[Congressional Record Volume 160, Number 49 (Thursday, March 27, 2014)]
[House]
[Pages H2700-H2718]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




               PROTECTING ACCESS TO MEDICARE ACT OF 2014

  Mr. PITTS. Mr. Speaker, I move to suspend the rules and pass the bill 
(H.R. 4302) to amend the Social Security Act to extend Medicare 
payments to physicians and other provisions of the Medicare and 
Medicaid programs, and for other purposes.
  The Clerk read the title of the bill.
  The text of the bill is as follows:

                               H.R. 4302

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

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Protecting 
     Access to Medicare Act of 2014''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.

                      TITLE I--MEDICARE EXTENDERS

Sec. 101. Physician payment update.
Sec. 102. Extension of work GPCI floor.
Sec. 103. Extension of therapy cap exceptions process.
Sec. 104. Extension of ambulance add-ons.
Sec. 105. Extension of increased inpatient hospital payment adjustment 
              for certain low-volume hospitals.
Sec. 106. Extension of the Medicare-dependent hospital (MDH) program.
Sec. 107. Extension for specialized Medicare Advantage plans for 
              special needs individuals.
Sec. 108. Extension of Medicare reasonable cost contracts.
Sec. 109. Extension of funding for quality measure endorsement, input, 
              and selection.
Sec. 110. Extension of funding outreach and assistance for low-income 
              programs.
Sec. 111. Extension of two-midnight rule.
Sec. 112. Technical changes to Medicare LTCH amendments.

                   TITLE II--OTHER HEALTH PROVISIONS

Sec. 201. Extension of the qualifying individual (QI) program.

[[Page H2701]]

Sec. 202. Temporary extension of transitional medical assistance (TMA).
Sec. 203. Extension of Medicaid and CHIP express lane option.
Sec. 204. Extension of special diabetes program for type I diabetes and 
              for Indians.
Sec. 205. Extension of abstinence education.
Sec. 206. Extension of personal responsibility education program 
              (PREP).
Sec. 207. Extension of funding for family-to-family health information 
              centers.
Sec. 208. Extension of health workforce demonstration project for low-
              income individuals.
Sec. 209. Extension of maternal, infant, and early childhood home 
              visiting programs.
Sec. 210. Pediatric quality measures.
Sec. 211. Delay of effective date for Medicaid amendments relating to 
              beneficiary liability settlements.
Sec. 212. Delay in transition from ICD-9 TO ICD-10 code sets.
Sec. 213. Elimination of limitation on deductibles for employer-
              sponsored health plans.
Sec. 214. GAO report on the Children's Hospital Graduate Medical 
              Education Program.
Sec. 215. Skilled nursing facility value-based purchasing.
Sec. 216. Improving Medicare policies for clinical diagnostic 
              laboratory tests.
Sec. 217. Revisions under the Medicare ESRD prospective payment system.
Sec. 218. Quality incentives for computed tomography diagnostic imaging 
              and promoting evidence-based care.
Sec. 219. Using funding from Transitional Fund for Sustainable Growth 
              Rate (SGR) Reform.
Sec. 220. Ensuring accurate valuation of services under the physician 
              fee schedule.
Sec. 221. Medicaid DSH.
Sec. 222. Realignment of the Medicare sequester for fiscal year 2024.
Sec. 223. Demonstration programs to improve community mental health 
              services.
Sec. 224. Assisted outpatient treatment grant program for individuals 
              with serious mental illness.
Sec. 225. Exclusion from PAYGO scorecards.

                      TITLE I--MEDICARE EXTENDERS

     SEC. 101. PHYSICIAN PAYMENT UPDATE.

       Section 1848(d) of the Social Security Act (42 U.S.C. 
     1395w-4(d)) is amended--
       (1) in paragraph (15)--
       (A) in the heading, by striking ``January through march 
     of'';
       (B) in subparagraph (A), by striking ``for the period 
     beginning on January 1, 2014, and ending on March 31, 2014''; 
     and
       (C) in subparagraph (B)--
       (i) in the heading, by striking ``remaining portion of 2014 
     and''; and
       (ii) by striking ``the period beginning on April 1, 2014, 
     and ending on December 31, 2014, and for''; and
       (2) by adding at the end the following new paragraph:
       ``(16) Update for january through march of 2015.--
       ``(A) In general.--Subject to paragraphs (7)(B), (8)(B), 
     (9)(B), (10)(B), (11)(B), (12)(B), (13)(B), (14)(B), and 
     (15)(B), in lieu of the update to the single conversion 
     factor established in paragraph (1)(C) that would otherwise 
     apply for 2015 for the period beginning on January 1, 2015, 
     and ending on March 31, 2015, the update to the single 
     conversion factor shall be 0.0 percent.
       ``(B) No effect on computation of conversion factor for 
     remaining portion of 2015 and subsequent years.--The 
     conversion factor under this subsection shall be computed 
     under paragraph (1)(A) for the period beginning on April 1, 
     2015, and ending on December 31, 2015, and for 2016 and 
     subsequent years as if subparagraph (A) had never applied.''.

     SEC. 102. EXTENSION OF WORK GPCI FLOOR.

       Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 
     1395w-4(e)(1)(E)) is amended by striking ``April 1, 2014'' 
     and inserting ``April 1, 2015''.

     SEC. 103. EXTENSION OF THERAPY CAP EXCEPTIONS PROCESS.

       Section 1833(g) of the Social Security Act (42 U.S.C. 
     1395l(g)) is amended--
       (1) in paragraph (5)(A), in the first sentence, by striking 
     ``March 31, 2014'' and inserting ``March 31, 2015''; and
       (2) in paragraph (6)(A)--
       (A) by striking ``March 31, 2014'' and inserting ``March 
     31, 2015''; and
       (B) by striking ``2012, 2013, or the first three months of 
     2014'' and inserting ``2012, 2013, 2014, or the first three 
     months of 2015''.

     SEC. 104. EXTENSION OF AMBULANCE ADD-ONS.

       (a) Ground Ambulance.--Section 1834(l)(13)(A) of the Social 
     Security Act (42 U.S.C. 1395m(l)(13)(A)) is amended by 
     striking ``April 1, 2014'' and inserting ``April 1, 2015'' 
     each place it appears.
       (b) Super Rural Ground Ambulance.--Section 1834(l)(12)(A) 
     of the Social Security Act (42 U.S.C. 1395m(l)(12)(A)) is 
     amended, in the first sentence, by striking ``April 1, 2014'' 
     and inserting ``April 1, 2015''.

     SEC. 105. EXTENSION OF INCREASED INPATIENT HOSPITAL PAYMENT 
                   ADJUSTMENT FOR CERTAIN LOW-VOLUME HOSPITALS.

       Section 1886(d)(12) of the Social Security Act (42 U.S.C. 
     1395ww(d)(12)) is amended--
       (1) in subparagraph (B), in the matter preceding clause 
     (i), by striking ``in the portion of fiscal year 2014 
     beginning on April 1, 2014, fiscal year 2015, and subsequent 
     fiscal years'' and inserting ``in fiscal year 2015 (beginning 
     on April 1, 2015), fiscal year 2016, and subsequent fiscal 
     years'';
       (2) in subparagraph (C)(i), by striking ``fiscal years 
     2011, 2012, and 2013, and the portion of fiscal year 2014 
     before'' and inserting ``fiscal years 2011 through 2014 and 
     fiscal year 2015 (before April 1, 2015),'' each place it 
     appears; and
       (3) in subparagraph (D), by striking ``fiscal years 2011, 
     2012, and 2013, and the portion of fiscal year 2014 before 
     April 1, 2014,'' and inserting ``fiscal years 2011 through 
     2014 and fiscal year 2015 (before April 1, 2015),''.

     SEC. 106. EXTENSION OF THE MEDICARE-DEPENDENT HOSPITAL (MDH) 
                   PROGRAM.

       (a) In General.--Section 1886(d)(5)(G) of the Social 
     Security Act (42 U.S.C. 1395ww(d)(5)(G)) is amended--
       (1) in clause (i), by striking ``April 1, 2014'' and 
     inserting ``April 1, 2015''; and
       (2) in clause (ii)(II), by striking ``April 1, 2014'' and 
     inserting ``April 1, 2015''.
       (b) Conforming Amendments.--
       (1) Extension of target amount.--Section 1886(b)(3)(D) of 
     the Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is 
     amended--
       (A) in the matter preceding clause (i), by striking ``April 
     1, 2014'' and inserting ``April 1, 2015''; and
       (B) in clause (iv), by striking ``through fiscal year 2013 
     and the portion of fiscal year 2014 before April 1, 2014'' 
     and inserting ``through fiscal year 2014 and the portion of 
     fiscal year 2015 before April 1, 2015''.
       (2) Permitting hospitals to decline reclassification.--
     Section 13501(e)(2) of the Omnibus Budget Reconciliation Act 
     of 1993 (42 U.S.C. 1395ww note) is amended by striking 
     ``through the first 2 quarters of fiscal year 2014'' and 
     inserting ``through the first 2 quarters of fiscal year 
     2015''.

     SEC. 107. EXTENSION FOR SPECIALIZED MEDICARE ADVANTAGE PLANS 
                   FOR SPECIAL NEEDS INDIVIDUALS.

       Section 1859(f)(1) of the Social Security Act (42 U.S.C. 
     1395w-28(f)(1)) is amended by striking ``2016'' and inserting 
     ``2017''.

     SEC. 108. EXTENSION OF MEDICARE REASONABLE COST CONTRACTS.

       Section 1876(h)(5)(C)(ii) of the Social Security Act (42 
     U.S.C. 1395mm(h)(5)(C)(ii)) is amended, in the matter 
     preceding subclause (I), by striking ``January 1, 2015'' and 
     inserting ``January 1, 2016''.

     SEC. 109. EXTENSION OF FUNDING FOR QUALITY MEASURE 
                   ENDORSEMENT, INPUT, AND SELECTION.

       Section 1890(d) of the Social Security Act (42 U.S.C. 
     1395aaa(d)) is amended--
       (1) by inserting ``(1)'' before ``For purposes''; and
       (2) by adding at the end the following new paragraph:
       ``(2) For purposes of carrying out this section and section 
     1890A (other than subsections (e) and (f)), the Secretary 
     shall provide for the transfer, from the Federal Hospital 
     Insurance Trust Fund under section 1817 and the Federal 
     Supplementary Medical Insurance Trust Fund under section 
     1841, in such proportion as the Secretary determines 
     appropriate, to the Centers for Medicare & Medicaid Services 
     Program Management Account of $5,000,000 for fiscal year 2014 
     and $15,000,000 for the first 6 months of fiscal year 2015. 
     Amounts transferred under the preceding sentence shall remain 
     available until expended.''.

     SEC. 110. EXTENSION OF FUNDING OUTREACH AND ASSISTANCE FOR 
                   LOW-INCOME PROGRAMS.

       (a) Additional Funding for State Health Insurance 
     Programs.--Subsection (a)(1)(B) of section 119 of the 
     Medicare Improvements for Patients and Providers Act of 2008 
     (42 U.S.C. 1395b-3 note), as amended by section 3306 of the 
     Patient Protection and Affordable Care Act Public Law 111-
     148), section 610 of the American Taxpayer Relief Act of 2012 
     (Public Law 112-240), and section 1110 of the Pathway for SGR 
     Reform Act of 2013 (Public Law 113-67), is amended--
       (1) in clause (iii), by striking ``and'' at the end;
       (2) by striking clause (iv); and
       (3) by adding at the end the following new clauses:
       ``(iv) for fiscal year 2014, of $7,500,000; and
       ``(v) for the portion of fiscal year 2015 before April 1, 
     2015, of $3,750,000.''.
       (b) Additional Funding for Area Agencies on Aging.--
     Subsection (b)(1)(B) of such section 119, as so amended, is 
     amended--
       (1) in clause (iii), by striking ``and'' at the end;
       (2) by striking clause (iv); and
       (3) by inserting after clause (iii) the following new 
     clauses:
       ``(iv) for fiscal year 2014, of $7,500,000; and
       ``(v) for the portion of fiscal year 2015 before April 1, 
     2015, of $3,750,000.''.
       (c) Additional Funding for Aging and Disability Resource 
     Centers.--Subsection (c)(1)(B) of such section 119, as so 
     amended, is amended--
       (1) in clause (iii), by striking ``and'' at the end;
       (2) by striking clause (iv); and
       (3) by inserting after clause (iii) the following new 
     clauses:
       ``(iv) for fiscal year 2014, of $5,000,000; and
       ``(v) for the portion of fiscal year 2015 before April 1, 
     2015, of $2,500,000.''.

[[Page H2702]]

       (d) Additional Funding for Contract With the National 
     Center for Benefits and Outreach Enrollment.--Subsection 
     (d)(2) of such section 119, as so amended, is amended--
       (1) in clause (iii), by striking ``and'' at the end;
       (2) by striking clause (iv); and
       (3) by inserting after clause (iii) the following new 
     clauses:
       ``(iv) for fiscal year 2014, of $5,000,000; and
       ``(v) for the portion of fiscal year 2015 before April 1, 
     2015, of $2,500,000.''.

     SEC. 111. EXTENSION OF TWO-MIDNIGHT RULE.

       (a) Continuation of Certain Medical Review Activities.--The 
     Secretary of Health and Human Services may continue medical 
     review activities described in the notice entitled 
     ``Selecting Hospital Claims for Patient Status Reviews: 
     Admissions On or After October 1, 2013'', posted on the 
     Internet website of the Centers for Medicare & Medicaid 
     Services, through the first 6 months of fiscal year 2015 for 
     such additional hospital claims as the Secretary determines 
     appropriate.
       (b) Limitation.--The Secretary of Health and Human Services 
     shall not conduct patient status reviews (as described in 
     such notice) on a post-payment review basis through recovery 
     audit contractors under section 1893(h) of the Social 
     Security Act (42 U.S.C. 1395ddd(h)) for inpatient claims with 
     dates of admission October 1, 2013, through March 31, 2015, 
     unless there is evidence of systematic gaming, fraud, abuse, 
     or delays in the provision of care by a provider of services 
     (as defined in section 1861(u) of such Act (42 U.S.C. 
     1395x(u))).

     SEC. 112. TECHNICAL CHANGES TO MEDICARE LTCH AMENDMENTS.

       (a) In General.--Subclauses (I) and (II) of section 
     1886(m)(6)(C)(iv) of the Social Security Act (42 U.S.C. 
     1395ww(m)(6)(C)(iv)) are each amended by striking 
     ``discharges'' and inserting ``Medicare fee-for-service 
     discharges''.
       (b) MMSEA Correction.--Section 114(d) of the Medicare, 
     Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395ww 
     note), as amended by sections 3106(b) and 10312(b) of Public 
     Law 111-148 and by section 1206(b)(2) of the Pathway for SGR 
     Reform Act of 2013 (division B of Public Law 113-67), is 
     amended--
       (1) in paragraph (1), in the matter preceding subparagraph 
     (A), by striking ``January 1, 2015,'' and inserting ``on the 
     date of the enactment of paragraph (7) of this subsection'';
       (2) in paragraph (6), by striking ``January 1, 2015,'' and 
     inserting ``on the date of the enactment of paragraph (7) of 
     this subsection''; and
       (3) by adding at the end the following new paragraph:
       ``(7) Additional exception for certain long-term care 
     hospitals.--The moratorium under paragraph (1)(A) shall not 
     apply to a long-term care hospital that--
       ``(A) began its qualifying period for payment as a long-
     term care hospital under section 412.23(e) of title 42, Code 
     of Federal Regulations, on or before the date of enactment of 
     this paragraph;
       ``(B) has a binding written agreement as of the date of the 
     enactment of this paragraph with an outside, unrelated party 
     for the actual construction, renovation, lease, or demolition 
     for a long-term care hospital, and has expended, before such 
     date of enactment, at least 10 percent of the estimated cost 
     of the project (or, if less, $2,500,000); or
       ``(C) has obtained an approved certificate of need in a 
     State where one is required on or before such date of 
     enactment.''.
       (c) Additional Amendments.--Section 1206(a) of the Pathway 
     for SGR Reform Act of 2013 (division B of Public Law 113-67) 
     is amended--
       (1) in paragraph (2)(A), by striking ``Assessment'' and 
     inserting ``Advisory''; and
       (2) in paragraph (3)(B), by striking ``shall not apply to a 
     hospital that is classified as of December 10, 2013, as a 
     subsection (d) hospital (as defined in section 1886(d)(1)(B) 
     of the Social Security Act, 42 U.S.C. 1395ww(d)(1)(B))'' and 
     inserting ``shall only apply to a hospital that is classified 
     as of December 10, 2013, as a long-term care hospital (as 
     defined in section 1861(ccc) of the Social Security Act, 42 
     U.S.C. 1395x(ccc))''.
       (d) Effective Date.--The amendments made by this section 
     are effective as of the date of the enactment of this Act.

                   TITLE II--OTHER HEALTH PROVISIONS

     SEC. 201. EXTENSION OF THE QUALIFYING INDIVIDUAL (QI) 
                   PROGRAM.

       (a) Extension.--Section 1902(a)(10)(E)(iv) of the Social 
     Security Act (42 U.S.C. 1396a(a)(10)(E)(iv)) is amended by 
     striking ``March 2014'' and inserting ``March 2015''.
       (b) Extending Total Amount Available for Allocation.--
     Section 1933(g) of the Social Security Act (42 U.S.C. 1396u-
     3(g)) is amended--
       (1) in paragraph (2)--
       (A) in subparagraph (T), by striking ``and'' at the end;
       (B) in subparagraph (U)--
       (i) by striking ``March 31, 2014'' and inserting 
     ``September 30, 2014''; and
       (ii) by striking ``$200,000,000.'' and inserting 
     ``$485,000,000;''; and
       (C) by adding at the end the following new subparagraphs:
       ``(V) for the period that begins on October 1, 2014, and 
     ends on December 31, 2014, the total allocation amount is 
     $300,000,000; and
       ``(W) for the period that begins on January 1, 2015, and 
     ends on March 31, 2015, the total allocation amount is 
     $250,000,000.''; and
       (2) in paragraph (3), in the matter preceding subparagraph 
     (A), by striking ``or (T)'' and inserting ``(T), or (V)''.

