FQHCs throughout the country?

    Answer. I look forward to working with Congress to implement 
reimbursement policies that expand health-care access to all Americans 
in a wide range of health-care settings, including FQHCs, which play an 
important role in our health care safety net.
                             contraception
    Question. Do you believe that all women should have access to all 
forms of contraception and family planning services without additional 
cost? How would you seek to expand access to and increase utilization 
of contraception for all women and their families in the United States?

    Answer. Women should have the health care that they need and want. 
As we work to replace the ACA, we should build on a system that gives 
women affordable options, not mandates, and puts women at the center of 
their own health care.

                                 ______
                                 
              Question Submitted by Hon. Thomas R. Carper 
                     and Hon. Robert P. Casey, Jr.
                       nutrition and malnutrition
    Question. Improving nutrition and lowering malnutrition are two 
areas that do not receive sufficient attention in Medicare, Medicaid, 
and private health insurance quality reporting programs. For example, 
even though there are many quality measures in place for other health 
conditions, there are no measures in place relating to malnutrition. 
How do you view the role of nutrition in improving health care, and how 
do we prioritize nutrition and malnutrition care as low cost solutions 
in improving clinical health outcomes? Do you believe that nutrition/
malnutrition care should be part of the quality reporting and 
performance programs for Medicare, Medicaid, and private health 
insurance plans?

    Answer. I agree that nutrition is an important part of overall 
health, and I look forward to reviewing current reporting and 
performance programs for Medicare, Medicaid, and private health 
insurance plans to make sure that we get the data we need to improve 
health outcomes and to understand the impact of determinants of health, 
such as nutrition.

                                 ______
                                 
             Questions Submitted by Hon. Benjamin L. Cardin
           center on medicare and medicaid innovation (cmmi)
    Question. Do you support continuing the work of the Center on 
Medicare and Medicaid Innovation (CMMI) to identify alternative payment 
models (APMs) which achieve savings and improve quality of care?

    Will you allow CMMI to continue implementing the various 
demonstration projects currently underway and expand them if they prove 
successful at reducing costs without harming quality of care?

    Answer. I support innovation in whatever format it can be 
encouraged in accordance with the law. I also believe that we should 
work in partnership with the States and that CMMI demonstration 
projects should be carefully considered on criteria involving their 
scale and the voluntary nature of the respective demonstration. I look 
forward to reviewing current CMMI projects, consistent with 
congressional actions.
                 children's health coverage in medicaid
    Question. Medicaid is one of the largest and most important 
components of the Nation's health care safety net, offering a pathway 
to health coverage for low-
income and medically vulnerable Americans. In my home State of 
Maryland, over 478,000 children receive essential health care through 
the program. That's one in three children in my State who can see a 
provider when they are sick and get the preventive health screenings 
they need to stay healthy.

    I am particularly concerned about the impact of a Medicaid block 
grant or per capita cap on the program's Early Periodic Screening, 
Diagnostic, and Treatment (EPSDT) benefit, under which children 
enrolled in the program receive both regular wellness visits, 
preventive services, and coverage for all medically necessary 
treatments, for example pediatric dental care, that a child needs. In 
FY 2014, over 40 million children nationwide were eligible for EPSDT 
benefits. In Maryland, over 705,500 children were eligible for EPSDT 
benefits in 2015--more than 171,000 of whom became eligible through the 
Patient Protection and Affordable Care Act's Children's Health 
Insurance Program (CHIP)--Medicaid expansion.

    Experts contend that if Medicaid expansion is repealed, States 
would no longer be required to provide coverage of this comprehensive 
benefit for children, and/or could eliminate the requirement that EPSDT 
services be provided without a copayment.

    If confirmed as CMS Administrator, do you commit to ensuring the 
Medicaid EPSDT benefit and coverage for vital pediatric services remain 
intact for the millions of children who rely on it?

    Answer. Our goal is to ensure every single American has access to 
the coverage they want for themselves or their children and dependents, 
and children are, and will continue to be, a high-priority population 
within the Medicaid program. States are well-positioned to determine 
the most appropriate ways to ensure access to the highest quality care 
for children, which may include diagnosis and screening procedures and 
the illnesses and conditions they uncover. As this is a matter for 
Congress, I look forward to working with Congress to improve our 
Medicaid system.
                       emergency health services
    Question. The Balanced Budget Act of 1997 requires Medicaid managed 
care organizations (MCOs) and others, to cover emergency services 
without prior authorization and established a Federal ``prudent 
layperson standard.'' This standard defines an ``emergency medical 
condition'' as one that manifests itself by acute symptoms of 
sufficient severity (including severe pain) such that a prudent 
layperson, who possess an average knowledge of health and medicine, 
could reasonably expect the absence of immediate medical attention to 
result in placing the health of the individual in serious jeopardy, 
serious bodily functions, or serious dysfunction of any bodily organ or 
part.

    Do you support this Federal policy?

    Will you ensure the Centers for Medicare and Medicaid Services 
continues to enforce the prudent layperson standard for all Medicaid 
MCOs?

    Answer. If confirmed, it would be my duty to implement the law as 
passed by Congress.
                              kidney care
    Question. The 2011 revisions of the end-stage renal disease (ESRD) 
payment system stressed the importance of protecting access to all 
treatment modalities and transplant for dialysis patients in the 
Medicare program. I share the concerns of many dialysis patients in my 
State, that efforts to repeal or replace the Patient Protection and 
Affordable Care Act will limit access to the modality of their choice 
or the full scope of transplant options.

    In recent years, CMS has reduced the in-center dialysis payment 
rate to increase an add-on for home dialysis training. I support the 
ability of ESRD patients to successfully manage their disease at home 
and while it may be appropriate to increase the rate for training home 
dialysis patients, we must find a way to ensure that individuals who 
require care at dialysis centers are able to do so.

    What will your approach be to protecting access to all dialysis 
modalities, as well as transplantation?

    Answer. As this is a matter for Congress, I look forward to working 
with Congress to make sure that patients with renal disease have access 
to high quality, affordable treatment.

                                 ______
                                 
            Questions Submitted by Hon. Benjamin L. Cardin 
                          and Hon. Bill Nelson
    Question. The 21st Century Cures Act, which was recently enacted 
into law, includes a provision I authored with Senators Crapo and 
Nelson, which requires Medicare Advantage (MA) plans to accept 
individuals with end-stage renal disease (ESRD). Federal law concerning 
when Medicare Supplemental Insurance carriers (Medigap) must be offered 
to individuals, does not require insurers to offer plans to people 
under the age of 65, including those with ESRD (although some States do 
require this).

    Do you believe that Medigap coverage should similarly be extended 
to those under the age of 65, including individuals with ESRD?

    Answer. As this is a matter for Congress, if confirmed, I will 
implement the laws passed by Congress and I look forward to providing 
any technical assistance which might be needed as Congress considers 
reforms.
                                medicare
    Question. People under the age of 65 with disabilities generally 
have a 2-year waiting period from when they first start receiving 
Social Security Disability Insurance (SSDI) before they are eligible 
for Medicare coverage. The Patient Protection and Affordable Care Act 
(ACA) provided an important protection for people in this waiting 
period who otherwise could not obtain coverage. If the ACA is repealed, 
do you think these individuals should be forced to again fend for 
themselves until Medicare coverage kicks in?

    Answer. As this is a matter for Congress, if confirmed, I will 
implement the law as passed by Congress.
                               notice act
    Question. With our growing, aging population, Medicare must evolve 
to meet the country's most pressing health-care demands. One issue 
we've started to address is hospital observation status for Medicare 
beneficiaries. Often, Medicare beneficiaries who receive care in 
hospitals, even for several days, may be surprised to learn that they 
have not actually been admitted as inpatients. Instead, these patients 
are classified as ``observation status'' or outpatients.

    Observation status is particularly concerning for Medicare 
beneficiaries who may require skilled nursing facility (SNF) care after 
being discharged from the hospital. Currently, Medicare only covers SNF 
care for patients who have a 3-day inpatient hospital stay.

    Do you believe that seniors deserve to know when their hospital 
care is classified as ``observation status''?

    Answer. If confirmed, I look forward to working with Congress to 
ensure that seniors have the information available to make the best 
decisions about their care, including CMS's implementation of the 
NOTICE Act, which requires hospitals to notify patients of their 
observation status.

    Question. Last Congress, my colleague Senator Enzi and I introduced 
the Notice of Observation Treatment and Implication for Care 
Eligibility (NOTICE) Act, which became law in December 2015. This 
legislation requires hospitals to give each Medicare patient who 
receives observation services as an outpatient for more than 24 hours 
an adequate oral and written notification within 36 hours.

    In December 2016, CMS finalized the NOTICE Act rule requiring 
hospitals to give patients the standardized Medicare Outpatient 
Observation Notice (MOON) beginning March 8, 2017. CMS anticipates that 
more than 1 million patients will receive the MOON annually.

    Will you commit to implementing this final rule to ensure that 
seniors are able to make informed health-care decisions?

    Answer. If confirmed, I look forward to reviewing that rule to make 
sure that CMS acts in accordance with Federal law and to working with 
you on any concerns you may have.

                                 ______
                                 
            Questions Submitted by Hon. Benjamin L. Cardin 
                        and Hon. Debbie Stabenow
                              oral health
    Question. Oral health and related illnesses have a significant 
impact on the severity of chronic diseases, which are the most 
burdensome for older people and people with disabilities, and costly 
for the Federal Government. The serious health risks and costs 
associated with untreated oral disease are increasingly apparent. For 
example, because they heighten the risk of systemic infection, 
unresolved oral health problems can preclude, delay, and even 
jeopardize the outcome of medical treatments such as organ and stem 
cell transplantation, heart valve repair or replacement, cancer 
chemotherapies, and placement of orthopedic prostheses. The 
relationship between periodontal disease and chronic conditions such as 
diabetes, arthritis, and heart disease is also well established.

    While Medicare statue precludes coverage of ``routine'' dental 
services, would you agree that untreated oral health problems, in these 
examples at least, would be medically necessary rather than 
``routine''?

    Answer. If confirmed, I will review what services have been 
classified as ``routine'' and what services have not.

    Question. Are you committed to using your authority as the CMS 
Administrator to ensure that Medicare covers medically necessary oral 
health care, as currently allowed by the statute?

    Answer. If confirmed, it will be my duty to follow Federal law 
including the implementation of laws related to Medicare Advantage 
plans which can provide quality oral health care.

    Question. Will you commit to evaluating proposals to expand oral 
health coverage for Medicare beneficiaries more broadly?

    Answer. I would be happy to evaluate any proposal that will lead to 
affordable, high quality health care.

                                 ______
                                 
             Questions Submitted by Hon Benjamin L. Cardin 
                       and Hon. Thomas R. Carper
         program for all-inclusive care for the elderly (pace)
    Question. Johns Hopkins has been on the forefront of innovative 
care for the most fragile and complex individuals. The Program for All-
inclusive Care for the Elderly (PACE) is widely recognized as the gold 
standard for fully-integrated, comprehensive care. Researchers have 
shown that the community-based, comprehensive and accountable care 
offered by PACE delivers quality care, improved health, and value for 
the health-care system. For over 30 years, regulations have limited the 
population served by the program.

    Given our growing, aging population, would you please describe in 
detail how you plan to enhance the successful work of PACE and other 
models to ensure that frail elderly patients who want community-based 
care, as opposed to institutional care, can get it.

    Answer. I look forward to working with the staff at CMS to get 
their input on how we can better serve our aging population as we 
implement PACE or other related policies enacted by Congress.
                            payment reforms
    Question. Patients, providers, as well as public and private payers 
benefit when valid, reliable, and risk-adjusted scientific measures are 
used to assess functional outcomes, support evidence-based clinical 
decision-making, and measure quality. Using these tools also assures 
the best value for dollars spent. Under your leadership will CMS 
continue to pursue further expansion of the Merit Based Incentive 
Payment System (MIPS) to other eligible providers such as physical and 
occupational therapists?

    Answer. I look forward to working with providers to implement MACRA 
as designed by Congress. I will work with the staff at CMS and 
providers to evaluate whether the MIPS program is achieving Congress's 
goals while ensuring that the impact on patients and the providers who 
care for them are at the center of any future reform efforts. It is 
especially important that we carefully consider feedback from providers 
on the frontlines of health care, especially those smaller providers or 
those providers in rural settings.
                           prescription drugs
    Question. The Patient Protection and Affordable Care Act's numerous 
patient protections have greatly helped beneficiaries, especially those 
living with chronic and serious health conditions such as HIV/AIDS and 
hepatitis, access the care they need to stay healthy. Of particular 
importance to the patients I represent, the regulations implementing 
the law's Essential Health Benefits (EHBs) and Non-discrimination 
provisions require health plans to use Pharmacy and Therapeutics 
committees to develop and regularly update their formularies; cover a 
minimum number of drugs in each therapeutic class; provide cost-
sharing, tiering, and utilization management information to enrollees 
and potential enrollees; have an exceptions and appeals process for 
accessing non-formulary drugs; and design and implement their benefits 
in a way that does not discriminate against or discourage enrollment by 
individuals living with particular health conditions.

    As CMS administrator, would you ensure that the critical patient 
protections afforded by the ACA remain and are enforced at the Federal 
level?

    Answer. If confirmed, it will be my duty to implement the laws 
passed by Congress and I look forward to evaluating the impact on 
patients and working with you to ensure patients are able to access 
high quality care.

                                 ______
                                 
 Questions Submitted by Hon. Benjamin L. Cardin, Hon. Robert P. Casey, 
                                 Jr., 
                         and Hon. Sherrod Brown
                              therapy caps
    Question. As you may know, limits on outpatient rehabilitation 
therapy services under Medicare were first imposed in 1997 as part of 
the Balanced Budget Act without regard to its impact to access on 
needed therapy services. Congress has acted several times to prevent 
the caps from going into effect by passing moratoria. Later in 2006, 
Congress created an ``exceptions process'' for beneficiaries whose 
conditions required more care than the annual limits would allow and at 
the end of 2015 year, Congress again extended the exceptions process by 
1 year. The current therapy cap for occupational therapy (OT) is $1,920 
and the combined cap for physical therapy (PT) and speech-language 
pathology services (SLP) is $1,920.

    What is the impact on seniors that hit the cap?

    Answer. If confirmed, I look forward to looking into the impacts of 
these statutory caps on seniors. It may be that other approaches to 
therapy provide greater quality care at reduced cost with more respect 
for the individual needs of each patient in consultation with their 
doctor. If confirmed, I will look at our Medicare system holistically 
to make sure that we are delivering access to quality, affordable 
health care to our citizens.

    Question. Do you support repealing the Medicare cap on therapy 
services?

    Answer. If confirmed, I look forward to working with Congress on 
this issue and providing technical assistance that you or others 
interested in Medicare therapy caps may need.

                                 ______
                                 
               Questions Submitted by Hon. Sherrod Brown
           medicaid expansion and addiction treatment in ohio
    Question. Your consulting firm, SVC, has played a role in 
developing Medicaid waiver proposals for a number of States including 
Ohio's proposal, the Healthy Ohio Program, last year.

    As you know, CMS denied Ohio's waiver application, citing concern 
that monthly premiums and late payment penalties would ``not support 
the objectives of the Medicaid program, because (they) could lead to a 
substantial population without access to affordable coverage.''

    At a time when Ohio is at the height of an opioid epidemic, it is 
important to maintain coverage and access to care for the more than 
500,000 Ohioans receiving mental health and addiction treatment through 
Medicaid--including more than 150,000 who now have coverage through 
Medicaid expansion.

    When Ohio submitted its waiver plan, data included in its 
application estimated that the policies proposed would lead to more 
than 125,000 Ohioans losing coverage.

    Given the opioid epidemic across the Nation and the critical role 
Medicaid plays in helping individuals access needed care, including 
medication assisted treatment, it is critical that the Administrator of 
CMS evaluate State waiver requests to ensure that no individual 
struggling with addiction or a mental health condition loses coverage 
or access to affordable coverage.

    Would you approve a State's Medicaid waiver request if the 
resulting waiver would result in a loss of coverage or access to 
coverage for individuals struggling with addiction or other mental 
health conditions--``yes'' or ``no''?

    Answer. To the extent I am not required to recuse from a particular 
matter under the terms of my Ethics agreement, I will carefully review 
any waivers on a case-by-case basis. I will consider all factors as 
required by law including evaluating the State's waiver request to 
ensure that all individuals struggling with addiction or a mental 
health condition continue to have access to treatment.

    Question. If confirmed, will you continue to support innovative 
models to improve treatment outcomes for individuals seeking addiction 
treatment, such as through the 1115 waivers, home health models, and 
the Innovation Accelerator Program?

    Answer. To the extent I am not required to recuse from a particular 
matter under the terms of my Ethics agreement, I will support 
effective, best practice, innovative treatment models. Opioid addiction 
has had a severe and devastating impact on communities and families 
across the country. If confirmed, I am committed to working with States 
to protect access to treatments and help low-income adults with mental 
health and substance use disorders through existing and evidence-based 
innovative solutions for these problems. To the extent I am not 
required to recuse from a particular matter under the terms of my 
Ethics agreement, I will work with States to ensure that access to 
treatment is not diminished.
                      infant mortality and tobacco
    Question. Ohio has one of the highest infant mortality rates in the 
country. In 2015 our State ranked 42nd in the Nation for infant 
mortality, and even worse for African American babies.

    We don't know exactly why Ohio does so poorly when it comes to 
infant mortality, but one thing that we do know is that health 
complications caused by preterm births are the leading causes of infant 
mortality.

    We also know that a major factor in premature births is tobacco 
use, and Ohio's smoking rate among pregnant women is nearly twice the 
national rate.

    In addition to providing coverage to an additional 20 million 
Americans, the Affordable Care Act also strengthened Medicaid coverage 
of services that help tobacco users to quit. Local groups have taken 
advantage of these provisions in their fight against infant mortality.

    Medicaid covers nearly 50% of births in this country.

    Do you support the current requirement that State Medicaid programs 
provide pregnant women with effective tobacco cessation services 
without cost sharing--``yes'' or ``no''?

    Will you work within the administration and with Congress to 
maintain this requirement so that all pregnant women--regardless of 
their income--have access to tobacco cessation services--``yes'' or 
``no''?

    Answer. The science is clear that tobacco use during pregnancy is 
risky for both moms and babies. States should have maximum flexibility 
to prioritize critical health risks such as smoking during pregnancy. 
The decision to maintain this requirement, however, is a legislative 
matter that rests with Congress.
                       fair pay/homecare workers
    Question. The majority of the home care workforce--or those 
individuals who provide services to older Americans and individuals 
with disabilities who receive home and community-based services through 
Medicaid--is made up of female workers.

    If confirmed as CMS Administrator, will you commit to working with 
your colleagues at the Department of Labor to support and advance 
policies to ensure women across the health-care workforce and 
reimbursed by CMS are paid fairly--and treated equally as compared to 
their male counterparts--regardless of their job--``yes'' or ``no''?

    The homecare workforce is primarily paid through Medicaid and, on 
average, States pay these workers just $13,000 a year. This means that 
those women caring for the disabled and elderly are often forced to 
rely on Medicaid themselves.

    In order to provide the highest level of quality care to our most 
vulnerable Americans--the elderly and those with disabilities--do you 
agree that those home care workers providing this care full-time should 
be paid more than $13,000 a year by their State Medicaid program--
``yes'' or ``no''?

    Past leadership at CMS committed in writing to exploring Federal 
actions under its current authority that could work with States to 
strengthen and support home care workers. It is important to me that 
this issue remain a priority for the current administration.

    If confirmed, will you commit to continuing this work to ensure 
fair pay and advancement opportunities for the home care workforce--
``yes'' or ``no''?

    Answer. I firmly believe that women should be compensated based on 
their ability and their contribution to the workforce, not based on 
their sex. If confirmed, I look forward to working with HHS and CMS 
staff as well as the Department of Labor to evaluate these important 
issues.
                                 epsdt
    Question. The Early and Periodic Screening, Diagnostic, and 
Treatment (EPSDT) benefit became an additional benefit for children in 
the Medicaid program in 1967. The EPSDT benefit establishes guidelines 
which ensure unlimited access to medically necessary, age-appropriate 
screenings and preventive care for children, including well-child 
exams.

    Providing preventive care services through EPSDT is essential for 
ensuring that every child has the opportunity to become a healthy 
adult. Are you committed to maintaining existing standards for child 
health care in the Medicaid program?

    Are you committed to ensuring that States enforce EPSDT so that 
children are able to access the services they need?

    One major threat to the EPSDT benefit and the health of children in 
this country is the possibility of restructuring Medicaid into a block 
grant or per capita cap, proposals which you have supported.

    If confirmed, can you guarantee that you will uphold the current 
standards of coverage, affordability, and especially of pediatric-
appropriate benefits for children through the Medicaid program?

    Answer. Our goal is to ensure every single American has access to 
the coverage they want for themselves or their children and dependents, 
and children are, and will continue to be, a high-priority population 
within the Medicaid program. States are well-positioned to determine 
the most appropriate ways to ensure access to the highest quality care 
for children, which may include diagnosis and screening procedures and 
the illnesses and conditions they uncover. As this is a matter for 
Congress, I look forward to working with Congress to improve our 
Medicaid system.
                      epsdt lead testing standards
    Question. One important provision in the EPSDT benefit is screening 
and testing for lead poisoning. More than a half a million children 
between the ages of 1 and 5 are estimated to have blood lead levels 
above the level at which the CDC recommends public health actions be 
taken.

    Despite these numbers, millions of at-risk children are never 
screened and tested for high lead levels despite early childhood lead 
screening and testing requirements. In fact, a Reuter's investigation 
last year found that less than half of the 1- and 2-year-olds enrolled 
in Medicaid--just 41 percent--are tested for lead exposure as required.