     SEC. 202. TEMPORARY EXTENSION OF TRANSITIONAL MEDICAL 
                   ASSISTANCE (TMA).

       Sections 1902(e)(1)(B) and 1925(f) of the Social Security 
     Act (42 U.S.C. 1396a(e)(1)(B), 1396r-6(f)) are each amended 
     by striking ``March 31, 2014'' and inserting ``March 31, 
     2015''.

     SEC. 203. EXTENSION OF MEDICAID AND CHIP EXPRESS LANE OPTION.

       Section 1902(e)(13)(I) of the Social Security Act (42 
     U.S.C. 1396a(e)(13)(I)) is amended by striking ``September 
     30, 2014'' and inserting ``September 30, 2015''.

     SEC. 204. EXTENSION OF SPECIAL DIABETES PROGRAM FOR TYPE I 
                   DIABETES AND FOR INDIANS.

       (a) Special Diabetes Programs for Type I Diabetes.--Section 
     330B(b)(2)(C) of the Public Health Service Act (42 U.S.C. 
     254c-2(b)(2)(C)) is amended by striking ``2014'' and 
     inserting ``2015''.
       (b) Special Diabetes Programs for Indians.--Section 
     330C(c)(2)(C) of the Public Health Service Act (42 U.S.C. 
     254c-3(c)(2)(C)) is amended by striking ``2014'' and 
     inserting ``2015''.

     SEC. 205. EXTENSION OF ABSTINENCE EDUCATION.

       Subsections (a) and (d) of section 510 of the Social 
     Security Act (42 U.S.C. 710) are each amended by striking 
     ``2014'' and inserting ``2015''.

     SEC. 206. EXTENSION OF PERSONAL RESPONSIBILITY EDUCATION 
                   PROGRAM (PREP).

       Section 513 of the Social Security Act (42 U.S.C. 713) is 
     amended--
       (1) in paragraphs (1)(A) and (4)(A) of subsection (a), by 
     striking ``2014'' and inserting ``2015'' each place it 
     appears;
       (2) in subsection (a)(4)(B)(i), by striking ``and 2014'' 
     and inserting ``2014, and 2015''; and
       (3) in subsection (f), by striking ``2014'' and inserting 
     ``2015''.

     SEC. 207. EXTENSION OF FUNDING FOR FAMILY-TO-FAMILY HEALTH 
                   INFORMATION CENTERS.

        Section 501(c)(1)(A) of the Social Security Act (42 U.S.C. 
     701(c)(1)(A)) is amended--
       (1) in clause (iii), by striking at the end ``and'';
       (2) in clause (iv), by striking the period at the end and 
     inserting a semicolon and by moving the margin to align with 
     the margin for clause (iii); and
       (3) by adding at the end the following new clauses:
       ``(v) $2,500,000 for the portion of fiscal year 2014 on or 
     after April 1, 2014; and
       ``(vi) $2,500,000 for the portion of fiscal year 2015 
     before April 1, 2015.''.

     SEC. 208. EXTENSION OF HEALTH WORKFORCE DEMONSTRATION PROJECT 
                   FOR LOW-INCOME INDIVIDUALS.

       Section 2008(c)(1) of the Social Security Act (42 U.S.C. 
     1397g(c)(1)) is amended by striking ``2014'' and inserting 
     ``2015''.

     SEC. 209. EXTENSION OF MATERNAL, INFANT, AND EARLY CHILDHOOD 
                   HOME VISITING PROGRAMS.

       Section 511(j) of the Social Security Act (42 U.S.C. 
     711(j)) is amended--
       (1) in paragraph (1)--
       (A) by striking ``and'' at the end of subparagraph (D);
       (B) by striking the period at the end of subparagraph (E) 
     and inserting ``; and''; and
       (C) by adding at the end the following new subparagraph:
       ``(F) for the period beginning on October 1, 2014, and 
     ending on March 31, 2015, an amount equal to the amount 
     provided in subparagraph (E).''; and
       (2) in paragraphs (2) and (3), by inserting ``(or portion 
     of a fiscal year)'' after ``for a fiscal year'' each place it 
     appears.

     SEC. 210. PEDIATRIC QUALITY MEASURES.

       (a) Continuation of Funding for Pediatric Quality Measures 
     for Improving the Quality of Children's Health Care.--Section 
     1139B(e) of the Social Security Act (42 U.S.C. 1320b-9b(e)) 
     is amended by adding at the end the following: ``Of the funds 
     appropriated under this subsection, not less than $15,000,000 
     shall be used to carry out section 1139A(b).''.
       (b) Elimination of Restriction on Medicaid Quality 
     Measurement Program.--Section 1139B(b)(5)(A) of the Social 
     Security Act (42 U.S.C. 1320b-9b(b)(5)(A)) is amended by 
     striking ``The aggregate amount awarded by the Secretary for 
     grants and contracts for the development, testing, and 
     validation of emerging and innovative evidence-based measures 
     under such program shall equal the aggregate amount awarded 
     by the Secretary for grants under section 1139A(b)(4)(A)''.

     SEC. 211. DELAY OF EFFECTIVE DATE FOR MEDICAID AMENDMENTS 
                   RELATING TO BENEFICIARY LIABILITY SETTLEMENTS.

       Effective as if included in the enactment of the Bipartisan 
     Budget Act of 2013 (Public Law 113-67), section 202(c) of 
     such Act is amended by striking ``October 1, 2014'' and 
     inserting ``October 1, 2016''.

     SEC. 212. DELAY IN TRANSITION FROM ICD-9 TO ICD-10 CODE SETS.

       The Secretary of Health and Human Services may not, prior 
     to October 1, 2015, adopt ICD-10 code sets as the standard 
     for code sets under section 1173(c) of the Social Security 
     Act (42 U.S.C. 1320d-2(c)) and section 162.1002 of title 45, 
     Code of Federal Regulations.

[[Page H2703]]

     SEC. 213. ELIMINATION OF LIMITATION ON DEDUCTIBLES FOR 
                   EMPLOYER-SPONSORED HEALTH PLANS.

       (a) In General.--Section 1302(c) of the Patient Protection 
     and Affordable Care Act (Public Law 111-148; 42 U.S.C. 
     18022(c)) is amended--
       (1) by striking paragraph (2); and
       (2) in paragraph (4)(A), by striking ``paragraphs (1)(B)(i) 
     and (2)(B)(i)'' and inserting ``paragraph (1)(B)(i)''.
       (b) Conforming Amendment.--Section 2707(b) of the Public 
     Health Service Act (42 U.S.C. 300gg-6(b)) is amended by 
     striking ``paragraphs (1) and (2)'' and inserting ``paragraph 
     (1)''.
       (c) Effective Date.--The amendments made by this Act shall 
     be effective as if included in the enactment of the Patient 
     Protection and Affordable Care Act (Public Law 111-148).

     SEC. 214. GAO REPORT ON THE CHILDREN'S HOSPITAL GRADUATE 
                   MEDICAL EDUCATION PROGRAM.

       (a) In General.--In the case that the Children's Hospital 
     GME Support Reauthorization Act of 2013 is enacted into law, 
     the Comptroller General of the United States shall, not later 
     than November 30, 2017, conduct an independent evaluation, 
     and submit to the appropriate committees of Congress a 
     report, concerning the implementation of section 340E(h) of 
     the Public Health Service Act, as added by section 3 of the 
     Children's Hospital GME Support Reauthorization Act of 2013.
       (b) Content.--The report described in subsection (a) shall 
     review and assess each of the following, with respect to 
     hospitals receiving payments under such section 340E(h) 
     during the period of fiscal years 2015 through 2017:
       (1) The number and type of such hospitals that applied for 
     such payments.
       (2) The number and type of such hospitals receiving such 
     payments.
       (3) The amount of such payments awarded to such hospitals.
       (4) How such hospitals used such payments.
       (5) The impact of such payments on--
       (A) the number of pediatric providers; and
       (B) health care needs of children.

     SEC. 215. SKILLED NURSING FACILITY VALUE-BASED PURCHASING.

       (a) In General.--Section 1888 of the Social Security Act 
     (42 U.S.C. 1395yy) is amended by adding at the end the 
     following new subsection:
       ``(g) Skilled Nursing Facility Readmission Measure.--
       ``(1) Readmission measure.--Not later than October 1, 2015, 
     the Secretary shall specify a skilled nursing facility all-
     cause all-condition hospital readmission measure (or any 
     successor to such a measure).
       ``(2) Resource use measure.--Not later than October 1, 
     2016, the Secretary shall specify a measure to reflect an 
     all-condition risk-adjusted potentially preventable hospital 
     readmission rate for skilled nursing facilities.
       ``(3) Measure adjustments.--When specifying the measures 
     under paragraphs (1) and (2), the Secretary shall devise a 
     methodology to achieve a high level of reliability and 
     validity, especially for skilled nursing facilities with a 
     low volume of readmissions.
       ``(4) Pre-rulemaking process (measure application 
     partnership process).--The application of the provisions of 
     section 1890A shall be optional in the case of a measure 
     specified under paragraph (1) and a measure specified under 
     paragraph (2).
       ``(5)  Feedback reports to skilled nursing facilities.--
     Beginning October 1, 2016, and every quarter thereafter, the 
     Secretary shall provide confidential feedback reports to 
     skilled nursing facilities on the performance of such 
     facilities with respect to a measure specified under 
     paragraph (1) or (2).
       ``(6) Public reporting of skilled nursing facilities.--
       ``(A) In general.--Subject to subparagraphs (B) and (C), 
     the Secretary shall establish procedures for making available 
     to the public by posting on the Nursing Home Compare Medicare 
     website (or a successor website) described in section 1819(i) 
     information on the performance of skilled nursing facilities 
     with respect to a measure specified under paragraph (1) and a 
     measure specified under paragraph (2).
       ``(B) Opportunity to review.--The procedures under 
     subparagraph (A) shall ensure that a skilled nursing facility 
     has the opportunity to review and submit corrections to the 
     information that is to be made public with respect to the 
     facility prior to such information being made public.
       ``(C) Timing.--Such procedures shall provide that the 
     information described in subparagraph (A) is made publicly 
     available beginning not later than October 1, 2017.
       ``(7) Non-application of paperwork reduction act.--Chapter 
     35 of title 44, United States Code (commonly referred to as 
     the `Paperwork Reduction Act of 1995') shall not apply to 
     this subsection.''.
       (b) Value-Based Purchasing Program for Skilled Nursing 
     Facilities.--Section 1888 of the Social Security Act (42 
     U.S.C. 1395yy), as amended by subsection (a), is further 
     amended by adding at the end the following new subsection:
       ``(h) Skilled Nursing Facility Value-Based Purchasing 
     Program.--
       ``(1) Establishment.--
       ``(A) In general.--Subject to the succeeding provisions of 
     this subsection, the Secretary shall establish a skilled 
     nursing facility value-based purchasing program (in this 
     subsection referred to as the `SNF VBP Program') under which 
     value-based incentive payments are made in a fiscal year to 
     skilled nursing facilities.
       ``(B) Program to begin in fiscal year 2019.--The SNF VBP 
     Program shall apply to payments for services furnished on or 
     after October 1, 2018.
       ``(2) Application of measures.--
       ``(A) In general.--The Secretary shall apply the measure 
     specified under subsection (g)(1) for purposes of the SNF VBP 
     Program.
       ``(B) Replacement.--For purposes of the SNF VBP Program, 
     the Secretary shall apply the measure specified under (g)(2) 
     instead of the measure specified under (g)(1) as soon as 
     practicable.
       ``(3) Performance standards.--
       ``(A) Establishment.--The Secretary shall establish 
     performance standards with respect to the measure applied 
     under paragraph (2) for a performance period for a fiscal 
     year.
       ``(B) Higher of achievement and improvement.--The 
     performance standards established under subparagraph (A) 
     shall include levels of achievement and improvement. In 
     calculating the SNF performance score under paragraph (4), 
     the Secretary shall use the higher of either improvement or 
     achievement.
       ``(C) Timing.--The Secretary shall establish and announce 
     the performance standards established under subparagraph (A) 
     not later than 60 days prior to the beginning of the 
     performance period for the fiscal year involved.
       ``(4) SNF performance score.--
       ``(A) In general.--The Secretary shall develop a 
     methodology for assessing the total performance of each 
     skilled nursing facility based on performance standards 
     established under paragraph (3) with respect to the measure 
     applied under paragraph (2). Using such methodology, the 
     Secretary shall provide for an assessment (in this subsection 
     referred to as the `SNF performance score') for each skilled 
     nursing facility for each such performance period.
       ``(B) Ranking of snf performance scores.--The Secretary 
     shall, for the performance period for each fiscal year, rank 
     the SNF performance scores determined under subparagraph (A) 
     from low to high.
       ``(5) Calculation of value-based incentive payments.--
       ``(A) In general.--With respect to a skilled nursing 
     facility, based on the ranking under paragraph (4)(B) for a 
     performance period for a fiscal year, the Secretary shall 
     increase the adjusted Federal per diem rate determined under 
     subsection (e)(4)(G) otherwise applicable to such skilled 
     nursing facility (and after application of paragraph (6)) for 
     services furnished by such facility during such fiscal year 
     by the value-based incentive payment amount under 
     subparagraph (B).
       ``(B) Value-based incentive payment amount.--The value-
     based incentive payment amount for services furnished by a 
     skilled nursing facility in a fiscal year shall be equal to 
     the product of--
       ``(i) the adjusted Federal per diem rate determined under 
     subsection (e)(4)(G) otherwise applicable to such skilled 
     nursing facility for such services furnished by the skilled 
     nursing facility during such fiscal year; and
       ``(ii) the value-based incentive payment percentage 
     specified under subparagraph (C) for the skilled nursing 
     facility for such fiscal year.
       ``(C) Value-based incentive payment percentage.--
       ``(i) In general.--The Secretary shall specify a value-
     based incentive payment percentage for a skilled nursing 
     facility for a fiscal year which may include a zero 
     percentage.
       ``(ii) Requirements.--In specifying the value-based 
     incentive payment percentage for each skilled nursing 
     facility for a fiscal year under clause (i), the Secretary 
     shall ensure that--

       ``(I) such percentage is based on the SNF performance score 
     of the skilled nursing facility provided under paragraph (4) 
     for the performance period for such fiscal year;
       ``(II) the application of all such percentages in such 
     fiscal year results in an appropriate distribution of value-
     based incentive payments under subparagraph (B) such that--

       ``(aa) skilled nursing facilities with the highest rankings 
     under paragraph (4)(B) receive the highest value-based 
     incentive payment amounts under subparagraph (B);
       ``(bb) skilled nursing facilities with the lowest rankings 
     under paragraph (4)(B) receive the lowest value-based 
     incentive payment amounts under subparagraph (B); and
       ``(cc) in the case of skilled nursing facilities in the 
     lowest 40 percent of the ranking under paragraph (4)(B), the 
     payment rate under subparagraph (A) for services furnished by 
     such facility during such fiscal year shall be less than the 
     payment rate for such services for such fiscal year that 
     would otherwise apply under subsection (e)(4)(G) without 
     application of this subsection; and

       ``(III) the total amount of value-based incentive payments 
     under this paragraph for all skilled nursing facilities in 
     such fiscal year shall be greater than or equal to 50 
     percent, but not greater than 70 percent, of the total amount 
     of the reductions to payments for such fiscal year under 
     paragraph (6), as estimated by the Secretary.

       ``(6) Funding for value-based incentive payments.--
       ``(A) In general.--The Secretary shall reduce the adjusted 
     Federal per diem rate determined under subsection (e)(4)(G) 
     otherwise applicable to a skilled nursing facility for 
     services furnished by such facility during

[[Page H2704]]

     a fiscal year (beginning with fiscal year 2019) by the 
     applicable percent (as defined in subparagraph (B)). The 
     Secretary shall make such reductions for all skilled nursing 
     facilities in the fiscal year involved, regardless of whether 
     or not the skilled nursing facility has been determined by 
     the Secretary to have earned a value-based incentive payment 
     under paragraph (5) for such fiscal year.
       ``(B) Applicable percent.--For purposes of subparagraph 
     (A), the term `applicable percent' means, with respect to 
     fiscal year 2019 and succeeding fiscal years, 2 percent.
       ``(7) Announcement of net result of adjustments.--Under the 
     SNF VBP Program, the Secretary shall, not later than 60 days 
     prior to the fiscal year involved, inform each skilled 
     nursing facility of the adjustments to payments to the 
     skilled nursing facility for services furnished by such 
     facility during the fiscal year under paragraphs (5) and (6).
       ``(8) No effect in subsequent fiscal years.--The value-
     based incentive payment under paragraph (5) and the payment 
     reduction under paragraph (6) shall each apply only with 
     respect to the fiscal year involved, and the Secretary shall 
     not take into account such value-based incentive payment or 
     payment reduction in making payments to a skilled nursing 
     facility under this section in a subsequent fiscal year.
       ``(9) Public reporting.--
       ``(A) SNF specific information.--The Secretary shall make 
     available to the public, by posting on the Nursing Home 
     Compare Medicare website (or a successor website) described 
     in section 1819(i) in an easily understandable format, 
     information regarding the performance of individual skilled 
     nursing facilities under the SNF VBP Program, with respect to 
     a fiscal year, including--
       ``(i) the SNF performance score of the skilled nursing 
     facility for such fiscal year; and
       ``(ii) the ranking of the skilled nursing facility under 
     paragraph (4)(B) for the performance period for such fiscal 
     year.
       ``(B)  Aggregate information.--The Secretary shall 
     periodically post on the Nursing Home Compare Medicare 
     website (or a successor website) described in section 1819(i) 
     aggregate information on the SNF VBP Program, including--
       ``(i) the range of SNF performance scores provided under 
     paragraph (4)(A); and
       ``(ii) the number of skilled nursing facilities receiving 
     value-based incentive payments under paragraph (5) and the 
     range and total amount of such value-based incentive 
     payments.
       ``(10) Limitation on review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise of the following:
       ``(A) The methodology used to determine the value-based 
     incentive payment percentage and the amount of the value-
     based incentive payment under paragraph (5).
       ``(B) The determination of the amount of funding available 
     for such value-based incentive payments under paragraph 
     (5)(C)(ii)(III) and the payment reduction under paragraph 
     (6).
       ``(C) The establishment of the performance standards under 
     paragraph (3) and the performance period.
       ``(D) The methodology developed under paragraph (4) that is 
     used to calculate SNF performance scores and the calculation 
     of such scores.
       ``(E) The ranking determinations under paragraph (4)(B).
       ``(11) Funding for program management.--The Secretary shall 
     provide for the one time transfer from the Federal Hospital 
     Insurance Trust Fund established under section 1817 to the 
     Centers for Medicare & Medicaid Services Program Management 
     Account of--
       ``(A) for purposes of subsection (g)(2), $2,000,000; and
       ``(B) for purposes of implementing this subsection, 
     $10,000,000.
     Such funds shall remain available until expended.''.
       (c) MedPAC Study.--Not later than June 30, 2021, the 
     Medicare Payment Advisory Commission shall submit to Congress 
     a report that reviews the progress of the skilled nursing 
     facility value-based purchasing program established under 
     section 1888(h) of the Social Security Act, as added by 
     subsection (b), and makes recommendations, as appropriate, on 
     any improvements that should be made to such program. For 
     purposes of the previous sentence, the Medicare Payment 
     Advisory Commission shall consider any unintended 
     consequences with respect to such skilled nursing facility 
     value-based purchasing program and any potential adjustments 
     to the readmission measure specified under section 1888(g)(1) 
     of such Act, as added by subsection (a), for purposes of 
     determining the effect of the socio-economic status of a 
     beneficiary under the Medicare program under title XVIII of 
     the Social Security Act for the SNF performance score of a 
     skilled nursing facility provided under section 1888(h)(4) of 
     such Act, as added by subsection (b).