    Last year, I was the lead author of a letter sent to CMS with more 
than 40 of my Senate colleagues to urge the agency to improve lead 
screening and testing across at-risk communities and do everything it 
can to help health-care providers quickly identify and track children 
who have been exposed to lead.

    Administrator Slavitt responded positively to that letter, and CMS 
put out an informational bulletin at the end of the year to help States 
improve their screening rates.

    If confirmed as Administrator of CMS, what specific next steps will 
you take to improve blood lead testing covered by the Medicaid program 
and ensure adherence to the EPSDT benefit for both screenings and 
follow-up treatment services?

    Answer. The Flint water crisis has highlighted the inherent dangers 
of lead poisoning and the importance of avoiding such exposure 
particularly for the young, elderly, and infirm. If confirmed as CMS 
Administrator, I look forward to working with my CMS colleagues to 
learn more about potential deficiencies in the EPSDT's lead testing 
standards and potential solutions for such problems.
                   preventive services with medicare
    Question. As you know, the ACA eliminated cost-sharing for 
preventive services covered under Medicare. Since the change took 
effect in 2011, Ohio seniors have benefited from access to life-saving 
screenings and wellness visits at no cost to them. In fact, more than 
885,000 Ohio seniors had at least one preventive Medicare service in 
2015.

    Are you in favor of repealing the ACA provisions that expanded 
cost-free preventive services in Medicare? If so, do you acknowledge 
that this will increase Medicare beneficiaries' out of pocket expenses?

    Which preventive services that are currently provided to Medicare 
beneficiaries without any copay do you believe should continue to be 
offered at no out-of-pocket cost?

    Considering President Trump's executive order to ``ease the 
burden'' of the ACA, how will you ensure that Medicare beneficiaries do 
not lose coverage of services they have relied upon--and in some cases, 
services that have saved lives--for the last 6 years?

    Answer. Should I be confirmed as Administrator of CMS, my duty will 
be to execute the law as passed by Congress and signed by the 
President. Ultimately, the question of ACA repeal is a legislative 
matter for Congress to decide.
                    medicare advantage under the aca
    Question. Your history in Indiana shows an interest in expanding 
the use of private insurance in the Medicaid space. This option is 
increasingly utilized in Medicare through Medicare Advantage plans. 
Previously, Medicare Advantage plans paid over 110% of the cost of a 
service compared to traditional Medicare spending, but this provision 
was removed through the ACA. If the ACA is repealed, it is assumed that 
these spending differences would be re-instated.

    Do you believe that Medicare Advantage plans should be paid more 
than what traditional Medicare spends on a given patient? Why or why 
not?

    Will you support or allow unequal reimbursement as compared to FFS 
Medicare through overpayments by CMS to Medicare Advantage plans?

    What will you do to ensure taxpayer dollars are utilized 
appropriately under the Medicare program when it comes to parity 
between FFS Medicare and MA?

    Answer. Medicare Advantage provides an important option for 
Medicare beneficiaries to access coordinated care and greater benefits. 
If confirmed as CMS Administrator, I would seek to ensure Medicare 
Advantage remains a stable option for beneficiaries and that Medicare 
Advantage issuers are afforded the flexibility to design plans that 
beneficiaries want and give them the coverage they want. It is my 
intention to fairly and accurately monitor the quality and 
effectiveness of our entire care system, including Medicare Advantage 
and original FFS Medicare.
                   medicare advantage bill of rights
    Question. As you know, the Medicare Advantage population is 
approaching one-third of all Medicare enrollees, and continues to grow. 
Last month, CMS published a review of more than 50 Medicare Advantage 
organizations that showed widespread inaccuracies in their provider 
directories published online.

    Inaccuracies ranged from listing the wrong location for a provider 
to including providers who were not accepting new patients even though 
the website said they were. This is a clear problem for an increasing 
number of consumers that should be addressed.

    If confirmed, what tools will you use to hold Medicare Advantage 
plans responsible for complying with program rules?

    Since oversight is one of the primary responsibilities of the 
Administrator for CMS, what specific proposals do you have to 
strengthen consumer protections in Medicare Advantage?

    In addition to getting away with publishing inaccurate provider 
directories, Medicare Advantage plans can also drop providers mid-year 
without warning their beneficiaries.

    That's why I have previously introduced legislation, the Medicare 
Advantage Bill of Rights, to prohibit Medicare Advantage from dropping 
providers without cause mid-year. It would also require Medicare 
Advantage plans to finalize their provider networks 60 days before open 
enrollment so that patients have the information they need before 
signing up for a plan. This fix does not require legislation. CMS can 
actually make this change on its own.

    Will you commit to strengthening beneficiary protections in 
Medicare Advantage by ensuring Medicare Advantage insurers are 
prohibited from dropping providers mid-plan year without cause?

    Answer. Medicare Advantage provides an important option for 
Medicare beneficiaries to access coordinated care and greater benefits. 
CMS should always make sure that seniors are in the driver's seat of 
their health care and have necessary, timely, and accurate information 
to make health-care decisions. Oversight is an important responsibility 
of CMS. If confirmed as CMS Administrator, I would seek to ensure 
Medicare Advantage plans comply with regulations and laws to ensure it 
remains a stable option for beneficiaries and that Medicare Advantage 
issuers are afforded the flexibility to design plans that beneficiaries 
want and give them the coverage they want.

    I would also look forward to working with my CMS colleagues to 
learn more about the options for strengthening beneficiary protections 
in Medicare Advantage, including improving the accuracy of provider 
directories. I welcome recommendations, particularly those that are 
evidence-based, that would achieve these results.

                                 ______
                                 
               Question Submitted by Hon. Sherrod Brown 
                          and Hon. Rob Portman
                           nursing education
    Question. The demand for nurses is on the rise, and the Bureau of 
Labor Statistics estimates that the United States will face a 1.2 
million nurse shortage by 2020. Ohio is home to 12 hospital-based 
nursing programs that receive Medicare pass-through funding for nursing 
education, which will help supply qualified professionals to meet the 
demands for the growing nursing workforce. Unfortunately, these 
hospital-based institutions are in jeopardy as they face competing 
qualifications between CMS's regulations and evolving accreditation 
requirements.

    To combat this threat to the funding of nursing education, we have 
introduced legislation in past Congresses--the MEND Act--which would 
simply ensure continued CMS support of nursing education through pass-
through funding at hospital-based nursing schools.

    If confirmed, will you commit to working with us on ways to ensure 
these institutions do not lose access to their pass-through funding, 
both through administrative action and through working with legislators 
to craft and quickly implement a solution that will allow for the 
continued education of nurses at hospital-based nursing programs?

    Answer. I look forward to working with you on this issue to share 
feedback and technical assistance on policies relating to nursing 
education funding, which has a broad geographic scope and impact. If 
the laws on the issue are enacted, and if confirmed, I will work to 
implement the laws on the timeline Congress imposes.

                                 ______
                                 

   Questions Submitted by Hon. Sherrod Brown, Hon. Robert Menendez, 
 Hon. Michael F. Bennet, Hon. Robert P. Casey, Jr., and Hon. Ron Wyden
                     laboratory payments under pama
    Question. Congress passed the Protecting Access to Medicare Act 
(PAMA) in 2014. This bipartisan law included policies to update and 
change the way Medicare reimburses clinical laboratories under the 
Clinical Laboratory Fee Schedule (CLFS), moving the reimbursements 
towards a market-based payment methodology. Under the law, all 
``applicable'' laboratories are required to report to CMS the payment 
rates and test volumes for their private payers.

    CMS finalized PAMA regulations in June 2016, and released further 
guidance in September 2016, which impose an unrealistic reporting 
timeline for laboratories. Additionally, we have heard from our 
regional and community-based laboratories about significant concerns 
they have about their ability to report accurate data and how the 
current rules' exclusion of market data from hospital outreach labs and 
definition of ``applicable laboratory'' will impact the accuracy of 
CMS's data.

    If confirmed, will you commit to looking at the current PAMA 
regulations and reporting requirements to ensure that independent, 
physician and hospital laboratories are appropriately and accurately 
accounted for in the market price data? Further, will you commit to 
evaluating the need to extend the March 31, 2017, reporting deadline to 
ensure that laboratories--especially smaller, community laboratories--
are able to successfully collect and report the data required under the 
regulations?

    Answer. Accuracy in reporting and data collection is essential for 
a market to thrive. In this case, we should certainly strive for 
accuracy in this market data collection process. I look forward to 
following up with CMS staff and regional and community-based 
laboratories to discuss workable solutions.
                             cds under pama
    Question. In addition to the issue in my previous question related 
to PAMA, I have heard from Ohio constituents who have concerns over the 
clinical decision support (CDS) mechanisms included in PAMA as it 
relates to advanced diagnostic imaging tests for Medicare Part B, 
including the use of appropriate use criteria (AUC) in the decision-
making process. I have heard concerns that CMS's new regulation 
threatens PAMA by putting severe limitations on the diagnostic imaging 
provision by limiting CDS to just 8 priority clinical areas (PCAs).

    Given your knowledge and previous work with CDS, if confirmed, will 
you work to implement CDS as fully intended by Congress? What specific 
actions will you take to ensure uptake of CDS in all PCAs?

    Answer. If confirmed as CMS Administrator, I would have a duty to 
implement laws as passed by Congress.
                                dir fees
    Question. In your hearing, you mentioned that Pharmacy Benefit 
Managers (PBMs) are negotiating prices for Part D, and you're glad that 
they do. I think that more can be done to negotiate lower drug prices 
for our seniors, and there is a lack of transparency with the status 
quo. This lack of transparency and limited capacity to negotiate 
results in higher costs for consumers and can result in significant 
challenges for small community pharmacies and long-term care 
pharmacies. These pharmacies are facing increased uncertainty because 
of Direct and Indirect Remuneration (DIR) fees imposed by PBMs.

    CMS has recognized some of these issues, and in January released a 
fact sheet showing that the use of DIR fees by Part D sponsors has been 
``growing significantly in recent years'' and has led to an increase in 
beneficiary cost-sharing, an increase in subsidy payments made by 
Medicare, and an overall decrease in plan liability for total drug 
costs.

    What role do you believe retroactive DIR fees have on exacerbating 
closures and consolidation across the delivery system?

    If confirmed, what specific steps would you take to improve 
transparency between plans and pharmacies in the use of DIR fees in the 
Medicare program?

    Would you make it a priority to re-visit the September 2014 
proposed guidance (Proposed Guidance on Direct and Indirect 
Remuneration and Pharmacy Price Concessions) to standardize the timing 
of how these fees are reported, that has not yet been finalized?

    Answer. If confirmed, I will welcome the opportunity to work with 
Congress and all stakeholders, including small community pharmacies and 
long-term care pharmacies, to preserve seniors' access to drugs. 
Additionally, I look forward to working with you to consider how to 
resolve this pending guidance issue. I would be happy to discuss the 
September 2014 Proposed Guidance on Direct and Indirect Remuneration 
and Pharmacy Price Concessions and other related issues with you.
                            provider status
    Question. It is estimated that by 2020, the United States will face 
a shortage of more than 91,000 doctors, which will be particularly 
painful in rural underserved areas like we have in Ohio and you in 
Indiana. I am an original cosponsor on a recently introduced 
bipartisan, bicameral bill, the Pharmacy and Medically Underserved 
Areas Enhancement Act, which would recognize pharmacists as providers 
in the Medicare program. This would allow pharmacists to serve 
beneficiaries in underserved areas by utilizing their advanced 
education, training, and consultation abilities to provide many 
Medicare services in addition to their essential role in administering 
and educating patients about their prescription medications.

    As CMS Administrator, what will you do to support the utilization 
of pharmacists to their full scope as a way to improve access to care 
and keep costs low for Medicare beneficiaries in underserved areas?

    Answer. If confirmed, I would be open to various solutions to 
address the impact of the ongoing physician shortage in underserved 
areas. Where permitted by law, I would consider the possibility that 
paying pharmacists in rural areas to engage in certain medical services 
could work well in those States where pharmacists have such licensure 
and a setting appropriate for the services, where primary care doctors 
continue to be involved in care, and where there is a patient and 
consumer demand for such services.
                           observation status
    Question. During your hearing, I tried to engage you on the issue 
of observation status for Medicare beneficiaries. As I mentioned, the 
NOTICE Act will initiate MOON notice requirements in just a couple of 
weeks, but this legislation does not address the underlying problem 
imposed by the 3-day stay rule.

    To follow up from the hearing, I hope you have had time to review 
the obstacles facing our seniors' access to affordable care in SNFs 
under current regulations. My Improving Access to Medicare Coverage 
Act, which I plan to reintroduce next month, would enable time that 
beneficiaries spend in the hospital under observation to count toward 
the 3-day requirement for Medicare coverage. I appreciate that you are 
willing to work with me on this huge issue for Ohioans, and hope that 
you will support my legislative efforts with this reintroduction.

    Have you had time to review this provision of law and provide some 
suggestions on ways to improve this issue for Medicare beneficiaries?

    Should you be confirmed, will you commit to swiftly issuing an 
opinion on CMS's authority in this regard?

    If confirmed, will you work to administratively correct this 
billing technicality that adversely impacts Medicare beneficiaries and 
work with Congress to correct this issue via legislation, if necessary?

    Answer. If confirmed, I will monitor the implementation of the 
NOTICE Act and the utilization of the Medicare Outpatient Observation 
Notice (MOON). I will also work to identify if more may need to be done 
with regard to this observation status issue to improve seniors' access 
to care in SNFs. And if the best path forward involves legislation, I 
would be pleased to work with you and provide technical assistance on 
that as well.
                   medicaid and chip quality of care
    Question. Over a decade ago, Congress enacted legislation to begin 
shifting the metrics in our health system away from paying for volume 
to paying for quality and safety. In recent years, this shift towards 
quality has shown improvement in important areas like rates of hospital 
acquired infections and hospital readmission.

    However, there is still much work to be done, especially for our 
most vulnerable populations. That's why I have introduced the Medicaid 
and CHIP Quality Improvement Act (MCQA) in past Congresses, to 
encourage data collection and define quality assessments for the more 
than 80 million Americans who currently receive care through these 
programs with no structured quality measures.

    I know that you understand the value of quality measures and 
holding States accountable for improving quality for Medicaid 
beneficiaries. I also know that you understand how collecting data for 
quality assessments of the Medicaid and CHIP populations is 
tremendously challenging given the wide variation across States.

    Do you believe that Congress and the administration should know the 
defined quality of care that State Medicaid and CHIP programs are 
delivering for that investment?

    Answer. Yes, and we should hold States accountable for achieving 
outcomes. To this end, we must ensure that State Medicaid programs are 
not beset by unnecessary administrative burdens that could impede 
progress on achieving this goal.

    Question. Would you be willing to work with Congress to try to 
implement and improve quality measurements for these vulnerable 
Americans across different structures and delivery mechanisms of the 
program?

    Answer. Yes. If confirmed as CMS Administrator, ensuring high-
quality care in Medicaid and CHIP will be one of my top priorities.
                        medicare quality of care
    Question. If confirmed, as Administrator of CMS, you would also 
have authority over the Medicare program and its budget of close to 
$600 billion dollars. This includes the ability to enact regulations 
and establish guidelines for reporting requirements.

    How would you specifically encourage collaboration between the 
Federal Government and individual States to identify program standards 
and incentives in Medicare programs?

    Some plans, including my MCQA legislation, champion incentivizing 
State performance in quality metrics. How would you oversee any such 
incentives programs?

    Answer. The States are well positioned to provide for the unique 
health-care needs of their residents. If confirmed, I would work to see 
that CMS is a helpful resource to the States. CMS can offer clarity 
regarding State flexibility, technical assistance, and provide support 
as needed to promote effective policies and practices.
                             accountability
    Question. In your work with SVP you have worked with States to 
craft Medicaid programs that require beneficiaries to pay premiums and 
potentially lock individuals out of coverage if they do not pay. Your 
website states that you have developed reform programs and waivers for 
other States, including Kentucky.

    Last year, Kentucky Governor Matt Bevin submitted a proposal 
modeled on Indiana's Medicaid expansion waiver that would go even 
further than Indiana's proposal by instituting a work requirement as a 
condition of eligibility for some beneficiaries. CMS has not approved 
this waiver, and has stated that work requirements are not consistent 
with the original intent of the Medicaid program or consistent with 
Federal Medicaid law.

    Studies have shown that the main effect of work requirements likely 
would be the loss of health coverage for substantial numbers of people 
who are unable to work or face major barriers that prevent them from 
holding part-time or full-time employment. Additionally, State Medicaid 
agencies would be stretched just covering the basic costs of 
administering and enforcing these requirements.

    As CMS Administrator do you plan to uphold the agencies previous 
decisions of not approving work requirements under Federal Medicaid 
law?

    Do you believe a child should be held responsible--and potentially 
lose health insurance coverage--if their parent does not pay a Medicaid 
premium or participate in a work requirement as required under some of 
the programs you have helped draft?

    Answer. Studies have confirmed the value of work to individual 
health and sense of well-being, and Medicaid has an historic role as 
part of a broader anti-poverty effort. If confirmed, I look forward to 
working with States to consider innovative strategies that improve 
outcomes. Every potential policy should consider the impact on the 
different Medicaid populations, while ensuring appropriate protections 
are in place for vulnerable populations like children.
                                  cmmi
    Question. As acknowledged during both your and Secretary Price's 
testimonies, CMMI is an important tool that exists within CMS for the 
testing and development of new, patient-centric, value-based payment 
models. These models will be critical to informing the future of care 
delivery.

    Are you committed to preserving CMMI?

    Answer. If confirmed, I plan to work with the Secretary to ensure 
that CMMI, or the ``Innovation Center,''--after consultation with 
Congress, the States, health-care stakeholders, and Innovation Center 
staff--tests appropriate innovative models that reduce costs and 
improve quality for Medicare and Medicaid beneficiaries. As such, I 
look forward to reviewing current CMMI projects, consistent with 
congressional actions.

    Question. How do you plan to involve both stakeholders and Congress 
in the development and implementation of models?

    Answer. Stakeholder engagement is crucial in the development of 
innovative models. For instance, the Medicare Access and CHIP 
Reauthorization Act of 2015 (MACRA) establishes the Physician-Focused 
Payment Model Technical Advisory Committee, to review proposals for 
physician-focused payment models that can ultimately be adopted through 
the Innovation Center. Communication and collaboration with Congress 
and stakeholders throughout the process is a major priority as CMS 
moves forward with implementing the law and fostering innovation.
                dual eligibility/cmmi/medicare standards
    Question. ASPE recently released a report that concludes dual 
status is one of the most powerful predictors of outcomes and that, 
with time, outcomes can be improved.

    What additional actions can and should CMS take to do more to help 
support programs and the integration of Medicare and Medicaid for 
duals?

    Answer. Sound integration between Medicare and Medicaid requires 
that regulations and administrative processes properly align. If 
confirmed, I will work to ensure that CMS continues to make progress in 
this area.
                 medicare/health system transformation
    Question. As Congress and the administration work to incentivize 
new models of care, it is important that we collect information from 
States and providers to help inform policy decisions and ensure quality 
and access.

    If confirmed, how will you ensure CMS is monitoring beneficiary 
access to care across new delivery system models? What factors will you 
use to measure access to care?

    Answer. Our goal is to ensure access to affordable, quality health 
care for all Americans, including individuals in rural or underserved 
areas. Accordingly, the best metric in the end is one that measures the 
extent of access to actual care, not just coverage, and the quality of 
that care as determined by patients working individually with their 
doctors. I look forward to partnering with States to best determine the 
real-life impact of health-care policy at the local level. We must hold 
States and providers accountable for enabling access to quality care.

    Question. If beneficiary access is hindered, how do you envision 
addressing these issues and ensuring access to care?

    Answer. I intend to work expediently with the Congress, the 
Secretary and CMS colleagues to strive for improved access to care, 
especially when access to care may be threatened. Our decisions must be 
data-driven and made with a focus on addressing the unique needs of the 
patients in question.

    Question. What advocacy organizations--and specifically consumer 
groups--will you engage in evaluating these alternative payment models 
throughout the stages of development and implementation?

    Answer. I appreciate feedback across the health-care industry to 
ensure workable payment models are being pursued. Organizations that 
represent consumer groups are especially important to engage with to 
understand the impact of the models on beneficiary care, both on the 
front end and throughout the development and implementation of the 
models.

    Question. How will you ensure CMS hears directly from impacted 
beneficiaries and resolves issues immediately so that access is not 
affected?

    Answer. The fundamental metric for knowing that our system is on 
the right track is the centrality of the patient in the system and 
their ability to make choices about their care in consultation with 
their doctor. Restrictions on access to care threaten this principle 
and ought to be swiftly examined. I look forward to working with CMS to 
ensure we have an open line of communication with beneficiaries.
           out-of-pocket protections for medicare population
    Question. Seniors are often on fixed incomes, and their yearly 
income certainly does not grow at the rate of medical inflation, 
however, out-of-pocket costs as a share of income continues to rise for 
Medicare beneficiaries each year. While the ACA helped protect 
Americans from caps on annual and lifetime out-of-pocket caps, this 
consumer protection does not exist for Medicare beneficiaries.

    What will you do, if confirmed, to help keep costs low for 
beneficiaries and protect seniors on fixed incomes from growing out-of-
pocket costs?

    Answer. I would convey to Medicare beneficiaries that I look 
forward to working with Congress to make certain that we preserve and 
strengthen Medicare for seniors.
                     medicare 2-year waiting period
    Question. As I'm sure you know, individuals who are under the age 
of 65 with a disability are generally required to wait for 2 years 
after receiving SSDI before they are eligible for Medicare coverage. 
Thanks to the ACA, individuals who are waiting for Medicare based on 
SSDI eligibility can sign up for insurance through the individual 
exchanges while they are waiting for Medicare eligibility to kick-in.