     SEC. 216. IMPROVING MEDICARE POLICIES FOR CLINICAL DIAGNOSTIC 
                   LABORATORY TESTS.

       (a) In General.--Title XVIII of the Social Security Act is 
     amended by inserting after section 1834 (42 U.S.C. 1395m) the 
     following new section:

     ``SEC. 1834A. IMPROVING POLICIES FOR CLINICAL DIAGNOSTIC 
                   LABORATORY TESTS.

       ``(a) Reporting of Private Sector Payment Rates for 
     Establishment of Medicare Payment Rates.--
       ``(1) In general.--Beginning January 1, 2016, and every 3 
     years thereafter (or, annually, in the case of reporting with 
     respect to an advanced diagnostic laboratory test, as defined 
     in subsection (d)(5)), an applicable laboratory (as defined 
     in paragraph (2)) shall report to the Secretary, at a time 
     specified by the Secretary, applicable information (as 
     defined in paragraph (3)) for a data collection period (as 
     defined in paragraph (4)) for each clinical diagnostic 
     laboratory test that the laboratory furnishes during such 
     period for which payment is made under this part.
       ``(2) Definition of applicable laboratory.--In this 
     section, the term `applicable laboratory' means a laboratory 
     that, with respect to its revenues under this title, a 
     majority of such revenues are from this section, section 
     1833(h), or section 1848. The Secretary may establish a low 
     volume or low expenditure threshold for excluding a 
     laboratory from the definition of applicable laboratory under 
     this paragraph, as the Secretary determines appropriate.
       ``(3) Applicable information defined.--
       ``(A) In general.--In this section, subject to subparagraph 
     (B), the term `applicable information' means, with respect to 
     a laboratory test for a data collection period, the 
     following:
       ``(i) The payment rate (as determined in accordance with 
     paragraph (5)) that was paid by each private payor for the 
     test during the period.
       ``(ii) The volume of such tests for each such payor for the 
     period.
       ``(B) Exception for certain contractual arrangements.--Such 
     term shall not include information with respect to a 
     laboratory test for which payment is made on a capitated 
     basis or other similar payment basis during the data 
     collection period.
       ``(4) Data collection period defined.--In this section, the 
     term `data collection period' means a period of time, such as 
     a previous 12 month period, specified by the Secretary.
       ``(5) Treatment of discounts.--The payment rate reported by 
     a laboratory under this subsection shall reflect all 
     discounts, rebates, coupons, and other price concessions, 
     including those described in section 1847A(c)(3).
       ``(6) Ensuring complete reporting.--In the case where an 
     applicable laboratory has more than one payment rate for the 
     same payor for the same test or more than one payment rate 
     for different payors for the same test, the applicable 
     laboratory shall report each such payment rate and the volume 
     for the test at each such rate under this subsection. 
     Beginning with January 1, 2019, the Secretary may establish 
     rules to aggregate reporting with respect to the situations 
     described in the preceding sentence.
       ``(7) Certification.--An officer of the laboratory shall 
     certify the accuracy and completeness of the information 
     reported under this subsection.
       ``(8) Private payor defined.--In this section, the term 
     `private payor' means the following:
       ``(A) A health insurance issuer and a group health plan (as 
     such terms are defined in section 2791 of the Public Health 
     Service Act).
       ``(B) A Medicare Advantage plan under part C.
       ``(C) A medicaid managed care organization (as defined in 
     section 1903(m)).
       ``(9) Civil money penalty.--
       ``(A) In general.--If the Secretary determines that an 
     applicable laboratory has failed to report or made a 
     misrepresentation or omission in reporting information under 
     this subsection with respect to a clinical diagnostic 
     laboratory test, the Secretary may apply a civil money 
     penalty in an amount of up to $10,000 per day for each 
     failure to report or each such misrepresentation or omission.
       ``(B) Application.--The provisions of section 1128A (other 
     than subsections (a) and (b)) shall apply to a civil money 
     penalty under this paragraph in the same manner as they apply 
     to a civil money penalty or proceeding under section 
     1128A(a).
       ``(10) Confidentiality of information.--Notwithstanding any 
     other provision of law, information disclosed by a laboratory 
     under this subsection is confidential and shall not be 
     disclosed by the Secretary or a Medicare contractor in a form 
     that discloses the identity of a specific payor or 
     laboratory, or prices charged or payments made to any such 
     laboratory, except--
       ``(A) as the Secretary determines to be necessary to carry 
     out this section;
       ``(B) to permit the Comptroller General to review the 
     information provided;
       ``(C) to permit the Director of the Congressional Budget 
     Office to review the information provided; and
       ``(D) to permit the Medicare Payment Advisory Commission to 
     review the information provided.
       ``(11) Protection from public disclosure.--A payor shall 
     not be identified on information reported under this 
     subsection. The name of an applicable laboratory under this 
     subsection shall be exempt from disclosure under section 
     552(b)(3) of title 5, United States Code.
       ``(12) Regulations.--Not later than June 30, 2015, the 
     Secretary shall establish through notice and comment 
     rulemaking parameters for data collection under this 
     subsection.
       ``(b) Payment for Clinical Diagnostic Laboratory Tests.--
       ``(1) Use of private payor rate information to determine 
     medicare payment rates.--

[[Page H2705]]

       ``(A) In general.--Subject to paragraph (3) and subsections 
     (c) and (d), in the case of a clinical diagnostic laboratory 
     test furnished on or after January 1, 2017, the payment 
     amount under this section shall be equal to the weighted 
     median determined for the test under paragraph (2) for the 
     most recent data collection period.
       ``(B) Application of payment amounts to hospital 
     laboratories.--The payment amounts established under this 
     section shall apply to a clinical diagnostic laboratory test 
     furnished by a hospital laboratory if such test is paid for 
     separately, and not as part of a bundled payment under 
     section 1833(t).
       ``(2) Calculation of weighted median.--For each laboratory 
     test with respect to which information is reported under 
     subsection (a) for a data collection period, the Secretary 
     shall calculate a weighted median for the test for the 
     period, by arraying the distribution of all payment rates 
     reported for the period for each test weighted by volume for 
     each payor and each laboratory.
       ``(3) Phase-in of reductions from private payor rate 
     implementation.--
       ``(A) In general.--Payment amounts determined under this 
     subsection for a clinical diagnostic laboratory test for each 
     of 2017 through 2022 shall not result in a reduction in 
     payments for a clinical diagnostic laboratory test for the 
     year of greater than the applicable percent (as defined in 
     subparagraph (B)) of the amount of payment for the test for 
     the preceding year.
       ``(B) Applicable percent defined.--In this paragraph, the 
     term `applicable percent' means--
       ``(i) for each of 2017 through 2019, 10 percent; and
       ``(ii) for each of 2020 through 2022, 15 percent.
       ``(C) No application to new tests.--This paragraph shall 
     not apply to payment amounts determined under this section 
     for either of the following.
       ``(i) A new test under subsection (c).
       ``(ii) A new advanced diagnostic test (as defined in 
     subsection (d)(5)) under subsection (d).
       ``(4) Application of market rates.--
       ``(A) In general.--Subject to paragraph (3), once 
     established for a year following a data collection period, 
     the payment amounts under this subsection shall continue to 
     apply until the year following the next data collection 
     period.
       ``(B) Other adjustments not applicable.--The payment 
     amounts under this section shall not be subject to any 
     adjustment (including any geographic adjustment, budget 
     neutrality adjustment, annual update, or other adjustment).
       ``(5) Sample collection fee.--In the case of a sample 
     collected from an individual in a skilled nursing facility or 
     by a laboratory on behalf of a home health agency, the 
     nominal fee that would otherwise apply under section 
     1833(h)(3)(A) shall be increased by $2.
       ``(c) Payment for New Tests That Are Not Advanced 
     Diagnostic Laboratory Tests.--
       ``(1) Payment during initial period.--In the case of a 
     clinical diagnostic laboratory test that is assigned a new or 
     substantially revised HCPCS code on or after the date of 
     enactment of this section, and which is not an advanced 
     diagnostic laboratory test (as defined in subsection (d)(5)), 
     during an initial period until payment rates under subsection 
     (b) are established for the test, payment for the test shall 
     be determined--
       ``(A) using cross-walking (as described in section 
     414.508(a) of title 42, Code of Federal Regulations, or any 
     successor regulation) to the most appropriate existing test 
     under the fee schedule under this section during that period; 
     or
       ``(B) if no existing test is comparable to the new test, 
     according to the gapfilling process described in paragraph 
     (2).
       ``(2) Gapfilling process described.--The gapfilling process 
     described in this paragraph shall take into account the 
     following sources of information to determine gapfill 
     amounts, if available:
       ``(A) Charges for the test and routine discounts to 
     charges.
       ``(B) Resources required to perform the test.
       ``(C) Payment amounts determined by other payors.
       ``(D) Charges, payment amounts, and resources required for 
     other tests that may be comparable or otherwise relevant.
       ``(E) Other criteria the Secretary determines appropriate.
       ``(3) Additional consideration.--In determining the payment 
     amount under crosswalking or gapfilling processes under this 
     subsection, the Secretary shall consider recommendations from 
     the panel established under subsection (f)(1).
       ``(4) Explanation of payment rates.--In the case of a 
     clinical diagnostic laboratory test for which payment is made 
     under this subsection, the Secretary shall make available to 
     the public an explanation of the payment rate for the test, 
     including an explanation of how the criteria described in 
     paragraph (2) and paragraph (3) are applied.
       ``(d) Payment for New Advanced Diagnostic Laboratory 
     Tests.--
       ``(1) Payment during initial period.--
       ``(A) In general.--In the case of an advanced diagnostic 
     laboratory test for which payment has not been made under the 
     fee schedule under section 1833(h) prior to the date of 
     enactment of this section, during an initial period of three 
     quarters, the payment amount for the test for such period 
     shall be based on the actual list charge for the laboratory 
     test.
       ``(B) Actual list charge.--For purposes of subparagraph 
     (A), the term `actual list charge', with respect to a 
     laboratory test furnished during such period, means the 
     publicly available rate on the first day at which the test is 
     available for purchase by a private payor.
       ``(2) Special rule for timing of initial reporting.--With 
     respect to an advanced diagnostic laboratory test described 
     in paragraph (1)(A), an applicable laboratory shall initially 
     be required to report under subsection (a) not later than the 
     last day of the second quarter of the initial period under 
     such paragraph.
       ``(3) Application of market rates after initial period.--
     Subject to paragraph (4), data reported under paragraph (2) 
     shall be used to establish the payment amount for an advanced 
     diagnostic laboratory test after the initial period under 
     paragraph (1)(A) using the methodology described in 
     subsection (b). Such payment amount shall continue to apply 
     until the year following the next data collection period.
       ``(4) Recoupment if actual list charge exceeds market 
     rate.--With respect to the initial period described in 
     paragraph (1)(A), if, after such period, the Secretary 
     determines that the payment amount for an advanced diagnostic 
     laboratory test under paragraph (1)(A) that was applicable 
     during the period was greater than 130 percent of the payment 
     amount for the test established using the methodology 
     described in subsection (b) that is applicable after such 
     period, the Secretary shall recoup the difference between 
     such payment amounts for tests furnished during such period.
       ``(5) Advanced diagnostic laboratory test defined.--In this 
     subsection, the term `advanced diagnostic laboratory test' 
     means a clinical diagnostic laboratory test covered under 
     this part that is offered and furnished only by a single 
     laboratory and not sold for use by a laboratory other than 
     the original developing laboratory (or a successor owner) and 
     meets one of the following criteria:
       ``(A) The test is an analysis of multiple biomarkers of 
     DNA, RNA, or proteins combined with a unique algorithm to 
     yield a single patient-specific result.
       ``(B) The test is cleared or approved by the Food and Drug 
     Administration.
       ``(C) The test meets other similar criteria established by 
     the Secretary.
       ``(e) Coding.--
       ``(1) Temporary codes for certain new tests.--
       ``(A) In general.--The Secretary shall adopt temporary 
     HCPCS codes to identify new advanced diagnostic laboratory 
     tests (as defined in subsection (d)(5)) and new laboratory 
     tests that are cleared or approved by the Food and Drug 
     Administration.
       ``(B) Duration.--
       ``(i) In general.--Subject to clause (ii), the temporary 
     code shall be effective until a permanent HCPCS code is 
     established (but not to exceed 2 years).
       ``(ii) Exception.--The Secretary may extend the temporary 
     code or establish a permanent HCPCS code, as the Secretary 
     determines appropriate.
       ``(2) Existing tests.--Not later than January 1, 2016, for 
     each existing advanced diagnostic laboratory test (as so 
     defined) and each existing clinical diagnostic laboratory 
     test that is cleared or approved by the Food and Drug 
     Administration for which payment is made under this part as 
     of the date of enactment of this section, if such test has 
     not already been assigned a unique HCPCS code, the Secretary 
     shall--
       ``(A) assign a unique HCPCS code for the test; and
       ``(B) publicly report the payment rate for the test.
       ``(3) Establishment of unique identifier for certain 
     tests.--For purposes of tracking and monitoring, if a 
     laboratory or a manufacturer requests a unique identifier for 
     an advanced diagnostic laboratory test (as so defined) or a 
     laboratory test that is cleared or approved by the Food and 
     Drug Administration, the Secretary shall utilize a means to 
     uniquely track such test through a mechanism such as a HCPCS 
     code or modifier.
       ``(f) Input From Clinicians and Technical Experts.--
       ``(1) In general.--The Secretary shall consult with an 
     expert outside advisory panel, established by the Secretary 
     not later than July 1, 2015, composed of an appropriate 
     selection of individuals with expertise, which may include 
     molecular pathologists, researchers, and individuals with 
     expertise in laboratory science or health economics, in 
     issues related to clinical diagnostic laboratory tests, which 
     may include the development, validation, performance, and 
     application of such tests, to provide--
       ``(A) input on--
       ``(i) the establishment of payment rates under this section 
     for new clinical diagnostic laboratory tests, including 
     whether to use crosswalking or gapfilling processes to 
     determine payment for a specific new test; and
       ``(ii) the factors used in determining coverage and payment 
     processes for new clinical diagnostic laboratory tests; and
       ``(B) recommendations to the Secretary under this section.
       ``(2) Compliance with faca.--The panel shall be subject to 
     the Federal Advisory Committee Act (5 U.S.C. App.).
       ``(3) Continuation of annual meeting.--The Secretary shall 
     continue to convene the annual meeting described in section 
     1833(h)(8)(B)(iii) after the implementation of

[[Page H2706]]

     this section for purposes of receiving comments and 
     recommendations (and data on which the recommendations are 
     based) as described in such section on the establishment of 
     payment amounts under this section.
       ``(g) Coverage.--
       ``(1) Issuance of coverage policies.--
       ``(A) In general.--A medicare administrative contractor 
     shall only issue a coverage policy with respect to a clinical 
     diagnostic laboratory test in accordance with the process for 
     making a local coverage determination (as defined in section 
     1869(f)(2)(B)), including the appeals and review process for 
     local coverage determinations under part 426 of title 42, 
     Code of Federal Regulations (or successor regulations).
       ``(B) No effect on national coverage determination 
     process.--This paragraph shall not apply to the national 
     coverage determination process (as defined in section 
     1869(f)(1)(B)).
       ``(C) Effective date.--This paragraph shall apply to 
     coverage policies issued on or after January 1, 2015.
       ``(2) Designation of one or more medicare administrative 
     contractors for clinical diagnostic laboratory tests.--The 
     Secretary may designate one or more (not to exceed 4) 
     medicare administrative contractors to either establish 
     coverage policies or establish coverage policies and process 
     claims for payment for clinical diagnostic laboratory tests, 
     as determined appropriate by the Secretary.
       ``(h) Implementation.--
       ``(1) Implementation.--There shall be no administrative or 
     judicial review under section 1869, section 1878, or 
     otherwise, of the establishment of payment amounts under this 
     section.
       ``(2) Administration.--Chapter 35 of title 44, United 
     States Code, shall not apply to information collected under 
     this section.
       ``(3) Funding.--For purposes of implementing this section, 
     the Secretary shall provide for the transfer, from the 
     Federal Supplementary Medical Insurance Trust Fund under 
     section 1841, to the Centers for Medicare & Medicaid Services 
     Program Management Account, for each of fiscal years 2014 
     through 2018, $4,000,000, and for each of fiscal years 2019 
     through 2023, $3,000,000. Amounts transferred under the 
     preceding sentence shall remain available until expended.
       ``(i) Transitional Rule.--During the period beginning on 
     the date of enactment of this section and ending on December 
     31, 2016, with respect to advanced diagnostic laboratory 
     tests under this part, the Secretary shall use the 
     methodologies for pricing, coding, and coverage in effect on 
     the day before such date of enactment, which may include 
     cross-walking or gapfilling methods.''.
       (b) Conforming Amendments.--
       (1) Section 1833(a) of the Social Security Act (42 U.S.C. 
     1395l(a)) is amended--
       (A) in paragraph (1)(D)--
       (i) by striking ``(i) on the basis'' and inserting ``(i)(I) 
     on the basis'';
       (ii) in subclause (I), as added by clause (i), by striking 
     ``subsection (h)(1)'' and inserting ``subsection (h)(1) (for 
     tests furnished before January 1, 2017)'';
       (iii) by striking ``or (ii)'' and inserting ``or (II) under 
     section 1834A (for tests furnished on or after January 1, 
     2017), the amount paid shall be equal to 80 percent (or 100 
     percent, in the case of such tests for which payment is made 
     on an assignment-related basis) of the lesser of the amount 
     determined under such section or the amount of the charges 
     billed for the tests, or (ii)''; and
       (iv) in clause (ii), by striking ``on the basis'' and 
     inserting ``for tests furnished before January 1, 2017, on 
     the basis'';
       (B) in paragraph (2)(D)--
       (i) by striking ``(i) on the basis'' and inserting ``(i)(I) 
     on the basis'';
       (ii) in subclause (I), as added by clause (i), by striking 
     ``subsection (h)(1)'' and inserting ``subsection (h)(1) (for 
     tests furnished before January 1, 2017)'';
       (iii) by striking ``or (ii)'' and inserting ``or (II) under 
     section 1834A (for tests furnished on or after January 1, 
     2017), the amount paid shall be equal to 80 percent (or 100 
     percent, in the case of such tests for which payment is made 
     on an assignment-related basis or to a provider having an 
     agreement under section 1866) of the lesser of the amount 
     determined under such section or the amount of the charges 
     billed for the tests, or (ii)''; and
       (iv) in clause (ii), by striking ``on the basis'' and 
     inserting ``for tests furnished before January 1, 2017, on 
     the basis'';
       (C) in subsection (b)(3)(B), by striking ``on the basis'' 
     and inserting ``for tests furnished before January 1, 2017, 
     on the basis'';
       (D) in subsection (h)(2)(A)(i), by striking ``and subject 
     to'' and inserting ``and, for tests furnished before the date 
     of enactment of section 1834A, subject to'';
       (E) in subsection (h)(3), in the matter preceding 
     subparagraph (A), by striking ``fee schedules'' and inserting 
     ``fee schedules (for tests furnished before January 1, 2017) 
     or under section 1834A (for tests furnished on or after 
     January 1, 2017), subject to subsection (b)(5) of such 
     section'';
       (F) in subsection (h)(6), by striking ``In the case'' and 
     inserting ``For tests furnished before January 1, 2017, in 
     the case''; and
       (G) in subsection (h)(7), in the first sentence--
       (i) by striking ``and (4)'' and inserting ``and (4) and 
     section 1834A''; and
       (ii) by striking ``under this subsection'' and inserting 
     ``under this part''.
       (2) Section 1869(f)(2) of the Social Security Act (42 
     U.S.C. 1395ff(f)(2)) is amended by adding at the end the 
     following new subparagraph:
       ``(C) Local coverage determinations for clinical diagnostic 
     laboratory tests.--For provisions relating to local coverage 
     determinations for clinical diagnostic laboratory tests, see 
     section 1834A(g).''.
       (c) GAO Study and Report; Monitoring of Medicare 
     Expenditures and Implementation of New Payment System for 
     Laboratory Tests.--
       (1) GAO study and report on implementation of new payment 
     rates for clinical diagnostic laboratory tests.--
       (A) Study.--The Comptroller General of the United States 
     (in this subsection referred to as the ``Comptroller 
     General'') shall conduct a study on the implementation of 
     section 1834A of the Social Security Act, as added by 
     subsection (a). The study shall include an analysis of--
       (i) payment rates paid by private payors for laboratory 
     tests furnished in various settings, including--

       (I) how such payment rates compare across settings;
       (II) the trend in payment rates over time; and
       (III) trends by private payors to move to alternative 
     payment methodologies for laboratory tests;

       (ii) the conversion to the new payment rate for laboratory 
     tests under such section;
       (iii) the impact of such implementation on beneficiary 
     access under title XVIII of the Social Security Act;
       (iv) the impact of the new payment system on laboratories 
     that furnish a low volume of services and laboratories that 
     specialize in a small number of tests;
       (v) the number of new Healthcare Common Procedure Coding 
     System (HCPCS) codes issued for laboratory tests;
       (vi) the spending trend for laboratory tests under such 
     title;
       (vii) whether the information reported by laboratories and 
     the new payment rates for laboratory tests under such section 
     accurately reflect market prices;
       (viii) the initial list price for new laboratory tests and 
     the subsequent reported rates for such tests under such 
     section;
       (ix) changes in the number of advanced diagnostic 
     laboratory tests and laboratory tests cleared or approved by 
     the Food and Drug Administration for which payment is made 
     under such section; and
       (x) healthcare economic information on downstream cost 
     impacts for such tests and decision making based on accepted 
     methodologies.
       (B) Report.--Not later than October 1, 2018, the 
     Comptroller General shall submit to the Committee on Ways and 
     Means and the Committee on Energy and Commerce of the House 
     of Representatives and the Committee on Finance of the Senate 
     a report on the study under subparagraph (A), including 
     recommendations for such legislation and administrative 
     action as the Comptroller General determines appropriate.
       (2) Monitoring of medicare expenditures and implementation 
     of new payment system for laboratory tests.--The Inspector 
     General of the Department of Health and Human Services 
     shall--
       (A) publicly release an annual analysis of the top 25 
     laboratory tests by expenditures under title XVIII of the 
     Social Security Act; and
       (B) conduct analyses the Inspector General determines 
     appropriate with respect to the implementation and effect of 
     the new payment system for laboratory tests under section 
     1834A of the Social Security Act, as added by subsection (a).

     SEC. 217. REVISIONS UNDER THE MEDICARE ESRD PROSPECTIVE 
                   PAYMENT SYSTEM.

       (a) Delay of Implementation of Oral-Only Policy.--Section 
     632(b)(1) of the American Taxpayer Relief Act of 2012 (42 
     U.S.C. 1395rr note) is amended--
       (1) by striking ``2016'' and inserting ``2024''; and
       (2) by adding at the end the following new sentence: 
     ``Notwithstanding section 1881(b)(14)(A)(ii) of the Social 
     Security Act (42 U.S.C. 1395rr(b)(14)(A)(ii)), implementation 
     of the policy described in the previous sentence shall be 
     based on data from the most recent year available.''.
       (b) Mitigation of the Application of Adjustment to ESRD 
     Bundled Payment Rate To Account for Changes in the 
     Utilization of Certain Drugs and Biologicals.--
       (1) In general.--Section 1881(b)(14)(I) of the Social 
     Security Act (42 U.S.C. 1395rr(b)(14)(I)) is amended by 
     inserting ``and before January 1, 2015,'' after ``January 1, 
     2014,''.
       (2) Market basket.--Section 1881(b)(14)(F)(i) of the Social 
     Security Act (42 U.S.C. 1395rr(b)(14)(F)(i)) is amended--
       (A) in subclause (I)--
       (i) by striking ``subclause (II)'' and inserting 
     ``subclauses (II) and (III)''; and
       (ii) by adding at the end the following new sentence: ``In 
     order to accomplish the purposes of subparagraph (I) with 
     respect to 2016, 2017, and 2018, after determining the 
     increase factor described in the preceding sentence for each 
     of 2016, 2017, and 2018, the Secretary shall reduce such 
     increase factor by 1.25 percentage points for each of 2016 
     and 2017 and by 1 percentage point for 2018.'';
       (B) in subclause (II), by striking ``For 2012'' and 
     inserting ``Subject to subclause (III), for 2012''; and
       (C) by adding at the end the following new subclause:

[[Page H2707]]

       ``(III) Notwithstanding subclauses (I) and (II), in order 
     to accomplish the purposes of subparagraph (I) with respect 
     to 2015, the increase factor described in subclause (I) for 
     2015 shall be 0.0 percent pursuant to the regulation issued 
     by the Secretary on December 2, 2013, entitled `Medicare 
     Program; End-Stage Renal Disease Prospective Payment System, 
     Quality Incentive Program, and Durable Medical Equipment, 
     Prosthetics, Orthotics, and Supplies; Final Rule' (78 Fed. 
     Reg. 72156).''.
       (c) Drug Designations.--As part of the promulgation of 
     annual rule for the Medicare end stage renal disease 
     prospective payment system under section 1881(b)(14) of the 
     Social Security Act (42 U.S.C. 1395rr(b)(14)) for calendar 
     year 2016, the Secretary of Health and Human Services (in 
     this subsection referred to as the ``Secretary'') shall 
     establish a process for--
       (1) determining when a product is no longer an oral-only 
     drug; and
       (2) including new injectable and intravenous products into 
     the bundled payment under such system.
       (d) Quality Measures Related to Conditions Treated by Oral-
     Only Drugs Under the ESRD Quality Incentive Program.--Section 
     1881(h)(2) of the Social Security Act (42 U.S.C. 
     1395rr(h)(2)) is amended--
       (1) in subparagraph (A)--
       (A) in clause (ii), by striking ``and'' at the end;
       (B) by redesignating clause (iii) as clause (iv); and
       (C) by inserting after clause (ii) the following new 
     clause:
       ``(iii) for 2016 and subsequent years, measures described 
     in subparagraph (E)(i); and'';
       (2) in subparagraph (B)(i), by striking ``(A)(iii)'' and 
     inserting ``(A)(iv)''; and
       (3) by adding at the end the following new subparagraph:
       ``(E) Measures specific to the conditions treated with 
     oral-only drugs.--
       ``(i) In general.--The measures described in this 
     subparagraph are measures specified by the Secretary that are 
     specific to the conditions treated with oral-only drugs. To 
     the extent feasible, such measures shall be outcomes-based 
     measures.
       ``(ii) Consultation.--In specifying the measures under 
     clause (i), the Secretary shall consult with interested 
     stakeholders.
       ``(iii) Use of endorsed measures.--

       ``(I) In general.--Subject to subclause (I), any measures 
     specified under clause (i) must have been endorsed by the 
     entity with a contract under section 1890(a).
       ``(II) Exception.--If the entity with a contract under 
     section 1890(a) has not endorsed a measure for a specified 
     area or topic related to measures described in clause (i) 
     that the Secretary determines appropriate, the Secretary may 
     specify a measure that is endorsed or adopted by a consensus 
     organization recognized by the Secretary that has expertise 
     in clinical guidelines for kidney disease.''.

       (e) Audits of Cost Reports of ESRD Providers as Recommended 
     by MedPAC.--
       (1) In general.--The Secretary of Health and Human Services 
     shall conduct audits of Medicare cost reports beginning 
     during 2012 for a representative sample of providers of 
     services and renal dialysis facilities furnishing renal 
     dialysis services.
       (2) Funding.--For purposes of carrying out paragraph (1), 
     the Secretary of Health and Human Services shall provide for 
     the transfer from the Federal Supplementary Medical Insurance 
     Trust Fund established under section 1841 of the Social 
     Security Act (42 U.S.C. 1395t) to the Centers for Medicare & 
     Medicaid Services Program Management Account of $18,000,000 
     for fiscal year 2014. Amounts transferred under this 
     paragraph for a fiscal year shall be available until 
     expended.

     SEC. 218. QUALITY INCENTIVES FOR COMPUTED TOMOGRAPHY 
                   DIAGNOSTIC IMAGING AND PROMOTING EVIDENCE-BASED 
                   CARE.

       (a) Quality Incentives To Promote Patient Safety and Public 
     Health in Computed Tomography Diagnostic Imaging.--
       (1) In general.--Section 1834 of the Social Security Act 
     (42 U.S.C. 1395m) is amended by adding at the end the 
     following new subsection:
       ``(p) Quality Incentives To Promote Patient Safety and 
     Public Health in Computed Tomography.--
       ``(1) Quality incentives.--In the case of an applicable 
     computed tomography service (as defined in paragraph (2)) for 
     which payment is made under an applicable payment system (as 
     defined in paragraph (3)) and that is furnished on or after 
     January 1, 2016, using equipment that is not consistent with 
     the CT equipment standard (described in paragraph (4)), the 
     payment amount for such service shall be reduced by the 
     applicable percentage (as defined in paragraph (5)).
       ``(2) Applicable computed tomography services defined.--In 
     this subsection, the term `applicable computed tomography 
     service' means a service billed using diagnostic radiological 
     imaging codes for computed tomography (identified as of 
     January 1, 2014, by HCPCS codes 70450-70498, 71250-71275, 
     72125-72133, 72191-72194, 73200-73206, 73700-73706, 74150-
     74178, 74261-74263, and 75571-75574 (and any succeeding 
     codes).
       ``(3) Applicable payment system defined.--In this 
     subsection, the term `applicable payment system' means the 
     following:
       ``(A) The technical component and the technical component 
     of the global fee under the fee schedule established under 
     section 1848(b).
       ``(B) The prospective payment system for hospital 
     outpatient department services under section 1833(t).
       ``(4) Consistency with ct equipment standard.--In this 
     subsection, the term `not consistent with the CT equipment 
     standard' means, with respect to an applicable computed 
     tomography service, that the service was furnished using 
     equipment that does not meet each of the attributes of the 
     National Electrical Manufacturers Association (NEMA) Standard 
     XR-29-2013, entitled `Standard Attributes on CT Equipment 
     Related to Dose Optimization and Management'. Through 
     rulemaking, the Secretary may apply successor standards.
       ``(5) Applicable percentage defined.--In this subsection, 
     the term `applicable percentage' means--
       ``(A) for 2016, 5 percent; and
       ``(B) for 2017 and subsequent years, 15 percent.
       ``(6) Implementation.--
       ``(A) Information.--The Secretary shall require that 
     information be provided and attested to by a supplier and a 
     hospital outpatient department that indicates whether an 
     applicable computed tomography service was furnished that was 
     not consistent with the CT equipment standard (described in 
     paragraph (4)). Such information may be included on a claim 
     and may be a modifier. Such information shall be verified, as 
     appropriate, as part of the periodic accreditation of 
     suppliers under section 1834(e) and hospitals under section 
     1865(a).
       ``(B) Administration.--Chapter 35 of title 44, United 
     States Code, shall not apply to information described in 
     subparagraph (A).''.
       (2) Conforming amendments.--
       (A) Prospective payment system for hospital outpatient 
     department services.--Section 1833(t) of the Social Security 
     Act (42 1395l(t)) is amended by adding at the end the 
     following new paragraph:
       ``(20) Not budget neutral application of reduced 
     expenditures resulting from quality incentives for computed 
     tomography.--The Secretary shall not take into account the 
     reduced expenditures that result from the application of 
     section 1834(p) in making any budget neutrality adjustments 
     this subsection.''.
       (B) Physician fee schedule.--Section 1848(c)(2)(B)(v) of 
     the Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)(v)) is 
     amended by adding at the end the following new subclause:

       ``(VIII) Reduced expenditures attributable to application 
     of quality incentives for computed tomography.--Effective for 
     fee schedules established beginning with 2016, reduced 
     expenditures attributable to the application of the quality 
     incentives for computed tomography under section 1834(p)''.