    If the ACA is repealed, what will you do as Administrator of CMS to 
ensure coverage options for these vulnerable individuals?

    Answer. Our goal is to ensure access to affordable, quality health 
care for all citizens, including individuals with disabilities. As 
such, I look forward to implementing the laws passed by Congress to 
enable affordable, quality care for individuals with disabilities.
                   medicare prescription drug prices
    Question. During your hearing, Senator Wyden asked you about 
soaring drug prices affecting seniors through Medicare Part D. I think 
you agree with many of us, and many Americans as you noted, that the 
prices of these prescription drugs are out of control and it should be 
a goal to make these drugs accessible and affordable to all Medicare 
beneficiaries.

    It is imperative that the American public and legislators know, if 
confirmed as CMS Administrator, how (specifically) will you address 
this drug pricing issue?

    Do you intend to use CMMI authority to test new methods to bring 
down Medicare drug spending? If so, how might you direct this 
authority?

    Answer. The issue of drug costs is one of great concern to all 
Americans. You have my commitment that I will work with you and others 
to make certain that Americans have access to the medications that they 
need. I share your concern regarding the importance of individuals and 
families being able to afford the prescription drugs they need. If 
confirmed, I look forward to working with HHS, CMS, and FDA to consider 
potential options to address the issue of access to, and the 
affordability of, prescription drugs.
                             medicaid churn
    Question. Medicaid churn--or the continual disenrollment and re-
enrollment, which can be caused by changes in income or changing life 
circumstances--can interrupt continuity of care and access to important 
services in the Medicaid population. This can be particularly 
disruptive for Medicaid beneficiaries using care coordination and care 
management services, which are interrupted every time a beneficiary is 
disenrolled.

    In your work with Medicaid, how have you helped mitigate the 
negative impacts of churning?

    Answer. One way to mitigate the impact of Medicaid churn is to 
institute enrollment and payment policies and procedures that are as 
consistent as possible with the commercial health insurance market. 
Coordination between State workforce development programs that help 
Medicaid members become more upwardly mobile can also help eliminate 
churn.

    Question. How will you ensure that eligible individuals will remain 
covered in Medicaid, even when there are changes in their life 
circumstances at no fault of their own?

    Answer. It is important that Medicaid's enrollment and payment 
policies strike the right balance between fairness and responsibility 
and contain the appropriate safeguards that consider changing 
circumstances for families.
                        physician reimbursement
    Question. On average, Medicaid pays providers about 70 percent of 
what a Medicare provider receives for the same service. The only 
difference is the age of the patient being served.

    There are 45 million children and 30 million adults enrolled in 
Medicaid. As you noted in your hearing, you want all patients to be 
able to access any doctor they choose, but typically low Medicaid 
payments--that are set by States--can impede the ability of providers 
to accept more patients--both pediatric and adult--covered through this 
program.

    Along with Senator Murray, I have worked to introduce the Ensuring 
Access to Primary Care for Women and Children Act in past Congresses, 
legislation that would solidify parity between Medicare and Medicaid 
reimbursements for primary care. If confirmed, you would oversee the 
budgets of both Medicare and Medicaid, and would be looked to for 
guidance on the issue of appropriate Medicaid reimbursement rates.

    Do you believe that a child's care should be valued at only 70% of 
that of an adult?

    Answer. No. Medicaid has a complex financing and payment system 
that includes base rates set by States, supplemental payments to 
providers, and other Federal and State funding sources for care to the 
Medicaid or uninsured populations.

    Question. If a State's Medicaid budget is cut by a per-capita-cap 
or block grant proposal, how will you prevent States from cutting 
reimbursement rates for providers to even worse than they are now?

    Answer. I look forward to working with Congress on the specifics of 
any new Medicaid financing and payment proposals in order to hold 
States accountable to ensure patient access to high quality health 
care.
                         preexisting conditions
    Question. As Senator Wyden said during your confirmation hearing, 
Americans cannot afford to go back to the days of when health care was 
only for the healthy and wealthy. I strongly believe that if pieces of 
the ACA are repealed, any replacement must ensure that every American--
regardless of whether they are a woman, have cancer, ESRD, or any other 
condition or preexisting condition--has access to affordable, 
comprehensive coverage equal to or better than coverage options 
currently available through the ACA, regardless of their income.

    I'm concerned that a one-sized-fits-all approach, like high risk 
pools, leaves those who truly need high quality and affordable health 
care out of luck.

    How will you ensure that those with the greatest needs will have 
continued access to high-quality health care?

    Answer. I believe it is important that we as a nation make sure 
that every American has access to the kind of health care and health 
coverage that best meets their needs. Additionally, it is imperative 
that all Americans have access to affordable coverage and that no one 
is priced out of the market due to their diagnosis. Nobody ought to 
lose insurance because they get a bad diagnosis. If confirmed as CMS 
Administrator, I intend to implement the laws passed by Congress to 
ensure access for all, including those with pre-existing conditions, is 
affordable.
                          medicaid guardrails
    Question. Through your work at SVC, you have helped several States 
attempt to change their Medicaid plans.

    In your experiences, what evidence have you seen that Medicaid 
guardrails help beneficiaries gain employment, transition off of 
Medicaid onto different health insurance coverage, and achieve other 
Stated goals of the individual programs?

    Is there any evidence that these requirements increase burdens by 
adding costs to the programs or by increasing administrative challenges 
and inefficiencies?

    Answer. I have been fortunate to be involved in many proposals and 
initiatives to help Medicaid beneficiaries along the lines described. 
In my experience, meeting Federal requirements like guardrails can be a 
limitation on State innovations and do not necessarily improve health 
outcomes. If confirmed as Administrator, I would endeavor to ensure 
States are given the flexibility to pursue innovative approaches that 
fit their needs while ensuring access to care.
                              biosimilars
    Question. During your hearing, Senator Roberts asked you about the 
need for CMS and FDA to work together to promote the uptake of 
biosimilars and enhance innovation across agencies to reduce costs of 
prescription drugs. I agree collaboration between agencies on this 
issue is important. I have also introduced legislation in the past that 
would help achieve this by shortening the patent exclusivity period for 
expensive, brand-name biologic drugs and allow biosimilars to enter the 
market sooner. Biosimilars, which are equivalent in safety and efficacy 
to their reference biologics, have the capacity to reduce prescription 
drug costs, yet physicians must be willing to prescribe them and 
patients need the information necessary for them to be confident in 
taking them.

    As CMS Administrator, how would you work with FDA to develop this 
burgeoning market and promote biosimilar uptake?

    As you mentioned multiple times in your hearing, you want to make 
sure all patients have access to the drugs that they want to take. 
Because the costs of drugs is an important factor in that decision, 
increasing the availability of biosimilars is an important step in that 
process and will ensure beneficiaries have access to choices when it 
comes to their prescription drugs.

    Educating patients and providers is an important component to 
ensure the widespread use of biosimilars. It is vital that providers 
are well informed about how a biosimilar can be prescribed, and how and 
when an interchangeable product can be substituted for another 
biological product. Simultaneously, it is imperative that patients, 
too, have confidence in the safety and efficacy of a given FDA-approved 
biosimilar.

    Please describe specific examples of patient and provider education 
efforts that you will encourage the FDA to engage in regarding 
biosimilars, if you are confirmed.

    Answer. If confirmed, under my leadership, CMS will work with the 
FDA to help ensure that Medicare and Medicaid beneficiaries have 
guidance on biosimilars. I understand that this will be increasingly 
important as more of these products are expected to become available to 
U.S. patients in the coming years.

                                 ______
                                 
               Question Submitted by Hon. Sherrod Brown 
                      and Hon. Benjamin L. Cardin
                              therapy caps
    Question. As you may know, limits on outpatient rehabilitation 
therapy services under Medicare were first imposed in 1997 as part of 
the Balanced Budget Act without regard to its impact to access on 
needed therapy services. Congress has acted several times to prevent 
the caps from going into effect by passing moratoria. Later in 2006, 
Congress created an ``exceptions process'' for beneficiaries whose 
conditions required more care than the annual limits would allow and at 
the end of 2015 year, Congress again extended the exceptions process by 
1 year. The current therapy cap for occupational therapy (OT) is $1,920 
and the combined cap for physical therapy (PT) and speech-language 
pathology services (SLP) is $1,920.

    What is the impact on seniors that hit the cap?

    Do you support repealing the Medicare cap on therapy services?

    Answer. If confirmed, I look forward to reviewing the impact of the 
statutory caps on seniors. It may be that other approaches to therapy 
provide greater quality care at reduced cost with more respect for the 
individual needs of each patient in consultation with their doctor. If 
confirmed, I will look at our Medicare system holistically to make sure 
that we are delivering quality, affordable health care to our citizens.

                                 ______
                                 
             Questions Submitted by Hon. Michael F. Bennet
    Question. This week, I worked with Senator Grassley to reintroduce 
the Advancing Care for Exceptional (ACE) Kids Act. The bill would help 
hospitals and other providers coordinate and standardize care across 
State lines for children with complex medical conditions. As you may 
know, Medicaid covers about two-thirds of the 3 million children with 
complex medical conditions. This represents nearly 40% of Medicaid 
costs for children. The bill is expected to reduce the burden on 
families who are often managing multiple specialists, improve outcomes, 
and lower costs.

    Does the administration support this concept? What are some other 
ways the administration may seek to help families who must care for 
children with complex medical conditions.

    Answer. If confirmed, I would support efforts to help coordinate 
care. I would start by working with my colleagues across the Department 
to identify all the ways in which HHS aims to help these children in 
need. And I would hope to encourage our use of existing authorities and 
funding to better align resources to meet this challenge, especially at 
CMS. I would also work with you and other members of Congress on their 
ideas on this important topic.

    Question. I worked with Senator Portman to introduce the Medicare 
PLUS Act, which would set up a pilot program to help the top 15% of the 
highest-cost Medicare beneficiaries by coordinating their health care 
needs. As you may know, 15% of Medicare beneficiaries have six or more 
chronic conditions and account for 50% of total Medicare spending.

    Would the administration consider piloting such a program through 
the CMS Innovation Center?

    Answer. If confirmed, I would explore what voluntary options we can 
make available to the Medicare beneficiaries with the greatest needs 
and their physicians. I think many will appreciate the opportunity to 
work with a care manager and possibly others who will spend the time 
and effort needed to help the patient make different choices to manage 
their own care. I would seek to work with you on your proposal to 
explore how it and others like it can be a path to empowering those who 
are subjected to the most uncoordinated and challenging aspects of our 
health care system.

    Question. Colorado has a strong commitment to community living and 
home and community based services. This includes a Community Mental 
Health Supports waiver, an Elderly, Blind, and Disabled waiver, and a 
Children with Autism waiver. We have several others that support the 
most vulnerable in the community.

    How can we support older Americans and individuals with 
disabilities who choose to live in the community?

    What additional flexibility do States need to innovate through 
waivers?