       (b) Promoting Evidence-Based Care.--
       (1) In general.--Section 1834 of the Social Security Act 
     (42 U.S.C. 1395m), as amended by subsection (a), is amended 
     by adding at the end the following new subsection:
       ``(q) Recognizing Appropriate Use Criteria for Certain 
     Imaging Services.--
       ``(1) Program established.--
       ``(A) In general.--The Secretary shall establish a program 
     to promote the use of appropriate use criteria (as defined in 
     subparagraph (B)) for applicable imaging services (as defined 
     in subparagraph (C)) furnished in an applicable setting (as 
     defined in subparagraph (D)) by ordering professionals and 
     furnishing professionals (as defined in subparagraphs (E) and 
     (F), respectively).
       ``(B) Appropriate use criteria defined.--In this 
     subsection, the term `appropriate use criteria' means 
     criteria, only developed or endorsed by national professional 
     medical specialty societies or other provider-led entities, 
     to assist ordering professionals and furnishing professionals 
     in making the most appropriate treatment decision for a 
     specific clinical condition for an individual. To the extent 
     feasible, such criteria shall be evidence-based.
       ``(C) Applicable imaging service defined.--In this 
     subsection, the term `applicable imaging service' means an 
     advanced diagnostic imaging service (as defined in subsection 
     (e)(1)(B)) for which the Secretary determines--
       ``(i) one or more applicable appropriate use criteria 
     specified under paragraph (2) apply;
       ``(ii) there are one or more qualified clinical decision 
     support mechanisms listed under paragraph (3)(C); and
       ``(iii) one or more of such mechanisms is available free of 
     charge.
       ``(D) Applicable setting defined.--In this subsection, the 
     term `applicable setting' means a physician's office, a 
     hospital outpatient department (including an emergency 
     department), an ambulatory surgical center, and any other 
     provider-led outpatient setting determined appropriate by the 
     Secretary.
       ``(E) Ordering professional defined.--In this subsection, 
     the term `ordering professional' means a physician (as 
     defined in section 1861(r)) or a practitioner described in 
     section 1842(b)(18)(C) who orders an applicable imaging 
     service.
       ``(F) Furnishing professional defined.--In this subsection, 
     the term `furnishing professional' means a physician (as 
     defined in section 1861(r)) or a practitioner described in 
     section 1842(b)(18)(C) who furnishes an applicable imaging 
     service.
       ``(2) Establishment of applicable appropriate use 
     criteria.--
       ``(A) In general.--Not later than November 15, 2015, the 
     Secretary shall through rulemaking, and in consultation with 
     physicians,

[[Page H2708]]

     practitioners, and other stakeholders, specify applicable 
     appropriate use criteria for applicable imaging services only 
     from among appropriate use criteria developed or endorsed by 
     national professional medical specialty societies or other 
     provider-led entities.
       ``(B) Considerations.--In specifying applicable appropriate 
     use criteria under subparagraph (A), the Secretary shall take 
     into account whether the criteria--
       ``(i) have stakeholder consensus;
       ``(ii) are scientifically valid and evidence based; and
       ``(iii) are based on studies that are published and 
     reviewable by stakeholders.
       ``(C) Revisions.--The Secretary shall review, on an annual 
     basis, the specified applicable appropriate use criteria to 
     determine if there is a need to update or revise (as 
     appropriate) such specification of applicable appropriate use 
     criteria and make such updates or revisions through 
     rulemaking.
       ``(D) Treatment of multiple applicable appropriate use 
     criteria.--In the case where the Secretary determines that 
     more than one appropriate use criterion applies with respect 
     to an applicable imaging service, the Secretary shall apply 
     one or more applicable appropriate use criteria under this 
     paragraph for the service.
       ``(3) Mechanisms for consultation with applicable 
     appropriate use criteria.--
       ``(A) Identification of mechanisms to consult with 
     applicable appropriate use criteria.--
       ``(i) In general.--The Secretary shall specify qualified 
     clinical decision support mechanisms that could be used by 
     ordering professionals to consult with applicable appropriate 
     use criteria for applicable imaging services.
       ``(ii) Consultation.--The Secretary shall consult with 
     physicians, practitioners, health care technology experts, 
     and other stakeholders in specifying mechanisms under this 
     paragraph.
       ``(iii) Inclusion of certain mechanisms.--Mechanisms 
     specified under this paragraph may include any or all of the 
     following that meet the requirements described in 
     subparagraph (B)(ii):

       ``(I) Use of clinical decision support modules in certified 
     EHR technology (as defined in section 1848(o)(4)).
       ``(II) Use of private sector clinical decision support 
     mechanisms that are independent from certified EHR 
     technology, which may include use of clinical decision 
     support mechanisms available from medical specialty 
     organizations.
       ``(III) Use of a clinical decision support mechanism 
     established by the Secretary.

       ``(B) Qualified clinical decision support mechanisms.--
       ``(i) In general.--For purposes of this subsection, a 
     qualified clinical decision support mechanism is a mechanism 
     that the Secretary determines meets the requirements 
     described in clause (ii).
       ``(ii) Requirements.--The requirements described in this 
     clause are the following:

       ``(I) The mechanism makes available to the ordering 
     professional applicable appropriate use criteria specified 
     under paragraph (2) and the supporting documentation for the 
     applicable imaging service ordered.
       ``(II) In the case where there is more than one applicable 
     appropriate use criterion specified under such paragraph for 
     an applicable imaging service, the mechanism indicates the 
     criteria that it uses for the service.
       ``(III) The mechanism determines the extent to which an 
     applicable imaging service ordered is consistent with the 
     applicable appropriate use criteria so specified.
       ``(IV) The mechanism generates and provides to the ordering 
     professional a certification or documentation that documents 
     that the qualified clinical decision support mechanism was 
     consulted by the ordering professional.
       ``(V) The mechanism is updated on a timely basis to reflect 
     revisions to the specification of applicable appropriate use 
     criteria under such paragraph.
       ``(VI) The mechanism meets privacy and security standards 
     under applicable provisions of law.
       ``(VII) The mechanism performs such other functions as 
     specified by the Secretary, which may include a requirement 
     to provide aggregate feedback to the ordering professional.

       ``(C) List of mechanisms for consultation with applicable 
     appropriate use criteria.--
       ``(i) Initial list.--Not later than April 1, 2016, the 
     Secretary shall publish a list of mechanisms specified under 
     this paragraph.
       ``(ii) Periodic updating of list.--The Secretary shall 
     identify on an annual basis the list of qualified clinical 
     decision support mechanisms specified under this paragraph.
       ``(4) Consultation with applicable appropriate use 
     criteria.--
       ``(A) Consultation by ordering professional.--Beginning 
     with January 1, 2017, subject to subparagraph (C), with 
     respect to an applicable imaging service ordered by an 
     ordering professional that would be furnished in an 
     applicable setting and paid for under an applicable payment 
     system (as defined in subparagraph (D)), an ordering 
     professional shall--
       ``(i) consult with a qualified decision support mechanism 
     listed under paragraph (3)(C); and
       ``(ii) provide to the furnishing professional the 
     information described in clauses (i) through (iii) of 
     subparagraph (B).
       ``(B) Reporting by furnishing professional.--Beginning with 
     January 1, 2017, subject to subparagraph (C), with respect to 
     an applicable imaging service furnished in an applicable 
     setting and paid for under an applicable payment system (as 
     defined in subparagraph (D)), payment for such service may 
     only be made if the claim for the service includes the 
     following:
       ``(i) Information about which qualified clinical decision 
     support mechanism was consulted by the ordering professional 
     for the service.
       ``(ii) Information regarding--

       ``(I) whether the service ordered would adhere to the 
     applicable appropriate use criteria specified under paragraph 
     (2);
       ``(II) whether the service ordered would not adhere to such 
     criteria; or
       ``(III) whether such criteria was not applicable to the 
     service ordered.

       ``(iii) The national provider identifier of the ordering 
     professional (if different from the furnishing professional).
       ``(C) Exceptions.--The provisions of subparagraphs (A) and 
     (B) and paragraph (6)(A) shall not apply to the following:
       ``(i) Emergency services.--An applicable imaging service 
     ordered for an individual with an emergency medical condition 
     (as defined in section 1867(e)(1)).
       ``(ii) Inpatient services.--An applicable imaging service 
     ordered for an inpatient and for which payment is made under 
     part A.
       ``(iii) Significant hardship.--An applicable imaging 
     service ordered by an ordering professional who the Secretary 
     may, on a case-by-case basis, exempt from the application of 
     such provisions if the Secretary determines, subject to 
     annual renewal, that consultation with applicable appropriate 
     use criteria would result in a significant hardship, such as 
     in the case of a professional who practices in a rural area 
     without sufficient Internet access.
       ``(D) Applicable payment system defined.--In this 
     subsection, the term `applicable payment system' means the 
     following:
       ``(i) The physician fee schedule established under section 
     1848(b).
       ``(ii) The prospective payment system for hospital 
     outpatient department services under section 1833(t).
       ``(iii) The ambulatory surgical center payment systems 
     under section 1833(i).
       ``(5) Identification of outlier ordering professionals.--
       ``(A) In general.--With respect to applicable imaging 
     services furnished beginning with 2017, the Secretary shall 
     determine, on an annual basis, no more than five percent of 
     the total number of ordering professionals who are outlier 
     ordering professionals.
       ``(B) Outlier ordering professionals.--The determination of 
     an outlier ordering professional shall--
       ``(i) be based on low adherence to applicable appropriate 
     use criteria specified under paragraph (2), which may be 
     based on comparison to other ordering professionals; and
       ``(ii) include data for ordering professionals for whom 
     prior authorization under paragraph (6)(A) applies.
       ``(C) Use of two years of data.--The Secretary shall use 
     two years of data to identify outlier ordering professionals 
     under this paragraph.
       ``(D) Process.--The Secretary shall establish a process for 
     determining when an outlier ordering professional is no 
     longer an outlier ordering professional.
       ``(E) Consultation with stakeholders.--The Secretary shall 
     consult with physicians, practitioners and other stakeholders 
     in developing methods to identify outlier ordering 
     professionals under this paragraph.
       ``(6) Prior authorization for ordering professionals who 
     are outliers.--
       ``(A) In general.--Beginning January 1, 2020, subject to 
     paragraph (4)(C), with respect to services furnished during a 
     year, the Secretary shall, for a period determined 
     appropriate by the Secretary, apply prior authorization for 
     applicable imaging services that are ordered by an outlier 
     ordering professional identified under paragraph (5).
       ``(B) Appropriate use criteria in prior authorization.--In 
     applying prior authorization under subparagraph (A), the 
     Secretary shall utilize only the applicable appropriate use 
     criteria specified under this subsection.
       ``(C) Funding.--For purposes of carrying out this 
     paragraph, the Secretary shall provide for the transfer, from 
     the Federal Supplementary Medical Insurance Trust Fund under 
     section 1841, of $5,000,000 to the Centers for Medicare & 
     Medicaid Services Program Management Account for each of 
     fiscal years 2019 through 2021. Amounts transferred under the 
     preceding sentence shall remain available until expended.
       ``(7) Construction.--Nothing in this subsection shall be 
     construed as granting the Secretary the authority to develop 
     or initiate the development of clinical practice guidelines 
     or appropriate use criteria.''.
       (2) Conforming amendment.--Section 1833(t)(16) of the 
     Social Security Act (42 U.S.C. 1395l(t)(16)) is amended by 
     adding at the end the following new subparagraph:
       ``(E) Application of appropriate use criteria for certain 
     imaging services.--For provisions relating to the application 
     of appropriate use criteria for certain imaging services, see 
     section 1834(q).''.
       (3) Report on experience of imaging appropriate use 
     criteria program.--Not later than 18 months after the date of 
     the enactment of this Act, the Comptroller General of the 
     United States shall submit to Congress a report that includes 
     a description of the extent to which appropriate use criteria 
     could be used for other services under part B of

[[Page H2709]]

     title XVIII of the Social Security Act (42 U.S.C. 1395j et 
     seq.), such as radiation therapy and clinical diagnostic 
     laboratory services.

     SEC. 219. USING FUNDING FROM TRANSITIONAL FUND FOR 
                   SUSTAINABLE GROWTH RATE (SGR) REFORM.

       Section 1898(b)(1) of the Social Security Act (42 U.S.C. 
     1395iii(b)(1)) is amended by striking ``$2,300,000,000'' and 
     inserting ``$0''.

     SEC. 220. ENSURING ACCURATE VALUATION OF SERVICES UNDER THE 
                   PHYSICIAN FEE SCHEDULE.

       (a) Authority To Collect and Use Information on Physicians' 
     Services in the Determination of Relative Values.--
       (1) In general.--Section 1848(c)(2) of the Social Security 
     Act (42 U.S.C. 1395w-4(c)(2)) is amended by adding at the end 
     the following new subparagraph:
       ``(M) Authority to collect and use information on 
     physicians' services in the determination of relative 
     values.--
       ``(i) Collection of information.--Notwithstanding any other 
     provision of law, the Secretary may collect or obtain 
     information on the resources directly or indirectly related 
     to furnishing services for which payment is made under the 
     fee schedule established under subsection (b). Such 
     information may be collected or obtained from any eligible 
     professional or any other source.
       ``(ii) Use of information.--Notwithstanding any other 
     provision of law, subject to clause (v), the Secretary may 
     (as the Secretary determines appropriate) use information 
     collected or obtained pursuant to clause (i) in the 
     determination of relative values for services under this 
     section.
       ``(iii) Types of information.--The types of information 
     described in clauses (i) and (ii) may, at the Secretary's 
     discretion, include any or all of the following:

       ``(I) Time involved in furnishing services.
       ``(II) Amounts and types of practice expense inputs 
     involved with furnishing services.
       ``(III) Prices (net of any discounts) for practice expense 
     inputs, which may include paid invoice prices or other 
     documentation or records.
       ``(IV) Overhead and accounting information for practices of 
     physicians and other suppliers.
       ``(V) Any other element that would improve the valuation of 
     services under this section.

       ``(iv) Information collection mechanisms.--Information may 
     be collected or obtained pursuant to this subparagraph from 
     any or all of the following:

       ``(I) Surveys of physicians, other suppliers, providers of 
     services, manufacturers, and vendors.
       ``(II) Surgical logs, billing systems, or other practice or 
     facility records.
       ``(III) Electronic health records.
       ``(IV) Any other mechanism determined appropriate by the 
     Secretary.

       ``(v) Transparency of use of information.--

       ``(I) In general.--Subject to subclauses (II) and (III), if 
     the Secretary uses information collected or obtained under 
     this subparagraph in the determination of relative values 
     under this subsection, the Secretary shall disclose the 
     information source and discuss the use of such information in 
     such determination of relative values through notice and 
     comment rulemaking.
       ``(II) Thresholds for use.--The Secretary may establish 
     thresholds in order to use such information, including the 
     exclusion of information collected or obtained from eligible 
     professionals who use very high resources (as determined by 
     the Secretary) in furnishing a service.
       ``(III) Disclosure of information.--The Secretary shall 
     make aggregate information available under this subparagraph 
     but shall not disclose information in a form or manner that 
     identifies an eligible professional or a group practice, or 
     information collected or obtained pursuant to a nondisclosure 
     agreement.

       ``(vi) Incentive to participate.--The Secretary may provide 
     for such payments under this part to an eligible professional 
     that submits such solicited information under this 
     subparagraph as the Secretary determines appropriate in order 
     to compensate such eligible professional for such submission. 
     Such payments shall be provided in a form and manner 
     specified by the Secretary.
       ``(vii) Administration.--Chapter 35 of title 44, United 
     States Code, shall not apply to information collected or 
     obtained under this subparagraph.
       ``(viii) Definition of eligible professional.--In this 
     subparagraph, the term `eligible professional' has the 
     meaning given such term in subsection (k)(3)(B).
       ``(ix) Funding.--For purposes of carrying out this 
     subparagraph, in addition to funds otherwise appropriated, 
     the Secretary shall provide for the transfer, from the 
     Federal Supplementary Medical Insurance Trust Fund under 
     section 1841, of $2,000,000 to the Centers for Medicare & 
     Medicaid Services Program Management Account for each fiscal 
     year beginning with fiscal year 2014. Amounts transferred 
     under the preceding sentence for a fiscal year shall be 
     available until expended.''.
       (2) Limitation on review.--Section 1848(i)(1) of the Social 
     Security Act (42 U.S.C. 1395w-4(i)(1)) is amended--
       (A) in subparagraph (D), by striking ``and'' at the end;
       (B) in subparagraph (E), by striking the period at the end 
     and inserting ``, and''; and
       (C) by adding at the end the following new subparagraph:
       ``(F) the collection and use of information in the 
     determination of relative values under subsection 
     (c)(2)(M).''.
       (b) Authority for Alternative Approaches To Establishing 
     Practice Expense Relative Values.--Section 1848(c)(2) of the 
     Social Security Act (42 U.S.C. 1395w-4(c)(2)), as amended by 
     subsection (a), is amended by adding at the end the following 
     new subparagraph:
       ``(N) Authority for alternative approaches to establishing 
     practice expense relative values.--The Secretary may 
     establish or adjust practice expense relative values under 
     this subsection using cost, charge, or other data from 
     suppliers or providers of services, including information 
     collected or obtained under subparagraph (M).''.
       (c) Revised and Expanded Identification of Potentially 
     Misvalued Codes.--Section 1848(c)(2)(K)(ii) of the Social 
     Security Act (42 U.S.C. 1395w-4(c)(2)(K)(ii)) is amended to 
     read as follows:
       ``(ii) Identification of potentially misvalued codes.--For 
     purposes of identifying potentially misvalued codes pursuant 
     to clause (i)(I), the Secretary shall examine codes (and 
     families of codes as appropriate) based on any or all of the 
     following criteria:

       ``(I) Codes that have experienced the fastest growth.
       ``(II) Codes that have experienced substantial changes in 
     practice expenses.
       ``(III) Codes that describe new technologies or services 
     within an appropriate time period (such as 3 years) after the 
     relative values are initially established for such codes.
       ``(IV) Codes which are multiple codes that are frequently 
     billed in conjunction with furnishing a single service.
       ``(V) Codes with low relative values, particularly those 
     that are often billed multiple times for a single treatment.
       ``(VI) Codes that have not been subject to review since 
     implementation of the fee schedule.
       ``(VII) Codes that account for the majority of spending 
     under the physician fee schedule.
       ``(VIII) Codes for services that have experienced a 
     substantial change in the hospital length of stay or 
     procedure time.
       ``(IX) Codes for which there may be a change in the typical 
     site of service since the code was last valued.
       ``(X) Codes for which there is a significant difference in 
     payment for the same service between different sites of 
     service.
       ``(XI) Codes for which there may be anomalies in relative 
     values within a family of codes.
       ``(XII) Codes for services where there may be efficiencies 
     when a service is furnished at the same time as other 
     services.
       ``(XIII) Codes with high intra-service work per unit of 
     time.
       ``(XIV) Codes with high practice expense relative value 
     units.
       ``(XV) Codes with high cost supplies.
       ``(XVI) Codes as determined appropriate by the 
     Secretary.''.

       (d) Target for Relative Value Adjustments for Misvalued 
     Services.--
       (1) In general.--Section 1848(c)(2) of the Social Security 
     Act (42 U.S.C. 1395w-4(c)(2)), as amended by subsections (a) 
     and (b), is amended by adding at the end the following new 
     subparagraph:
       ``(O) Target for relative value adjustments for misvalued 
     services.--With respect to fee schedules established for each 
     of 2017 through 2020, the following shall apply:
       ``(i) Determination of net reduction in expenditures.--For 
     each year, the Secretary shall determine the estimated net 
     reduction in expenditures under the fee schedule under this 
     section with respect to the year as a result of adjustments 
     to the relative values established under this paragraph for 
     misvalued codes.
       ``(ii) Budget neutral redistribution of funds if target met 
     and counting overages towards the target for the succeeding 
     year.--If the estimated net reduction in expenditures 
     determined under clause (i) for the year is equal to or 
     greater than the target for the year--

       ``(I) reduced expenditures attributable to such adjustments 
     shall be redistributed for the year in a budget neutral 
     manner in accordance with subparagraph (B)(ii)(II); and
       ``(II) the amount by which such reduced expenditures 
     exceeds the target for the year shall be treated as a 
     reduction in expenditures described in clause (i) for the 
     succeeding year, for purposes of determining whether the 
     target has or has not been met under this subparagraph with 
     respect to that year.

       ``(iii) Exemption from budget neutrality if target not 
     met.--If the estimated net reduction in expenditures 
     determined under clause (i) for the year is less than the 
     target for the year, reduced expenditures in an amount equal 
     to the target recapture amount shall not be taken into 
     account in applying subparagraph (B)(ii)(II) with respect to 
     fee schedules beginning with 2017.
       ``(iv) Target recapture amount.--For purposes of clause 
     (iii), the target recapture amount is, with respect to a 
     year, an amount equal to the difference between--

       ``(I) the target for the year; and
       ``(II) the estimated net reduction in expenditures 
     determined under clause (i) for the year.

       ``(v) Target.--For purposes of this subparagraph, with 
     respect to a year, the target is calculated as 0.5 percent of 
     the estimated

[[Page H2710]]

     amount of expenditures under the fee schedule under this 
     section for the year.''.
       (2) Conforming amendment.--Section 1848(c)(2)(B)(v) of the 
     Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)(v)) is 
     amended by adding at the end the following new subclause:

       ``(VIII) Reductions for misvalued services if target not 
     met.--Effective for fee schedules beginning with 2017, 
     reduced expenditures attributable to the application of the 
     target recapture amount described in subparagraph 
     (O)(iii).''.

       (e) Phase-In of Significant Relative Value Unit (RVU) 
     Reductions.--
       (1) In general.--Section 1848(c) of the Social Security Act 
     (42 U.S.C. 1395w-4(c)) is amended by adding at the end the 
     following new paragraph:
       ``(7) Phase-in of significant relative value unit (rvu) 
     reductions.--Effective for fee schedules established 
     beginning with 2017, for services that are not new or revised 
     codes, if the total relative value units for a service for a 
     year would otherwise be decreased by an estimated amount 
     equal to or greater than 20 percent as compared to the total 
     relative value units for the previous year, the applicable 
     adjustments in work, practice expense, and malpractice 
     relative value units shall be phased-in over a 2-year 
     period.''.
       (2) Conforming amendments.--Section 1848(c)(2) of the 
     Social Security Act (42 U.S.C. 1395w-4(c)(2)) is amended--
       (A) in subparagraph (B)(ii)(I), by striking ``subclause 
     (II)'' and inserting ``subclause (II) and paragraph (7)''; 
     and
       (B) in subparagraph (K)(iii)(VI)--
       (i) by striking ``provisions of subparagraph (B)(ii)(II)'' 
     and inserting ``provisions of subparagraph (B)(ii)(II) and 
     paragraph (7)''; and
       (ii) by striking ``under subparagraph (B)(ii)(II)'' and 
     inserting ``under subparagraph (B)(ii)(I)''.
       (f) Authority To Smooth Relative Values Within Groups of 
     Services.--Section 1848(c)(2)(C) of the Social Security Act 
     (42 U.S.C. 1395w-4(c)(2)(C)) is amended--
       (1) in each of clauses (i) and (iii), by striking ``the 
     service'' and inserting ``the service or group of services'' 
     each place it appears; and
       (2) in the first sentence of clause (ii), by inserting ``or 
     group of services'' before the period.
       (g) GAO Study and Report on Relative Value Scale Update 
     Committee.--
       (1) Study.--The Comptroller General of the United States 
     (in this subsection referred to as the ``Comptroller 
     General'') shall conduct a study of the processes used by the 
     Relative Value Scale Update Committee (RUC) to provide 
     recommendations to the Secretary of Health and Human Services 
     regarding relative values for specific services under the 
     Medicare physician fee schedule under section 1848 of the 
     Social Security Act (42 U.S.C. 1395w-4).
       (2) Report.--Not later than 1 year after the date of the 
     enactment of this Act, the Comptroller General shall submit 
     to Congress a report containing the results of the study 
     conducted under paragraph (1).
       (h) Adjustment to Medicare Payment Localities.--
       (1) In general.--Section 1848(e) of the Social Security Act 
     (42 U.S.C. 1395w-4(e)) is amended by adding at the end the 
     following new paragraph:
       ``(6) Use of msas as fee schedule areas in california.--
       ``(A) In general.--Subject to the succeeding provisions of 
     this paragraph and notwithstanding the previous provisions of 
     this subsection, for services furnished on or after January 
     1, 2017, the fee schedule areas used for payment under this 
     section applicable to California shall be the following:
       ``(i) Each Metropolitan Statistical Area (each in this 
     paragraph referred to as an `MSA'), as defined by the 
     Director of the Office of Management and Budget as of 
     December 31 of the previous year, shall be a fee schedule 
     area.
       ``(ii) All areas not included in an MSA shall be treated as 
     a single rest-of-State fee schedule area.
       ``(B) Transition for msas previously in rest-of-state 
     payment locality or in locality 3.--
       ``(i) In general.--For services furnished in California 
     during a year beginning with 2017 and ending with 2021 in an 
     MSA in a transition area (as defined in subparagraph (D)), 
     subject to subparagraph (C), the geographic index values to 
     be applied under this subsection for such year shall be equal 
     to the sum of the following:

       ``(I) Current law component.--The old weighting factor 
     (described in clause (ii)) for such year multiplied by the 
     geographic index values under this subsection for the fee 
     schedule area that included such MSA that would have applied 
     in such area (as estimated by the Secretary) if this 
     paragraph did not apply.
       ``(II) MSA-based component.--The MSA-based weighting factor 
     (described in clause (iii)) for such year multiplied by the 
     geographic index values computed for the fee schedule area 
     under subparagraph (A) for the year (determined without 
     regard to this subparagraph).

       ``(ii) Old weighting factor.--The old weighting factor 
     described in this clause--

       ``(I) for 2017, is \5/6\; and
       ``(II) for each succeeding year, is the old weighting 
     factor described in this clause for the previous year minus 
     \1/6\.

       ``(iii) MSA-based weighting factor.--The MSA-based 
     weighting factor described in this clause for a year is 1 
     minus the old weighting factor under clause (ii) for that 
     year.
       ``(C) Hold harmless.--For services furnished in a 
     transition area in California during a year beginning with 
     2017, the geographic index values to be applied under this 
     subsection for such year shall not be less than the 
     corresponding geographic index values that would have applied 
     in such transition area (as estimated by the Secretary) if 
     this paragraph did not apply.
       ``(D) Transition area defined.--In this paragraph, the term 
     `transition area' means each of the following fee schedule 
     areas for 2013:
       ``(i) The rest-of-State payment locality.
       ``(ii) Payment locality 3.
       ``(E) References to fee schedule areas.--Effective for 
     services furnished on or after January 1, 2017, for 
     California, any reference in this section to a fee schedule 
     area shall be deemed a reference to a fee schedule area 
     established in accordance with this paragraph.''.
       (2) Conforming amendment to definition of fee schedule 
     area.--Section 1848(j)(2) of the Social Security Act (42 
     U.S.C. 1395w-4(j)(2)) is amended by striking ``The term'' and 
     inserting ``Except as provided in subsection (e)(6)(D), the 
     term''.
       (i) Disclosure of Data Used To Establish Multiple Procedure 
     Payment Reduction Policy.--The Secretary of Health and Human 
     Services shall make publicly available the information used 
     to establish the multiple procedure payment reduction policy 
     to the professional component of imaging services in the 
     final rule published in the Federal Register, v. 77, n. 222, 
     November 16, 2012, pages 68891-69380 under the physician fee 
     schedule under section 1848 of the Social Security Act (42 
     U.S.C. 1395w-4).

     SEC. 221. MEDICAID DSH.

       (a) Modifications of Reductions to Allotments.--Section 
     1923(f) of the Social Security Act (42 U.S.C. 1396r-4(f)) is 
     amended--
       (1) in paragraph (7)(A)--
       (A) in clause (i), by striking ``2016 through 2020'' and 
     inserting ``2017 through 2024''; and
       (B) in clause (ii), by striking subclauses (I) through 
     (IV), and inserting the following:

       ``(I) $1,800,000,000 for fiscal year 2017;
       ``(II) $4,700,000,000 for fiscal year 2018;
       ``(III) $4,700,000,000 for fiscal year 2019;
       ``(IV) $4,700,000,000 for fiscal year 2020;
       ``(V) $4,800,000,000 for fiscal year 2021;
       ``(VI) $5,000,000,000 for fiscal year 2022;
       ``(VII) $5,000,000,000 for fiscal year 2023; and
       ``(VIII) $4,400,000,000 for fiscal year 2024.''; and

       (2) by striking paragraph (8) and inserting the following:
       ``(8) Calculation of DSH allotments after reductions 
     period.--The DSH allotment for a State for fiscal years after 
     fiscal year 2024 shall be calculated under paragraph (3) 
     without regard to paragraph (7).''.
       (b) MACPAC Review and Report.--Section 1900(b)(6) of the 
     Social Security Act (42 U.S.C. 1396(b)(6)) is amended--
       (1) by striking ``MACPAC shall consult'' and inserting the 
     following:
       ``(A) In general.--MACPAC shall consult''; and
       (2) by adding at the end the following:
       ``(B) Review and reports regarding medicaid dsh.--
       ``(i) In general.--MACPAC shall review and submit an annual 
     report to Congress on disproportionate share hospital 
     payments under section 1923. Each report shall include the 
     information specified in clause (ii).
       ``(ii) Required report information.--Each report required 
     under this subparagraph shall include the following:

       ``(I) Data relating to changes in the number of uninsured 
     individuals.
       ``(II) Data relating to the amount and sources of 
     hospitals' uncompensated care costs, including the amount of 
     such costs that are the result of providing unreimbursed or 
     under-reimbursed services, charity care, or bad debt.
       ``(III) Data identifying hospitals with high levels of 
     uncompensated care that also provide access to essential 
     community services for low-income, uninsured, and vulnerable 
     populations, such as graduate medical education, and the 
     continuum of primary through quarternary care, including the 
     provision of trauma care and public health services.
       ``(IV) State-specific analyses regarding the relationship 
     between the most recent State DSH allotment and the projected 
     State DSH allotment for the succeeding year and the data 
     reported under subclauses (I), (II), and (III) for the State.

       ``(iii) Data.--Notwithstanding any other provision of law, 
     the Secretary regularly shall provide MACPAC with the most 
     recent State reports and most recent independent certified 
     audits submitted under section 1923(j), cost reports 
     submitted under title XVIII, and such other data as MACPAC 
     may request for purposes of conducting the reviews and 
     preparing and submitting the annual reports required under 
     this subparagraph.
       ``(iv) Submission deadlines.--The first report required 
     under this subparagraph shall be submitted to Congress not 
     later than February 1, 2016. Subsequent reports shall be 
     submitted as part of, or with, each annual report required 
     under paragraph (1)(C) during the period of fiscal years 2017 
     through 2024.''.

     SEC. 222. REALIGNMENT OF THE MEDICARE SEQUESTER FOR FISCAL 
                   YEAR 2024.

       Paragraph (6) (relating to implementing direct spending 
     reductions) of section 251A of

[[Page H2711]]

     the Balanced Budget and Emergency Deficit Control Act of 1985 
     (2 U.S.C. 901a) is amended by adding at the end the following 
     new subparagraph:
       ``(D) Notwithstanding the 2 percent limit specified in 
     subparagraph (A) for payments for the Medicare programs 
     specified in section 256(d), the sequestration order of the 
     President under such subparagraph for fiscal year 2024 shall 
     be applied to such payments so that--
       ``(i) with respect to the first 6 months in which such 
     order is effective for such fiscal year, the payment 
     reduction shall be 4.0 percent; and
       ``(ii) with respect to the second 6 months in which such 
     order is so effective for such fiscal year, the payment 
     reduction shall be 0.0 percent.''.

     SEC. 223. DEMONSTRATION PROGRAMS TO IMPROVE COMMUNITY MENTAL 
                   HEALTH SERVICES.

       (a) Criteria for Certified Community Behavioral Health 
     Clinics To Participate in Demonstration Programs.--
       (1) Publication.--Not later than September 1, 2015, the 
     Secretary shall publish criteria for a clinic to be certified 
     by a State as a certified community behavioral health clinic 
     for purposes of participating in a demonstration program 
     conducted under subsection (d).
       (2) Requirements.--The criteria published under this 
     subsection shall include criteria with respect to the 
     following:
       (A) Staffing.--Staffing requirements, including criteria 
     that staff have diverse disciplinary backgrounds, have 
     necessary State-required license and accreditation, and are 
     culturally and linguistically trained to serve the needs of 
     the clinic's patient population.
       (B) Availability and accessibility of services.--
     Availability and accessibility of services, including crisis 
     management services that are available and accessible 24 
     hours a day, the use of a sliding scale for payment, and no 
     rejection for services or limiting of services on the basis 
     of a patient's ability to pay or a place of residence.
       (C) Care coordination.--Care coordination, including 
     requirements to coordinate care across settings and providers 
     to ensure seamless transitions for patients across the full 
     spectrum of health services including acute, chronic, and 
     behavioral health needs. Care coordination requirements shall 
     include partnerships or formal contracts with the following:
       (i) Federally-qualified health centers (and as applicable, 
     rural health clinics) to provide Federally-qualified health 
     center services (and as applicable, rural health clinic 
     services) to the extent such services are not provided 
     directly through the certified community behavioral health 
     clinic.
       (ii) Inpatient psychiatric facilities and substance use 
     detoxification, post-detoxification step-down services, and 
     residential programs.
       (iii) Other community or regional services, supports, and 
     providers, including schools, child welfare agencies, 
     juvenile and criminal justice agencies and facilities, Indian 
     Health Service youth regional treatment centers, State 
     licensed and nationally accredited child placing agencies for 
     therapeutic foster care service, and other social and human 
     services.
       (iv) Department of Veterans Affairs medical centers, 
     independent outpatient clinics, drop-in centers, and other 
     facilities of the Department as defined in section 1801 of 
     title 38, United States Code.
       (v) Inpatient acute care hospitals and hospital outpatient 
     clinics.
       (D) Scope of services.--Provision (in a manner reflecting 
     person-centered care) of the following services which, if not 
     available directly through the certified community behavioral 
     health clinic, are provided or referred through formal 
     relationships with other providers:
       (i) Crisis mental health services, including 24-hour mobile 
     crisis teams, emergency crisis intervention services, and 
     crisis stabilization.
       (ii) Screening, assessment, and diagnosis, including risk 
     assessment.
       (iii) Patient-centered treatment planning or similar 
     processes, including risk assessment and crisis planning.
       (iv) Outpatient mental health and substance use services.
       (v) Outpatient clinic primary care screening and monitoring 
     of key health indicators and health risk.
       (vi) Targeted case management.
       (vii) Psychiatric rehabilitation services.
       (viii) Peer support and counselor services and family 
     supports.
       (ix) Intensive, community-based mental health care for 
     members of the armed forces and veterans, particularly those 
     members and veterans located in rural areas, provided the 
     care is consistent with minimum clinical mental health 
     guidelines promulgated by the Veterans Health Administration 
     including clinical guidelines contained in the Uniform Mental 
     Health Services Handbook of such Administration.
       (E) Quality and other reporting.--Reporting of encounter 
     data, clinical outcomes data, quality data, and such other 
     data as the Secretary requires.
       (F) Organizational authority.--Criteria that a clinic be a 
     non-profit or part of a local government behavioral health 
     authority or operated under the authority of the Indian 
     Health Service, an Indian tribe or tribal organization 
     pursuant to a contract, grant, cooperative agreement, or 
     compact with the Indian Health Service pursuant to the Indian 
     Self-Determination Act (25 U.S.C. 450 et seq.), or an urban 
     Indian organization pursuant to a grant or contract with the 
     Indian Health Service under title V of the Indian Health Care 
     Improvement Act (25 U.S.C. 1601 et seq.).
       (b) Guidance on Development of Prospective Payment System 
     for Testing Under Demonstration Programs.--
       (1) In general.--Not later than September 1, 2015, the 
     Secretary, through the Administrator of the Centers for 
     Medicare & Medicaid Services, shall issue guidance for the 
     establishment of a prospective payment system that shall only 
     apply to medical assistance for mental health services 
     furnished by a certified community behavioral health clinic 
     participating in a demonstration program under subsection 
     (d).
       (2) Requirements.--The guidance issued by the Secretary 
     under paragraph (1) shall provide that--
       (A) no payment shall be made for inpatient care, 
     residential treatment, room and board expenses, or any other 
     non-ambulatory services, as determined by the Secretary; and
       (B) no payment shall be made to satellite facilities of 
     certified community behavioral health clinics if such 
     facilities are established after the date of enactment of 
     this Act.
       (c) Planning Grants.--
       (1) In general.--Not later than January 1, 2016, the 
     Secretary shall award planning grants to States for the 
     purpose of developing proposals to participate in time-
     limited demonstration programs described in subsection (d).
       (2) Use of funds.--A State awarded a planning grant under 
     this subsection shall--
       (A) solicit input with respect to the development of such a 
     demonstration program from patients, providers, and other 
     stakeholders;
       (B) certify clinics as certified community behavioral 
     health clinics for purposes of participating in a 
     demonstration program conducted under subsection (d); and
       (C) establish a prospective payment system for mental 
     health services furnished by a certified community behavioral 
     health clinic participating in a demonstration program under 
     subsection (d) in accordance with the guidance issued under 
     subsection (b).
       (d) Demonstration Programs.--
       (1) In general.--Not later than September 1, 2017, the 
     Secretary shall select States to participate in demonstration 
     programs that are developed through planning grants awarded 
     under subsection (c), meet the requirements of this 
     subsection, and represent a diverse selection of geographic 
     areas, including rural and underserved areas.
       (2) Application requirements.--
       (A) In general.--The Secretary shall solicit applications 
     to participate in demonstration programs under this 
     subsection solely from States awarded planning grants under 
     subsection (c).
       (B) Required information.--An application for a 
     demonstration program under this subsection shall include the 
     following:
       (i) The target Medicaid population to be served under the 
     demonstration program.
       (ii) A list of participating certified community behavioral 
     health clinics.
       (iii) Verification that the State has certified a 
     participating clinic as a certified community behavioral 
     health clinic in accordance with the requirements of 
     subsection (b).
       (iv) A description of the scope of the mental health 
     services available under the State Medicaid program that will 
     be paid for under the prospective payment system tested in 
     the demonstration program.
       (v) Verification that the State has agreed to pay for such 
     services at the rate established under the prospective 
     payment system.
       (vi) Such other information as the Secretary may require 
     relating to the demonstration program including with respect 
     to determining the soundness of the proposed prospective 
     payment system.
       (3) Number and length of demonstration programs.--Not more 
     than 8 States shall be selected for 2-year demonstration 
     programs under this subsection.
       (4) Requirements for selecting demonstration programs.--
       (A) In general.--The Secretary shall give preference to 
     selecting demonstration programs where participating 
     certified community behavioral health clinics--
       (i) provide the most complete scope of services described 
     in subsection (a)(2)(D) to individuals eligible for medical 
     assistance under the State Medicaid program;
       (ii) will improve availability of, access to, and 
     participation in, services described in subsection (a)(2)(D) 
     to individuals eligible for medical assistance under the 
     State Medicaid program;
       (iii) will improve availability of, access to, and 
     participation in assisted outpatient mental health treatment 
     in the State; or
       (iv) demonstrate the potential to expand available mental 
     health services in a demonstration area and increase the 
     quality of such services without increasing net Federal 
     spending.
       (5) Payment for medical assistance for mental health 
     services provided by certified community behavioral health 
     clinics.--
       (A) In general.--The Secretary shall pay a State 
     participating in a demonstration program under this 
     subsection the Federal