    Answer. The goal of CMS is to ensure access to affordable, quality 
health care for all citizens. This, of course, includes people with 
disabilities who depend on Medicaid. If confirmed, I hope to implement 
the law so as to allow States the flexibility to approach this 
population in a way that makes sense for their program and its 
beneficiaries, so long as it is done in accordance with Federal law.

    Question. Colorado has participated in many multi-payer initiatives 
like the Comprehensive Primary Care Initiative and the State Innovation 
Model and has worked closely with the Center for Medicare and Medicaid 
Innovation. Our Medicaid program is also participating in the 
demonstration project for individuals dually enrolled in Medicare and 
Medicaid. The State also has a highly successful Accountable Care 
Collaborative delivery system model.

    Moving forward, how do you foresee CMS preserving these types of 
innovations?

    What steps will you take to ensure that CMMI models increase 
quality and access to care for patients?

    How will you ensure that innovative demonstrations are developed 
with input from clinical experts and interested stakeholders?

    Answer. While I cannot comment on specific demonstrations at this 
time, if confirmed, I plan to work with the Secretary to ensure that 
the Innovation Center--after consultation with Congress, the States, 
healthcare stakeholders, and Innovation Center staff--tests appropriate 
innovative models that reduce costs and improve quality for Medicare 
and Medicaid beneficiaries. As such, I look forward to reviewing all 
current CMMI projects, consistent with congressional actions.

    Question. Over 700,000 Coloradans live in a rural community. The 
Medicaid Expansion provided some financial stability to rural hospitals 
that were on the brink of closure before the Affordable Care Act. In 
fact, hospitals in Colorado saw a 30% drop in uncompensated care. I 
have heard from rural hospitals in our State that several will face 
significant financial challenges if the law is repealed. This is 
concerning, considering that there are counties in Colorado without 
access to a clinic or a hospital.

    Would you support an Affordable Care Act replacement bill that 
reduced access to health care in rural communities?

    How would a replacement ensure that these communities continue to 
have access to quality health care?

    Answer. Oftentimes rural health-care providers and patients are 
overlooked in the broader discussion of national health-care issues. 
Significant health disparities exist for rural populations for a 
variety of reasons, including challenges with access to affordable 
coverage and health-care services. Moreover, small rural providers face 
a unique set of challenges depending on where they are, who they serve 
and what Federal and State requirements they are subject to. If 
confirmed, I will work tirelessly to address the health-care needs of 
all Americans, rural or urban. I look forward to working with Congress 
to implement the laws they pass to ensure every single American has 
access to the coverage they want for themselves and that individuals 
who lost coverage under the Affordable Care Act get or maintain 
coverage. This of course includes individuals who access care at rural 
hospitals or clinics.

    Question. A Colorado-based orthopedic practice is participating in 
one of CMMI's voluntary demonstration projects, the Bundled Payments 
for Care Improvement (BPCI) program. Under the program, health-care 
organizations enter into payment arrangements that include a new 
revenue structure based on financial and performance accountability for 
entire episodes of care, in this case joint replacements. The program 
is showing promise for Colorado patients, who are seeing improved 
outcomes.

    There are concerns with the implementation of the program, 
specifically the National Trend Factor, which continuously updates the 
target prices set by CMS. Providers have asked for increasing clarity 
from CMS and CMMI.

    As CMS Administrator, how would you address these issues so that 
providers continue to participate in voluntary demonstration projects 
that improve outcomes for patients?

    Answer. If confirmed, I plan to work to ensure that the Innovation 
Center--after appropriate consultation with Congress, the States, 
health-care stakeholders, and Innovation Center staff--address such 
concerns in testing innovative models that reduce costs and improve 
quality for Medicare and Medicaid beneficiaries. I look forward to 
reviewing current CMMI projects, consistent with congressional actions.

    Question. Reforming the Stark Law has been a topic of discussion 
over the past few years as we move toward alternative payment models 
that pay for value.

    In your role as CMS Administrator, will you recommend updates to 
Stark Law when alternative payment models are used?

    Answer. While there are a number of legitimate concerns regarding 
physician referrals and compensation, I think it may be appropriate to 
examine regulations implementing the Stark Law and its impact on reform 
efforts. In some cases, the Stark Law may discourage coordination of 
care, and lead to a more fractured health-care system. I would consider 
these situations closely, in consultation with Congress and in context 
when considering what changes might be needed. I look forward to 
working with Congress to implement the law on critical issues related 
to APMs and the Stark Law.

    Question. Current CMS health-reform efforts are based on the 
concept of the triple aim--improving the patient health-care 
experience, improving the health of the population at large, and 
reducing the per capita costs of health care.

    If confirmed as CMS Administrator, will the triple aim remain a 
central tenant of CMS efforts?

    What metrics will you use to ensure these goals are met?

    Answer. The triple aim includes the goals we all share for our 
health-care system and, if confirmed, I would work to ensure its 
elements would remain important to CMS's work. The fundamental metric 
for knowing that our system is on the right track is the centrality of 
the patient in the system and their ability to make choices about their 
care in consultation with their doctor. Without that, the most 
impressive facilities and technology are not serving our people's 
needs, nor is the most efficient system doing what is most important. 
With the patient at the center of the system as a foundation, all else 
is possible and achievable.

    Question. Physicians have noted that the lack of interoperability 
between electronic health record (EHR) systems has been a key barrier 
to complying with requirements for meaningful use of health IT.

    How do you plan to address the ongoing challenges related to EHR 
interoperability?

    How do you plan on restructuring the incentives for meaningfully 
using EHRs?

    Answer. If confirmed, I look forward to working with Congress to 
implement laws related to improving the use of EHRs. Patients and 
providers depend on the fast exchange of information across health 
systems. Having access to a patient's complete medical record enables a 
medical professional to better diagnose and treat a patient. Doctors 
know best how to treat their patients and we should think of EHRs as a 
means to enable that better care. As Congress considers options to 
improve the interoperability of this system so that the burdens on 
physicians do not hinder their ability to practice medicine, I will 
stand ready to provide technical assistance and support through that 
process.

                                 ______
                                 
            Questions Submitted by Hon. Robert P. Casey, Jr.
    Question. Elected officials on both sides of the aisle have said 
they strongly support the ACA's provision allowing young adults to stay 
on their parents' insurance until age 26. As you know, there is a 
parallel provision in Medicaid law allowing youth aging out of foster 
care to maintain health coverage until they turn 26, given they have no 
parents to provide that benefit for them.

    Do you agree that foster youth--children who were removed from 
their homes due to abuse and neglect--should have the same Federal 
health coverage protections as children who are fortunate enough to be 
able to stay on their parents' health coverage?

    Answer. This would be a part of the new legislation that Congress 
will be voting on, so that decision is in Congress' hands. If 
confirmed, I will work to ensure that CMS appropriately implements the 
statutes within its purview.

    Question. The Children's Health Insurance Program (CHIP) has been 
an enormously successful program and has helped, along with Medicaid 
and the Affordable Care Act, to bring children's insurance rates up to 
95 percent--the highest rate ever. The program currently covers about 8 
million children per year, is popular, and has enjoyed significant 
bipartisan support from Congress. It is also due to be reauthorized 
this year.

    Will you pledge to work with Congress to reauthorize and fully fund 
the CHIP program in a timely manner?

    If confirmed, will you guarantee that under your leadership, CHIP 
will continue to be a viable option for America's children, and that it 
will continue to cover medically necessary care for the children who 
are enrolled?

    Answer. It is important that every child has access to high-quality 
health coverage. CHIP plays an important role in accomplishing this 
objective, but there is also a need to focus on family coverage in the 
private market and employer plans, and on giving States needed 
flexibility. Each State has different needs, and I believe CMS needs to 
work with States to ensure that, consistent with those needs, the CHIP 
program provides the best possible coverage to their residents. If 
confirmed, I look forward to working with you on this issue to share 
feedback and technical assistance on policies relating to CHIP. I will 
work to implement CHIP reauthorization as passed by Congress.

    Question. At the end of last year, the HHS Assistant Secretary for 
Planning and Evaluation (ASPE) put out a report that I and other 
members requested on the impact of socioeconomic status (SES) on the 
Medicare quality programs like hospital readmissions and the Medicare 
Advantage star ratings. All these ratings either reward or penalize 
monetarily for good or bad results and those that serve a high number 
of low SES individuals have a harder time achieving high quality 
ratings because of the complications of the populations. In this report 
ASPE discussed options on how to improve the quality programs and more 
accurately account for these populations.

    What do you think we need to do, to improve how Medicare accounts 
for SES in the quality programs?

    Answer. My work with vulnerable populations has highlighted for me 
the impact of social determinants of health and the role of life 
choices in managing one's own health. At the end of the day, health-
care programs for this population ought to empower and enable ownership 
of one's health care. If confirmed, we ought to explore ways that SES 
as well as the way other important factors impact quality programs and 
design the programs with the goal of ensuing patient empowerment front 
and center.

    Question. Many people with disabilities want to work and can do so 
with the services only available through Medicaid, to help them work. 
These services include supported employment for people with mental 
health disabilities or personal care attendants for those with 
intellectual or physical disabilities. Without these services, many 
people with disabilities will be unable to work.

    How will you ensure that a person with a disability, mental health, 
intellectual, physical, sensory, or any other type of disability as 
defined by the Americans with Disabilities Act, has access to the 
services currently available through Medicaid?

    Answer. Our goal is to ensure access to affordable, quality health 
care for all citizens. This, of course, includes people with 
disabilities who depend on Medicaid. Towards this end, I support the 
principles of community integration, beneficiary autonomy in decision 
making, and person-centered planning articulated in CMS's approach to 
Home and Community Based Services and the HCBS Settings Rule (with a 
compliance date in March 2019). If confirmed as CMS Administrator, I 
would rely on these principles in making decisions appropriate to CMS' 
role in administering Medicaid and working with Congress to implement 
and support efforts that help people work.

    Question. The Center for Medicare and Medicaid Innovation (CMMI) 
was created to test new payment models and encourage the Medicare and 
Medicaid programs to look beyond traditional payment systems and find 
new ways to help individuals benefit from the many advances of modern 
medicine. These advances have been seen in the clinical setting and in 
the form of new, innovative therapies, some of which even offer 
potential cures for diseases that previously could only be managed with 
chronic therapies.

    Would you be willing to work with Congress to develop alternative 
payment models that test these advances and examine the benefits these 
advances could have on Medicaid and Medicare beneficiaries, as well as 
how such alternative payment models could affect the cost of care over 
a decade or more, and work with Congress to remove any obstacles that 
might prevent those models from moving forward?

    Answer. If confirmed, I plan to work to ensure that the Innovation 
Center--after appropriate consultation with Congress, the States, 
health-care stakeholders, and Innovation Center staff--tests innovative 
models that reduce costs and improve quality for Medicare, Medicaid, 
and CHIP beneficiaries. I look forward to reviewing current CMMI 
projects, consistent with congressional actions.