[[Page H2712]]

     matching percentage specified in subparagraph (B) for amounts 
     expended by the State to provide medical assistance for 
     mental health services described in the demonstration program 
     application in accordance with paragraph (2)(B)(iv) that are 
     provided by certified community behavioral health clinics to 
     individuals who are enrolled in the State Medicaid program. 
     Payments to States made under this paragraph shall be 
     considered to have been under, and are subject to the 
     requirements of, section 1903 of the Social Security Act (42 
     U.S.C. 1396b).
       (B) Federal matching percentage.--The Federal matching 
     percentage specified in this subparagraph is with respect to 
     medical assistance described in subparagraph (A) that is 
     furnished--
       (i) to a newly eligible individual described in paragraph 
     (2) of section 1905(y) of the Social Security Act (42 U.S.C. 
     1396d(y)), the matching rate applicable under paragraph (1) 
     of that section; and
       (ii) to an individual who is not a newly eligible 
     individual (as so described) but who is eligible for medical 
     assistance under the State Medicaid program, the enhanced 
     FMAP applicable to the State.
       (C) Limitations.--
       (i) In general.--Payments shall be made under this 
     paragraph to a State only for mental health services--

       (I) that are described in the demonstration program 
     application in accordance with paragraph (2)(iv);
       (II) for which payment is available under the State 
     Medicaid program; and
       (III) that are provided to an individual who is eligible 
     for medical assistance under the State Medicaid program.

       (ii) Prohibited payments.--No payment shall be made under 
     this paragraph--

       (I) for inpatient care, residential treatment, room and 
     board expenses, or any other non-ambulatory services, as 
     determined by the Secretary; or
       (II) with respect to payments made to satellite facilities 
     of certified community behavioral health clinics if such 
     facilities are established after the date of enactment of 
     this Act.

       (6) Waiver of statewideness requirement.--The Secretary 
     shall waive section 1902(a)(1) of the Social Security Act (42 
     U.S.C. 1396a(a)(1)) (relating to statewideness) as may be 
     necessary to conduct demonstration programs in accordance 
     with the requirements of this subsection.
       (7) Annual reports.--
       (A) In general.--Not later than 1 year after the date on 
     which the first State is selected for a demonstration program 
     under this subsection, and annually thereafter, the Secretary 
     shall submit to Congress an annual report on the use of funds 
     provided under all demonstration programs conducted under 
     this subsection. Each such report shall include--
       (i) an assessment of access to community-based mental 
     health services under the Medicaid program in the area or 
     areas of a State targeted by a demonstration program compared 
     to other areas of the State;
       (ii) an assessment of the quality and scope of services 
     provided by certified community behavioral health clinics 
     compared to community-based mental health services provided 
     in States not participating in a demonstration program under 
     this subsection and in areas of a demonstration State that 
     are not participating in the demonstration program; and
       (iii) an assessment of the impact of the demonstration 
     programs on the Federal and State costs of a full range of 
     mental health services (including inpatient, emergency and 
     ambulatory services).
       (B) Recommendations.--Not later than December 31, 2021, the 
     Secretary shall submit to Congress recommendations concerning 
     whether the demonstration programs under this section should 
     be continued, expanded, modified, or terminated.
       (e) Definitions.--In this section:
       (1) Federally-qualified health center services; federally-
     qualified health center; rural health clinic services; rural 
     health clinic.--The terms ``Federally-qualified health center 
     services'', ``Federally-qualified health center'', ``rural 
     health clinic services'', and ``rural health clinic'' have 
     the meanings given those terms in section 1905(l) of the 
     Social Security Act (42 U.S.C. 1396d(l)).
       (2) Enhanced fmap.--The term ``enhanced FMAP'' has the 
     meaning given that term in section 2105(b) of the Social 
     Security Act (42 U.S.C. 1397dd(b)) but without regard to the 
     second and third sentences of that section.
       (3) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (4) State.--The term ``State'' has the meaning given such 
     term for purposes of title XIX of the Social Security Act (42 
     U.S.C. 1396 et seq.).
       (f) Funding.--
       (1) In general.--Out of any funds in the Treasury not 
     otherwise appropriated, there is appropriated to the 
     Secretary--
       (A) for purposes of carrying out subsections (a), (b), and 
     (d)(7), $2,000,000 for fiscal year 2014; and
       (B) for purposes of awarding planning grants under 
     subsection (c), $25,000,000 for fiscal year 2016.
       (2) Availability.--Funds appropriated under paragraph (1) 
     shall remain available until expended.

     SEC. 224. ASSISTED OUTPATIENT TREATMENT GRANT PROGRAM FOR 
                   INDIVIDUALS WITH SERIOUS MENTAL ILLNESS.

       (a) In General.--The Secretary shall establish a 4-year 
     pilot program to award not more than 50 grants each year to 
     eligible entities for assisted outpatient treatment programs 
     for individuals with serious mental illness.
       (b) Consultation.--The Secretary shall carry out this 
     section in consultation with the Director of the National 
     Institute of Mental Health, the Attorney General of the 
     United States, the Administrator of the Administration for 
     Community Living, and the Administrator of the Substance 
     Abuse and Mental Health Services Administration.
       (c) Selecting Among Applicants.--The Secretary--
       (1) may only award grants under this section to applicants 
     that have not previously implemented an assisted outpatient 
     treatment program; and
       (2) shall evaluate applicants based on their potential to 
     reduce hospitalization, homelessness, incarceration, and 
     interaction with the criminal justice system while improving 
     the health and social outcomes of the patient.
       (d) Use of Grant.--An assisted outpatient treatment program 
     funded with a grant awarded under this section shall 
     include--
       (1) evaluating the medical and social needs of the patients 
     who are participating in the program;
       (2) preparing and executing treatment plans for such 
     patients that--
       (A) include criteria for completion of court-ordered 
     treatment; and
       (B) provide for monitoring of the patient's compliance with 
     the treatment plan, including compliance with medication and 
     other treatment regimens;
       (3) providing for such patients case management services 
     that support the treatment plan;
       (4) ensuring appropriate referrals to medical and social 
     service providers;
       (5) evaluating the process for implementing the program to 
     ensure consistency with the patient's needs and State law; 
     and
       (6) measuring treatment outcomes, including health and 
     social outcomes such as rates of incarceration, health care 
     utilization, and homelessness.
       (e) Report.--Not later than the end of each of fiscal years 
     2016, 2017, and 2018, the Secretary shall submit a report to 
     the appropriate congressional committees on the grant program 
     under this section. Each such report shall include an 
     evaluation of the following:
       (1) Cost savings and public health outcomes such as 
     mortality, suicide, substance abuse, hospitalization, and use 
     of services.
       (2) Rates of incarceration by patients.
       (3) Rates of homelessness among patients.
       (4) Patient and family satisfaction with program 
     participation.
       (f) Definitions.--In this section:
       (1) The term ``assisted outpatient treatment'' means 
     medically prescribed mental health treatment that a patient 
     receives while living in a community under the terms of a law 
     authorizing a State or local court to order such treatment.
       (2) The term ``eligible entity'' means a county, city, 
     mental health system, mental health court, or any other 
     entity with authority under the law of the State in which the 
     grantee is located to implement, monitor, and oversee 
     assisted outpatient treatment programs.
       (3) The term ``Secretary'' means the Secretary of Health 
     and Human Services.
       (g) Funding.--
       (1) Amount of grants.--A grant under this section shall be 
     in an amount that is not more than $1,000,000 for each of 
     fiscal years 2015 through 2018. Subject to the preceding 
     sentence, the Secretary shall determine the amount of each 
     grant based on the population of the area, including 
     estimated patients, to be served under the grant.
       (2) Authorization of appropriations.--There is authorized 
     to be appropriated to carry out this section $15,000,000 for 
     each of fiscal years 2015 through 2018.

     SEC. 225. EXCLUSION FROM PAYGO SCORECARDS.

       (a) Statutory Pay-As-You-Go Scorecards.--The budgetary 
     effects of this Act shall not be entered on either PAYGO 
     scorecard maintained pursuant to section 4(d) of the 
     Statutory Pay-As-You-Go Act of 2010.
       (b) Senate PAYGO Scorecards.--The budgetary effects of this 
     Act shall not be entered on any PAYGO scorecard maintained 
     for purposes of section 201 of S. Con. Res. 21 (110th 
     Congress).

  The SPEAKER pro tempore. Pursuant to the rule, the gentleman from 
Pennsylvania (Mr. Pitts) and the gentleman from New Jersey (Mr. 
Pallone) each will control 20 minutes.
  The Chair recognizes the gentleman from Pennsylvania.


                             General Leave

  Mr. PITTS. Mr. Speaker, I ask unanimous consent that all Members may 
have 5 legislative days in which to revise and extend their remarks and 
insert extraneous materials in the Record on the bill.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Pennsylvania?
  There was no objection.
  Mr. PITTS. Mr. Speaker, I yield myself such time as I may consume.

[[Page H2713]]

  I sorely wish I were here getting ready to vote on a bill that would 
permanently repeal and replace the sustainable growth rate. In this 
Chamber, we passed a bill that would do that and that would have fully 
offset the cost of the repeal by delaying a provision of the Affordable 
Care Act that the administration just keeps delaying itself. In fact, 
it was partially delayed again just yesterday. Unfortunately, we have 
reached another doc fix deadline. I believe that we must act to protect 
America's seniors and ensure that they can continue to see the doctors 
whom they know and trust.
  That is why I have introduced legislation that represents a 
bipartisan-bicameral agreement that will give us additional time to 
work out our differences and pass permanent repeal. We are closer than 
ever to reaching that goal. We have an agreement on policy. We need to 
overcome our differences about the responsible way to pay for those new 
policies. I hope that we can act before we reach the new deadline of 
March 31, 2015. In fact, we should try to reach a bicameral agreement 
before the end of this Congress.
  I am glad that Speaker Boehner has offered his continuing support to 
this effort. With the House's having acted, we hope that the Senate can 
also pass an SGR repeal that has real pay-fors. Then we can begin the 
process of working through our differences in a conference committee. I 
am sponsoring this bill today because it is my earnest hope that this 
is the last patch we will have to pass, and I urge all of my colleagues 
to support this bill.
  I reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, I yield myself such time as I may consume.
  I am sorry, but I simply cannot support yet another temporary SGR 
patch. This bill is bad for seniors, and it is bad for doctors. We want 
to achieve a permanent solution to this ongoing problem. This bill does 
nothing to achieve that goal. In fact, it sets back months and months 
of hard work. What we should be considering today is the bipartisan-
bicameral agreement that my colleagues and I developed. That bill is 
what doctors' groups and patients' groups support. That bill can also 
be offset without robbing one provider to pay another provider.
  What is before us today doesn't fix the problem. It exacerbates it. 
We had a true opportunity to finally accomplish what our constituents 
have asked us to do for a decade, and that is to pass a permanent 
repeal of the SGR, but the Republican leadership is letting that 
opportunity slip away. I respect my colleague from Pennsylvania, but I 
don't believe that if we pass another patch that we are going to go 
back and do a permanent fix. My fear is, by doing this, we will lose 
the opportunity to do the permanent fix and that it will simply slip 
away.
  Two weeks ago, the Republicans brought to the floor our agreement, 
and they added a poison pill offset that they knew the President and 
the Senate would never accept, a delay of critical Affordable Care Act 
provisions. All that accomplished was wasting time, which has led us to 
this scenario of spending another nearly $20 billion on a patch. 
Meanwhile, this bill includes health policies that have never seen the 
light of day. Some have been used as offsets, others as sweeteners, to 
get Members to vote for it, but I am not falling for it. That is no way 
to govern. The Senate is actually poised to vote on our bipartisan 
agreement that is fully offset. It does so without cutting from the 
health care system, and that is the bill we should be considering here 
today.
  Seniors do not want us to kick the can again for another year. The 
doctor community spoke loudly and clearly yesterday--no more patches. 
So I say to my colleagues: let's not go down this road again. Instead, 
let's come together and pass a permanent solution. Let's get the job 
done. Vote ``no'' on this bill.
  I reserve the balance of my time.
  Mr. PITTS. Mr. Speaker, at this time, I am pleased to yield 2 minutes 
to the gentleman from Florida (Mr. Bilirakis), an important member of 
the Health Subcommittee.
  Mr. BILIRAKIS. Thank you, Mr. Chairman.
  Mr. Speaker, the SGR cuts would reduce doctors' compensation for 
treating Medicare patients by 24 percent. Seniors and physicians cannot 
afford that, and Congress cannot let it happen in 5 days.
  The legislation before us would patch the SGR for a year. I support 
this legislation--of course, reluctantly. Two weeks ago, the House 
passed a permanent repeal and replacement of the SGR that was fully 
paid for. The fix provided certainty for doctors who treat Medicare 
patients--that is what they need--and it incentivized and rewarded 
doctors to keep seniors healthy.
  The Senate needs to negotiate, Mr. Speaker. If they don't like the 
House pay-for, come up with one. Let's come together and get this done. 
A patch isn't the best solution. We can replace the SGR, but the Senate 
has to work with us. Again, let's get this done. Let's work together, 
and let's get it done for our seniors.
  Mr. PALLONE. Mr. Speaker, I now yield 3 minutes to the gentleman from 
Washington (Mr. McDermott).
  Mr. McDERMOTT. Mr. Speaker, apparently, Winston Churchill once said:

       Americans will always do the right thing but only after 
     they have tried everything else.

  Then again, Churchill never tried to get the doc fix passed in the 
United States Congress.
  For 10 years, we have been trying to fix the sustainable growth rate 
in Medicare, and for 10 years, we have kicked the can down the road 
with 17 different short-term patch votes. The Protecting Access to 
Medicare Act of 2014 is a mixed bag of some important compromises, like 
ensuring that there is an accurate valuation of services of the 
Physician Fee Schedule; some problematic provisions, such as the end-
stage renal disease policy; and some provisions that have never been 
vetted in front of the Congress, in front of committees--at all. More 
importantly, this bill represents our 18th failure to rebuild the 
bedrock of the Medicare program, our 18th failure to provide America's 
seniors with the safety and security of a permanent fix to the SGR.
  That is why the AMA is voting ``no'' on this bill. That is why most 
physicians' groups are strongly opposed to this bill. Last night, my 
office was flooded with messages from various physician groups.
  I, for one, still believe in finding the will to do what is right. I, 
for one, am dedicated to the principle of seizing the moment and 
accomplishing big things on behalf of the American people. We thought 
we were going to do it this time.