                                 ______
                                 
               Questions Submitted by Hon. Mark R. Warner
    Question. Eleven percent of Virginians rely on Medicaid for their 
health insurance, even without Medicaid expansion. This coverage is 
more efficient than most other forms of insurance; Virginia also 
operates the 3rd most efficient Medicaid program in the country, 
receives the lowest allowable Federal matching rate, and the vast 
majority of beneficiaries are enrolled in a managed care plan. Block 
granting or imposing a cap on Medicaid would be damaging to States like 
Virginia. Do you oppose structural changes to Medicaid that shift costs 
onto the States like block granting or per capita caps?

    Answer. If confirmed as Administrator, I intend to work with States 
and Congress to improve Medicaid and implement the laws enacted by 
Congress. From demographic and budgetary concerns to ensuring access 
for special populations, each State faces different challenges in 
Medicaid. A one-size-fits-all approach will not work and that is why 
flexibility for States in how they design their Medicaid programs is 
crucial. At the same time, States must be held accountable to standards 
that result in better health-care quality and access. The mechanics of 
Medicaid reform will be a legislative decision that will need to 
account for how to encourage States to work together on making 
improvements to the program while increasing flexibility.

    Question. Seventy-seven percent of Virginia Medicaid enrollees are 
in families where at least one individual is employed, and 
unfortunately many of the rest are forced to rely on the program not by 
choice, but because they are unable to work--perhaps requiring child 
care or job training, or have a disability. The evidence shows that 
imposing a work requirement actually has a limited impact on 
employment, especially in the long-term. Do you intend to require 
States, or make it easier through the waiver process, to include work 
requirements as a condition to receive Medicaid services? If you were 
to impose work requirements in Medicaid, would you also commit to 
supporting those enrollees who need access to child care, 
transportation, or job training?

    Answer. If confirmed, I will coordinate with States to provide 
greater flexibility for determining how to care for their most needy 
citizens as we encourage work and opportunity.

    Question. Do you agree with President Trump's statement on the 
campaign trail that he would not reduce Medicare benefits, or make 
major changes to Medicare outside of eliminating waste, fraud and 
abuse? Would structural changes to Medicare maintain the basic Medicare 
guarantee, while also strengthening the program's solvency?

    Answer. If confirmed, I will serve at the pleasure of the President 
and will support his policy initiatives within the bounds of the law. 
As Congress considers structural changes to Medicare, I will stand 
ready to provide technical assistance as needed if I am confirmed. 
Ultimately, the decision whether to enact structural changes to the 
program is the province of Congress. Whatever reforms are considered, 
CMS will put the patient first in our implementation of the reform in 
question.

    Question. I have worked with bipartisan members of the Finance 
committee to expand the use of telehealth, especially in Medicare, 
which lags most State Medicaid programs and the commercial sector. CMS 
already has the authority to lower some barriers for telehealth and 
remote patient monitoring in Medicare without Congress. What actions, 
especially around alternative payment models such as ACOs, should CMS 
take to increase the utilization of technology in a way that improves 
quality while maintaining fiscal integrity? Under what circumstances 
should fee-for-service Medicare cover telehealth services? What 
evidence does CMS need to similarly increase access to remote patient 
monitoring services in fee-for-service Medicare?

    Answer. I share your interest in promoting telehealth. Telehealth 
can provide innovative means of making health care more flexible and 
patient-centric. Innovation within the telehealth space could help to 
expand access within rural and underserved areas. If confirmed, I look 
forward to continued discussions on telehealth, including on the best 
means to offer patients increased access, greater control and more 
choices that fit their medical needs.

    Question. Despite the ACA lowering the percentage of uninsured by 8 
percentage points in rural counties, rural hospitals are still facing 
immense challenges, serving older, sometimes more economically 
disadvantaged populations challenged by less access to primary, dental, 
and family health care than their urban counterparts. CMS threatened to 
reclassify Page Memorial Hospital in Luray so that it would no longer 
serve as a Critical Access Hospital, which would have effectively led 
to the hospital significantly reducing services such as treatments for 
heart disease and diabetes, which occur in Page County at far higher 
rates than statewide. I worked with CMS to ensure that Page kept its 
Critical Access Hospital classification As CMS Administrator, what 
improvements to the hospital classification system will implement to 
ensure that Critical Access Hospitals like Luray are adequately funded?

    Answer. As you may be aware, roughly one-third of America's 
counties now have only one health insurer offering coverage on the 
individual market Exchange. The problem is especially acute in rural 
counties, as insurers continue to exit the market and costs continue to 
rise, making coverage less affordable and reducing choices for 
patients. Moving forward, our goal must be to ensure every American has 
access to the coverage they need, including those who access care at 
rural or Critical Access Hospitals. I believe the best metric in the 
end is one that measures the extent of access to care rather than 
simply looking at coverage. If confirmed, I look forward to working 
with CMS staff to evaluate the hospital classification system and to 
understanding the unique issues for your State and its hospitals.

    Question. The Obama administration made significant progress to 
better align fee-for-service Medicare payments with value and quality, 
and I have spent the better part of 2 years working with bipartisan 
members of this committee to improve care for Medicare beneficiaries 
with chronic illness. In what sector of the Medicare program will you 
focus on accelerating value-based purchasing or the broader move to 
align with value and quality?

    Answer. If confirmed, I plan to evaluate the respective sectors of 
the Medicare program to understand how payment reforms are working--or 
not working--for providers and their patients, especially as we 
implement MACRA in accordance with the law. Measuring value and quality 
is a challenge that requires careful planning and broad collaboration 
among all involved stakeholders, especially the beneficiaries who are 
impacted most.

    Question. By moving toward a consolidated quality-reporting and 
payment system under MACRA, Physicians are incentivized through payment 
adjustments into alternative payment models, and those who remain in 
fee-for-service report on quality, resource use, clinical practice 
improvement, and use of electronic health records. Which of these 
metrics do you expect to be most challenging for providers to meet, and 
how quickly would you anticipate payment adjustments moving providers 
into alternative payment models?

    Answer. For small providers, especially in rural Virginia and other 
rural locations around the country, change can be difficult. The 
implementation challenges created by new government-directed programs 
are different and oftentimes more significant for smaller health-care 
providers than they are for larger providers who might have the 
resources and personnel to handle such changes. As we move forward with 
the implementation of MACRA it is critical that we collaborate and 
communicate with all providers on the frontlines to better understand 
what challenges they are facing and how we can support them through its 
implementation.

    Question. The Obama administration made significant progress to 
better align fee-for-service Medicare payments with value and quality, 
and I have spent the better part of 2 years working with bipartisan 
members of this committee to improve care for Medicare beneficiaries 
with chronic illness. The Annual Wellness Visit, or AWV, is an 
important preventative benefit for Medicare beneficiaries. One of the 
key required components of this visit is an assessment of the 
beneficiary's cognitive functioning, which could be particularly useful 
in detecting early signs of Alzheimer's or other forms of dementia, 
helping beneficiaries receive a timely diagnosis and access additional 
services and supports, like the new assessment and care planning 
services for beneficiaries. Despite existing for 6 years, as of last 
year fewer than 20 percent of Medicare beneficiaries utilized the 
Annual Wellness Visit. What concrete steps will CMS take to increase 
access to the Medicare Wellness Visit?

    Answer. If confirmed, I look forward to working with you to enable 
better access to preventative care for Medicare beneficiaries. First, 
we should evaluate what is working well and what the areas are for 
improvement. Your counsel as we move forward in evaluating the AWV will 
be critical.

    Question. Effectively caring for patients at all stages of illness 
is an important part of moving Medicare into the 21st century. I have 
worked with Senator Isakson and others to ensure that conversations 
between patients and the care team help patients to navigate this 
difficult process: improvements to care planning would give individuals 
and their families the ability to make smarter decisions, and provide 
information and support so they can make informed choices based upon 
their own values and goals. One CMMI demonstration provides hospice 
beneficiaries with the option to receive supportive care services 
typically provided by hospice while continuing to receive curative 
services, called Medicare Care Choices. What additional steps would you 
take to expand timely access to concurrent curative care and hospice 
services? What other steps would you explore to expand access to 
hospice and palliative care?

    Answer. As you know, the Medicare hospice benefit covers services 
designed to provide palliative care and management of a terminal 
illness, including drugs and medical and support services. Under the 
current structure, hospice care is provided in lieu of most other 
Medicare services related to the curative treatment of the terminal 
illness. Through the Medicare Care Choices Model, the Innovation Center 
is piloting a new option for Medicare beneficiaries to receive hospice-
like support services from certain hospice providers while concurrently 
receiving services provided by their curative care providers. Should I 
be confirmed as Administrator, I intend to carefully examine this 
Innovation Center model as well as look at other options for expanding 
access to hospice and palliative care.

    Question. The Center for Medicare and Medicaid Innovation (CMMI) is 
conducting several demonstration projects for alternative payment 
models in Medicare with the potential to save taxpayer dollars while 
maintaining or improving the quality of care for beneficiaries, 
including bundled payments for cardiac care, competitive bidding and 
value-based insurance design. With a voluntary approach, only those who 
are already efficient or performing well may participate. Out of the 
over 75 CMMI demonstrations, which 2 do you think have the most 
potential to improve care and lower cost? Please specify two additional 
demonstrations you would plan to build upon, if confirmed as CMS 
Administrator?

    Answer. The Innovation Center provides significant opportunity for 
testing new models for health-care financing and delivery. I cannot 
comment on specific demonstrations at this time, without examining the 
outcome data. However, if confirmed, I intend to examine the range of 
demonstrations currently underway, as well as look for potential new 
initiatives to explore innovative approaches to lower health-care costs 
and improve quality for Medicare and Medicaid beneficiaries. I look 
forward to reviewing current CMMI projects, consistent with 
congressional actions.

    Question. The Affordable Care Act included many provisions with 
budget savings, including increased revenue and Medicare savings. Fully 
repealing the Affordable Care Act, including revenue provisions and 
Medicare savings, would add significantly to the national debt, cost 
$350 billion over 10 years under conventional scoring, and hasten 
Medicare's insolvency by 5 years. Are you in favor of an ACA repeal 
that will contribute to our national debt and deficit? Do you believe 
the revenues in ACA, much of which funded the coverage expansion, 
should be retained, set aside for a possible replacement, or fully 
repealed?

    Answer. Should I be confirmed as Administrator of CMS, my duty will 
be to execute the law as passed by Congress and signed by the 
President. This includes ensuring that the Medicare program is well 
administered, effective, and available for eligible beneficiaries, and 
that it is sustainable for the future.

    Question. While we are moving towards paying for value in many 
areas of health care, in the drug space we have largely lagged behind. 
In the past year, some insurers and drug manufacturers piloted value-
based arrangements that hold the manufacturer accountable for how their 
product performs in the real world on an agreed upon set of metrics. In 
2015, I was the lead author of a letter to CMS asking them to examine 
the potential of using value-based arrangements in Medicare and other 
public programs. Will you commit to working with me to identify 
potential policy barriers that Congress should review in order to move 
towards reimbursement for value rather than volume in the drug space?

    Answer. If confirmed, I look forward to working with you and 
providing technical assistance, when appropriate, as Congress considers 
legislation that impacts CMS and the beneficiaries served by Medicare 
and Medicaid.

    Question. As Governor of Virginia, I prioritized the Commonwealth's 
Children's Health Insurance Program (FAMIS), and streamlined the 
program so that it could fund coverage for 200,000 Virginia children 
each year, almost 98% of eligible children. ACA repeal could result in 
the loss of $114 million from Virginia's Children's Health Insurance 
Program, and increase the uninsured rate among Virginia kids from 3% to 
8%. Block granting or capping Medicaid would also damage the 
Commonwealth's ability to cover children, who represent half of 
Virginia Medicaid enrollees but only 20% of costs. Will you support any 
policy, regulation, or proposal that would increase the uninsured rate 
among children?

    Answer. It is important that every child has access to high-quality 
health coverage, and CHIP plays an important role in accomplishing this 
objective. CHIP plays a major role in this, but there is also a need to 
focus on family coverage in the private market and employer plans, and 
giving States needed flexibility. Each State has different needs, and I 
believe CMS needs to work with States to ensure that, consistent with 
those needs, the CHIP program provide the best possible coverage to 
their residents. If confirmed, I would work with Congress on CHIP 
reauthorization with these principles in mind.

                                 ______
                                 
               Question Submitted by Hon. Mark R. Warner 
                        and Hon. Johnny Isakson
    Question. Over the past 3 decades, rural hospitals in Virginia and 
Georgia have lost out on millions of dollars of Medicare payments 
annually because of this skewed wage index formula. I worked with 
Senator Isakson and others to help rural hospitals in many parts of the 
country receive fair Medicare reimbursement, by introducing the 
bipartisan Fair Medicare Hospital Payments Act. The bill would level 
the playing field for at least 19 hospitals in rural Virginia and over 
100 in Georgia. As CMS Administrator will you work with us to correct 
the gaming of the Medicare wage index, and ensure that we shore up 
rural hospitals nationwide?

    Answer. If confirmed as Administrator, I intend to examine the 
impact of the statutory wage index, as well as the range of issues 
facing Medicare, as we look for ways to improve the program and make it 
sustainable for the future.

                                 ______
                                 
              Questions Submitted by Hon. Claire McCaskill
    Question. Before the passage of the ACA, it was legal for insurers 
in some States to use being a survivor of domestic violence as a pre-
existing condition.

    Do you have a plan to ensure that survivors of sexual assault have 
access to affordable comprehensive insurance coverage and that they are 
not subject to discrimination or higher prices?

    Answer. No one should have to pay higher health insurance rates due 
to being a victim of domestic violence or sexual assault. If confirmed, 
I look forward to taking steps to increase access to affordable, 
quality health care for all Americans, including those who are victims 
of domestic violence or sexual assault.

    Question. Do you believe that the Federal Government should have 
access to State data in order to perform evaluations of the Medicaid 
program generally and Medicaid demonstration projects specifically?

    Answer. If confirmed, I will work within the confines of the law to 
partner with States to exchange appropriate data in order to evaluate 
and improve our health care delivery systems. I am a strong proponent 
of State innovation and flexibility--and States must also be held 
accountable for ensuring the programs they operate provide access to 
high-quality care.

    Question. Earlier this month, the CDC released data showing that 
the uninsured rate was 8.8 percent for the first 9 months of 2016, 
which was a historic low.

    Will you advise against measures that increase the number of people 
without insurance?

    Answer. I have fought for coverage and greater access to health 
care throughout my career. If confirmed, I will work with you and your 
office, the Congress and all interested parties to increase access to 
high-quality health care. However, we should not assume that just 
because people have an insurance card that they have access to health 
care. Many people have out of pocket expenses they cannot afford and 
others face limitations on the providers they can see. If confirmed, I 
will do everything I can to ensure that coverage results in better 
access to care.

                                 ______
                                 
                 Prepared Statement of Hon. Ron Wyden, 
                       a U.S. Senator From Oregon
    The health-care post the Finance Committee is going to discuss this 
morning might not be dinner-table conversation, but it's one of the 
most consequential roles in American government--the Administrator of 
the Centers for Medicare and Medicaid Services.

    CMS is responsible for the health care of over 100 million 
Americans who count on Medicare and Medicaid. It also plays a big role 
in implementing the ACA. That's a weighty responsibility, and that's 
why CMS needs the most experienced and qualified people for the job--
people who know the ins and outs of health-care policy across the 
entire system: Medicare, Medicaid, and the private insurance market.

    CMS needs to have a strong and experienced authority on policy at a 
time when many in the administration, as well as some of my colleagues 
on Capitol Hill, are pushing to make radical changes to America's 
health-care system. In my view, many of these proposals would take the 
country back to the days when health care was mostly for the healthy 
and the wealthy. I'll be listening closely to see if Ms. Verma is up to 
the task.

    I'd like to start off with the promise of Medicare--the promise of 
guaranteed health benefits for seniors. Medicare makes up more than 
half of CMS's spending--roughly $2.2 billion a day. With more seniors 
entering the program every year, there's a lot of work that needs to be 
done to protect and update the Medicare guarantee for the 21st century.

    Updating Medicare means addressing the high and rising cost of 
prescription drugs that are putting a big time strain on seniors' 
budgets. It means making the program work better for people who have to 
manage multiple chronic diseases, like heart disease, cancer, diabetes 
and stroke that constitute the vast majority of the Medicare dollar 
today. Those are the kind of bipartisan concerns Congress and CMS 
should be collaborating on.

    Privatizing Medicare is the wrong direction for people across the 
country who expect the program to be there for them in their later 
years. I want to hear how Ms. Verma's views differ from those of the 
policymakers, including now-Secretary Price, who want to turn the 
entire program into a voucher system.

    Additionally, if confirmed, Ms. Verma will play a key role in 
implementing the bipartisan Medicare physician payment reforms. It's 
essential that she implement the law as intended by Congress as 
America's health-care system continues the long-needed shift from 
paying for volume to paying for value.

    CMS also implements and oversees the rules of the road in the 
private insurance market established by the ACA. Today, many of those 
rules amount to bedrock values for health insurance in America:

          Not discriminating against those with pre-existing 
        conditions no matter what;

          Setting the bar for what type of medical care insurance 
        companies must cover; and

          Letting young adults keep their parent's insurance until 26.

    However, just yesterday, CMS released a proposed rule affecting 
insurance coverage next year. From where I sit, the message from that 
rule is clear: insurance companies are back in charge, and patients are 
taking a back seat. The open enrollment period was cut in half, from 3 
months to 6 weeks. If someone dropped coverage during the year for any 
reason, insurance companies could collect back-premiums before an 
individual is able to get health insurance again. And insurance 
companies will have free reign to offer less generous coverage at the 
same or higher costs. All of this sounds to me like a step backward 
towards health care only for the healthy and wealthy.

    This administration has been saying--on repeat--that the best is 
yet to come, but the evidence suggests otherwise. The President could 
have taken steps to create more stability on a bipartisan basis, but 
instead issued an Executive order on the day he was sworn in that is 
creating market uncertainty and anxiety. You don't need to look further 
than Humana's recent decision to leave the market to see that 
confidence in the President's promise is low.

    So it will be important to hear from Ms. Verma this morning about 
how she plans to implement this program that millions of Americans 
count on as Republicans in Congress actively discuss, even today, how 
they will begin to unravel the law. I hope Ms. Verma will use her 
position if confirmed to move beyond the tired ``repeal and run'' ideas 
that look increasingly impossible.

    The repeal and run scheme goes beyond disrupting the individual 
market. It would also end the Medicaid expansion that has brought 
millions of low-income, vulnerable Americans into the health-care 
system, many for the first time in their lives. This is the area where 
Ms. Verma has had most of her health-care experience. The project she 
is known best for is what's called ``Healthy Indiana 2.0,'' which 
expanded Medicaid in her home State.

    The tradeoff for that expansion is something I'd like to focus on 
in more detail. I'm particularly concerned about the possibility that 
someone making barely $12,000 dollars a year would get locked out of 
health coverage for no less than 6 months because they couldn't pay for 
health care due to an upcoming rent check, for example, or an emergency 
car repair.

    According to an independent evaluation commissioned by the State of 
Indiana, more than 2,500 people were bumped from coverage due to a 
situation like this. I'm also concerned about data from the same report 
that found more than 20,000 people were pushed onto a more expensive, 
less comprehensive Medicaid plans because they couldn't pay or navigate 
the complicated system Ms. Verma put in place. These complex rules 
apply no matter your situation: homeless, suffering from a mental 
health crisis, or without a regular income, to name a few.

    I have great reservations about taking these questionable ideas on 
a nationwide tour. Flexibility for States to pursue policies that work 
well for them is something I've always championed. But I'm in favor of 
flexibility for States when it helps them do better, not when it helps 
them do worse. I'm proud to say my home State has one of the leading 
Medicaid programs in the country--and it just got a renewed waiver. 
States should not be denied the opportunity to do what they want 
because they don't pursue policies like Indiana's.

    However, Ms. Verma will not only be responsible for the 11 million 
individuals who gained coverage under the expansion, but also for the 
60 plus million Americans who rely on Medicaid: to help pay for nursing 
and home-based care; to provide comprehensive coverage for one out of 
three children; and to help people live healthy lives in their 
communities. All of them are at risk under Republican proposals to 
slash the social safety net through block grants or caps.

    Before I wrap up, I'd like to discuss one more issue that relates 
to Ms. Verma's work in Indiana. Ms. Verma and her consulting firm were 
awarded more than $8.3 million in contracts directly by the State of 
Indiana to advise the State and help manage its health-care programs. 
In effect, she was the policy architect. At the same time, she 
contracted with at least five other companies that provided hundreds of 
millions of dollars of services and products to those very programs--HP 
Enterprises, Milliman, Inc., Maximus, Health Management Associates (or 
HMA), and Roche Diagnostics. In the case of at least two of these 
firms--HP and HMA--the terms of her State contracts appear to have had 
her directly overseeing work these firms performed.

    Instead of offering my own views on this arrangement, I'll quote 
President George W. Bush's ethics lawyer Richard Painter, hardly a 
liberal, who yesterday said that this arrangement, quote, ``clearly 
should not happen and is definitely improper.'' Ms. Verma is on both 
sides of the deal, helping manage state's health programs while being 
paid by vendors to those same programs. Richard Painter called that a 
``conflict of interest.'' I agree.

    These companies she consults with--HP, Maximus, Milliman, and 
HighPoint Global--also work with CMS, which she'd be running if 
confirmed. While her ethics agreement specifically requires recusal 
with regard to HMA, it does not specifically address the question of 
her recusal obligations with regard to these other companies.

    I think the committee has an obligation to find out more about Ms. 
Verma's work for companies that did business with the State while she 
worked for the State. Senators also need to be assured that if she 
becomes the CMS Administrator, she will recuse herself from decisions 
that affect the companies that were her clients.

    Ms. Verma, I thank you for joining the committee this morning, and 
I appreciate your willingness to serve. I look forward to your 
testimony.

                                   [all]