  When it comes to this mixed-bag piece of legislation, cooked up in 
the dead of night, put on the Web at 2 minutes before midnight a couple 
of days ago, revised several times since--not much more than 48 hours 
ago this stuff started--I vote ``no.'' Enough with trying everything 
else. It is time to do what is right--a permanent doc fix that is 
argued, debated, agreed upon. It is what our seniors need. It is what 
our doctors need to help them manage their practices. It is what our 
Nation needs and deserves.
  Mr. PITTS. Mr. Speaker, I yield myself such time as I may consume.
  We have groups who have expressed support for this bill: the American 
Clinical Laboratory Association; the American College of Radiology; 
Easter Seals; the Family Research Council; the Juvenile Diabetes 
Research Foundation; the Medical Imaging and Technology Alliance, MITA; 
the National Abstinence Education Association; the Pennsylvania 
Partnerships for Children; the Pew Charitable Trusts; the ZERO to 
THREE: National Center on Infants, Toddlers, and Families; AdvaMed, 
among others.
  I would urge Members to seriously consider this.
  Mr. Speaker, at this time, I am pleased to yield such time as he may 
consume to the gentleman from Michigan (Mr. Upton), the chairman of the 
Energy and Commerce Committee.
  Mr. UPTON. I thank the distinguished chair of the Health 
Subcommittee.
  Mr. Speaker, here we are at the very end of when the doc fix expires, 
March 31. That is next week. We have tried in a very responsible way 
for many months to try and resolve this issue, and I commend my friend 
Mr. Waxman and others for passing our bill out of committee last summer 
at 51-0. I think it was Speaker Boehner who said he

[[Page H2714]]

didn't think we could honor Mother Teresa for sainthood with a vote 
like that.
  I commend my good friend Mr. Camp from Michigan and Sandy Levin, the 
gentleman from Michigan, who is on the floor now, as we worked together 
and worked with the Senate as well to actually lock in place a bill on 
literally the last day that Chairman Baucus was in the United States 
Senate in order to try and resolve this, and we knew all along that we 
were going to have to have a pay-for. Here in the House a couple weeks 
ago, we passed a bill, somewhat on partisan lines, I know--it was not 
100 percent on either side--but we passed a 10-year fix with a pay-for.
  Now, I had a great ninth grade civics teacher, Mr. Denekas, who is no 
longer with us. He is with the Lord. I will tell you, as I sit down 
with my students as I did this week--a lot of them are here in town, my 
Close Up groups and others--and as I speak to my high schools and 
colleges, they know there is never such a thing, maybe, as a perfect 
bill. One of the first lessons in civics is that you pass a bill in the 
House, and you pass a bill in the Senate, and they are always 
different. You go to conference, and you work out the differences, and 
it comes back.
  Nobody wants this expiration of the doc fix--nobody. It hurts our 
physician community. They care about the folks that they treat. 
Literally, they are going to have almost a 30 percent reduction cut as 
early as next week in the services that they provide. Let's think about 
our most vulnerable, too--our seniors. They have got those doctor 
appointments, and they want to be there. Maybe, with a 30 percent cut, 
those physicians will say: Gosh, we just can't do this. That 
appointment is canceled. We are going to just stop serving Medicare 
patients--period--those over 65.
  We don't want that. We don't want that hurting our most vulnerable. 
So we passed here in the House a couple of weeks ago a 10-year bill. 
The response from the Senate is--nothing. Yes, we have had some 
discussions. We have talked with Senator Wyden, a former member of our 
committee. He is diligently trying to get something done, but they have 
got no bill ready for passage on the Senate floor that matches what we 
did to go to conference. They have got nothing. There is a lot of talk 
about maybe just doing a bill without a pay-for or some phony savings. 
That is not what this House is about. It is a lot of money, and we have 
some rules in the House that you have got to have a pay-for for it, and 
that is the real difficulty in trying to get things done.
  So here we are at the end of the week. The cuts come in next Tuesday, 
April 1, so we are trying to send another offer to the Senate. If you 
are not going to take the 10-year fix, let's try a 1-year fix. It is 
paid for. It is about $20 billion, and there are a number of little 
provisions that are in there that, I think, are important, again, in 
working with all sides. Last night, we were somewhat surprised that a 
number of groups came out against it, but the alternative is that the 
door gets shut. We don't have a backup plan, all right?
  This is the bill. If we can get 290 votes--everybody is here--a two-
thirds vote, that is great. We will send yet another offer to the 
Senate, and they can choose either one. They can take our 10-year bill. 
They can take a 1-year bill. They can pass something different, and we 
can go to conference. I must say that this bill is now a 1-year bill, 
but it doesn't stop us from still trying to negotiate something for a 
permanent fix, because that is what every one of us wants. It doesn't 
stop us from getting that done, but at least it stops what otherwise 
will be the denial of services to the most vulnerable, our seniors, who 
may not understand what is happening. It continues the process moving 
forward.
  We have got a couple of options that we are teeing up, but, 
obviously, we have to pass it today, here, with a two-thirds vote. Then 
let the Senate decide which alternative or it can pass something else, 
but pass something so that we can go to conference; but if that 
happens, then the doc fix is not fixed, and for however long that 
period is the cuts go into place. It would be nice if we could actually 
pass this by voice. What do you think? It will get us off the dime, 
and, again, we will toss it to the Senate to try and get it done. No 
one wants it to expire, but without one of these two bills, it expires, 
and we don't want that to happen.
  I would urge my colleagues on both sides of the aisle--my friend Mr. 
Pallone, my friend Mr. Waxman, and others--because, yes, we need to get 
this done. It is the best that we can do right now, and there is not a 
plan B for next week.
  Mr. Speaker, the specter of physician cuts under Medicare, or SGR, 
has been an unwelcome threat to seniors' access to quality health care 
well for over a decade. I rise in support of Chairman Pitts' H.R. 4302, 
the Protecting Access to Medicare Act, so we can ensure that seniors' 
access to quality health care is not jeopardized as we continue the 
effort to permanently resolving this broken system.
  While we're not yet over the finish line, we are closer than ever 
before. Republicans and Democrats of the House and Senate have agreed 
to the policy of a permanent solution, and this chamber has already 
passed a bipartisan, fully paid-for bill that would make it a reality.
  We understand that our colleagues in the Senate may have a different 
vision for next steps, and we'd be happy to meet with them to find a 
package of true offsets that we can all get behind. But, while we wait 
for the Senate to join us, it is important for us to keep the promises 
we have made to seniors who depend on the Medicare program.
  By coming together with this patch, we will ensure that care will be 
there when Medicare beneficiaries need it. This package prevents the 
scheduled 24 percent cut in payment rates, updates the rate through the 
end of the year, and maintains many of the so-called extenders programs 
for another year, including the Special Diabetes Program and abstinence 
program. Finally, it includes important mental health provisions like 
the Assistant Outpatient Treatment program from Chairman Murphy's H.R. 
3717, the Helping Families in Mental Health Crisis Act of 2013. All of 
this is achieved in a fiscally responsible manner, saving $1.2 billion 
while we continue to strive for our permanent solution.
  Our work is far from done, but today we restore some certainty to our 
seniors that their trusted doctor will be available when they are in 
need of care.
  I ask my colleagues to support this bill.

                              {time}  1000

  Mr. PALLONE. Mr. Speaker, I yield 3 minutes to the gentleman from 
Oregon (Mr. Blumenauer).
  Mr. BLUMENAUER. Thank you, Mr. Pallone.
  Mr. Speaker, I cannot express my disappointment with the proposed 
additional temporary patch to the sustainable growth rate, or the SGR--
the ``doc fix.''
  This was a contrived solution from the very beginning, and it has 
morphed into a shameful annual ritual, disrupting the provision of 
medical services in this country, as the parade of medical 
professionals come to Washington, D.C., to plead with us to not do 
something crazy.
  It is simply, today, an accounting sleight of hand. It is a power 
play and a fundraising tool, to be sure, that disrupts the practice of 
medicine.
  We have absolutely no intention of ever having the SGR cut occur, but 
we are not going to allow a reduction on that order of magnitude. We 
will find some sort of adjustment, as we always have, that will not be 
satisfactory and will continue the uncertainty and the indignity that 
is inflicted on people in the health care space and, more important, on 
the people that they serve.
  If you want to actually cut health care spending, we could do so. And 
if we would stop this charade of meaningless gestures of repealing the 
Affordable Care Act and actually get down to cases, fine-tuning, and 
moving forward, we could be there.
  There are a range of potential savings within the health care space 
that is acknowledged by virtually everybody in the industry and every 
expert that has looked at it. But it can't be done in a cavalier 
fashion according to some ritualistic formula, and it can't be done 
overnight, and it is going to require a steady hand, including 
politicians acting like grownups.
  In the meantime, I think it is important to stop this travesty.
  Remember, when we had a similar pointless exercise with the 
alternative minimum tax, realizing that the supposed savings were not 
real, that the full bite would never take effect, what did we do? We 
didn't ``pay for it,'' we finally reset the budget baseline and moved 
on.

[[Page H2715]]

  That is exactly what we should do with the SGR, and then deal 
meaningfully with the adjustments in accelerating health care reform, 
not a 54th time to repeal the Affordable Care Act.
  We should be rewarding people who are providing high-value care and 
finding ways to be more efficient, and adjusting the system to slowly 
squeeze out our areas of inefficiency. It won't be easy, but it is 
definitely within our capacity--and it is already starting around the 
country.
  Maybe Congress should consider debating this issue with an open rule, 
allowing everybody to come to the floor to speak, to offer amendments, 
to debate it fully, and see what we can come up with. It won't be any 
worse.
  Let's end this charade, give the health care space some certainty, 
and get down to work being a full partner in the reform and enhancement 
of our health care system.
  Mr. PITTS. Mr. Speaker, may I inquire of the time remaining?
  The SPEAKER pro tempore (Mr. Duncan of Tennessee). The gentleman from 
Pennsylvania has 10\1/2\ minutes remaining. The gentleman from New 
Jersey has 12\1/2\ minutes remaining.
  Mr. PITTS. Mr. Speaker, can I inquire of the minority how many 
speakers they have left?
  Mr. PALLONE. I have at least two left.
  Mr. PITTS. Mr. Speaker, I reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, I yield 3 minutes to the gentleman from 
California (Mr. Waxman), the ranking member of the Energy and Commerce 
Committee.
  Mr. WAXMAN. I thank the gentleman for yielding to me.
  Mr. Speaker, today, Congress will vote on yet another patch to the 
Medicare physician payment system. But it should not be that way. We 
need a permanent fix.
  Earlier this year, we seemed on track for a permanent fix. We reached 
a bipartisan agreement on what a permanent fix should look like. That 
bill was introduced by both Republican and Democratic leaders: Mr. 
Camp, Mr. Upton, Dr. Burgess, Mr. Levin, myself, Mr. Pallone, Senator 
Baucus, and Senator Hatch. That bipartisan bill is broadly supported by 
physician and patient groups.
  That bill would not cut providers or beneficiaries to fix payments to 
physicians, and that bill would fix this problem permanently. The bill 
before us today is not a permanent fix. It is a short-term fix.
  Two weeks ago, Republicans brought up a bipartisan bill with a poison 
pill offset for the permanent fix that undermines reform for low-income 
families. That was 2 weeks wasted, where we could have worked towards a 
permanent solution.
  I have heard my Republican colleagues say it is too hard to find 
offsets or we don't have enough time to come up with the offsets to get 
a permanent bill done. Let's not forget, Republicans do not insist on 
offsets for things they really care about. Trillions in tax cuts for 
the wealthy? No need to offset that. A Medicare prescription drug bill 
that costs far more than this permanent fix to the SGR? No need to 
offset that. But when we talk about protecting seniors' access to their 
doctors, their answer is different.
  Mr. Speaker, I would urge that, in the end, this is a vote Members 
will need to make up their own minds on. We may end up being forced to 
support a short-term patch, but I am not ready to concede that yet.
  I am not ready to support this bill that is before us. Let's keep 
working on getting a permanent solution.
  Mr. PITTS. Mr. Speaker, I continue to reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, I yield 3 minutes to the gentleman from 
Michigan (Mr. Levin), the ranking member of the Ways and Means 
Committee.
  (Mr. LEVIN asked and was given permission to revise and extend his 
remarks.)
  Mr. LEVIN. Mr. Speaker, let me describe briefly the challenge before 
us.
  This bill is very disappointing. The three committees have worked on 
a bipartisan basis to put together a bill that would address once and 
for all SGR and would reform the payment system. Indeed, it would 
transform this bill that we worked on on a bipartisan basis--the 
physician payment system--into one that is more acceptable for high 
quality care, rewards value, and provides needed stability for 
providers and beneficiaries.
  The bill has a much larger cost than this patch, though patches 
themselves are expensive.
  In response to the chairman of the Energy and Commerce Committee, I 
want to make a few comments.
  There has been no serious discussion all of these weeks about how we 
would pay for the permanent fix. There has been a dereliction of 
responsibility.
  Also, what has happened here is this patch is a product that hasn't 
gone through the legislative process. Instead, it is a complex $20 
billion bill with no public hearing, no committee hearings, and no 
regular order.
  The draft of the bill became publicly available at midnight Tuesday, 
and there were flaws, so it was refiled, and we got this bill just 24 
hours ago.
  This present legislation contains a completely new, unvetted lab 
payment system. It undermines delivery system reforms for dialysis 
patients. It includes promising policy to hold nursing homes 
accountable for patient care but fails to include key protections to 
minimize discrimination against certain patients.
  In a few words, we deserve better, and we need to do better.
  As a result, a large number of physician groups have expressed their 
opposition to this.
  What this bill does today is miss the opportunity to do full-scale 
repeal and replace the physician payment system.
  The Senate still needs to vote on a permanent fix. The chairman of 
the Energy and Commerce Committee said, We passed that kind of bill. 
Yes, the 10-year fix was a partisan bill that had no chance of passage 
in the Senate. It has zero chance of passage. The Senate still plans, 
as I understand, to vote on a permanent fix. We should let the Senate 
process unfold. We have more time to get this right.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. PALLONE. I yield the gentleman an additional 1 minute.
  Mr. LEVIN. It is not correct that, if we don't act today, there will 
be any impact on seniors. We could let the Senate act to try to do 
something permanently and come back next week, if we have to, and take 
up this bill.
  So this is the challenge before us. We are here once again doing 
something that is very temporary, that is very, very expensive, and we 
are failing to step up to the plate on permanent reform and a permanent 
fix, and doing it with a legislative process with a product that has 
not gone through committee, has had no public hearings, has had no real 
airing. We should not be acting blindly.
  Mr. PITTS. Mr. Speaker, I continue to reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentlewoman from 
California (Ms. Pelosi), the Democratic leader.
  Ms. PELOSI. Mr. Speaker, I thank the gentleman for yielding. I also 
thank him for his leadership on issues that relate to the health and 
well-being of the American people. I also commend the leadership of the 
previous speaker, Mr Waxman, and our ranking member on the Ways and 
Means committee, Mr. Levin. They have been two champions on the subject 
of health care in America--and doing so in a fiscally sound way.
  While I appreciate and share the concerns here--and I will speak to 
that--I do think that we have to think carefully about the decision 
that we make. I know that they have.
  The leadership is bringing this bill to the floor on a short fuse, 
with an expiration date of March 31, without most people in this room 
having ever seen what is in the bill, which is a missed opportunity.
  We should be considering right now a bill that would permanently 
speak to the SGR. For those in the public, I know it is inside baseball 
talk, SGR. That is the rate that docs are compensated for treating 
Medicare patients.
  So don't think of SGR--think of the patients. That is what we are 
doing here. Think of the certainty that they need in terms of their 
health care, and that is our seniors. Think of the certainty that a 
permanent fix, paid for or not--but let's say paid for--would mean to 
remove the uncertainty from this debate.
  The American Medical Association is opposed to this bill that is on 
the floor today because it is a patch.

[[Page H2716]]

  How many times have you heard people talk about a Band-Aid? We are 
just putting a Band-Aid on it. We are not getting to the underlying 
challenge that we face. This is a Band-Aid, and that is why the docs 
oppose this patch.
  I did hear the distinguished gentleman from Florida (Mr. Bilirakis) 
say, If you don't like these pay-fors, suggest your own. Well, we have 
suggested our own. It is called OCO. It is the Overseas Contingency 
Operations. The Republicans said that is a gimmick, but it wasn't a 
gimmick when you put it in the Ryan budget. It is in the Ryan budget. 
So it works for you where it works for you, but you don't want to put 
it to work for America's seniors.

                              {time}  1015

  So here is the thing. The Senate majority and the House majority came 
together to produce this patch--this Band-Aid. It is the wrong way to 
go. It does not address the underlying problem.
  We could have done that. We have been trying to do it for 10 years, 
and it is always, always, always something that the Republican majority 
has backed away from and limited and done on a short fuse.
  There are so many things that are wrong with this bill, but the 
simple fact is that the clock is ticking, and on March 31, it is bad 
news for seniors and for the doctors who treat them and the Medicare 
program.
  Our seniors depend on Medicare. They depend on Medicare, and this is 
a weakening of it. It is just the same old-same old let's see what we 
can do to find some pay-fors that really undermine the health and well-
being of the American people.
  Those same pay-fors, done properly, could be part of a permanent fix, 
but instead, they are part of the Band-Aid. So this is all to say to my 
colleagues: you are going to have to make your decision as you weigh 
the equities.
  Is it better to just succumb to what we have, no matter how mediocre 
and how missed an opportunity it is? Or is it better to say: Let's hold 
out until our Republican colleagues agree to the full SGR, essentially, 
a fix forever, paid for by OCO?
  It is really important to note the following: the shorter the fix, 
the more expensive it is. We have been seeing that year in and year 
out. If we had dealt with this, say, 6, 7 years ago, it would have cost 
much less than it is to patch 1 year to the next, sometimes less than a 
year to the next.
  This is not about reducing the deficit. It is not about the good 
health of the American people. It is just an ideological reality that 
we have to deal with from the Republican side of the aisle.
  So when the docs--the AMA--says, We are opposed to this, vote it 
down, that is important to us. I say to them, Talk to your Republican 
friends, they have the power to do a permanent fix paid for by OCO; 
they refuse to do it.
  So we have something less good that we can do for the American 
people, and if this sounds a little confusing, it is because it is; and 
Members have to make the decision as to whether they will vote for 
this, just because we are forced into it, or whether they want to hold 
out for something much better.
  This would be a more appropriate debate a month ago, where the clock 
does not run out over the weekend, but this is a tactic. It is a 
technique used by the majority to force the hand without the proper 
weighing of equities in all of it.
  So, my colleagues, I just urge you to try to weigh those equities. I, 
myself, come down on the side of supporting the legislation because, 
frankly, I believe that any uncertainty in the minds of our seniors 
about their ability to see their doctors will certainly be--the 
Republicans will say this is because of the Affordable Care Act, and I 
just don't want to give them another opportunity to misrepresent what 
this is about.
  If the Affordable Care Act never existed, we would still be here 
debating SGR. They are two separate subjects; but as we know, any 
excuse will do to undermine the great legislation that the Affordable 
Care Act was about, life, a healthier life, the liberty of people to 
pursue their happiness because they had the freedom to do so--better 
quality, lower cost, more accessibility.
  So that is how I come to the conclusion of let's not give them 
another false claim. Let's just get this done, but let us not give up 
on the prospect, even before this expires, of having a long-term, 
permanent fix to SGR.
  It makes all the sense in the world. It has no partisanship about it. 
It is sensible, and it will cost less to do more for our seniors. The 
challenge is there. The solution is clear. The Republicans have 
rejected it, so we are at their mercy.
  My conclusion is to vote ``yes.'' Members will have to come to their 
own conclusions on it. I, frankly, wish that the Republicans, in their 
power, would have brought the bill to the floor under a rule, so we 
could have a proper debate on it, instead of requiring a 290-vote 
requirement to pass it.
  With the shortness of receiving this information, only this morning, 
Members are finding out what it is. It is really hard to predict who 
will vote pro, who will vote con, who will vote ``aye,'' who will vote 
``no.'' This is really a silly decision to bring this to the floor in 
this form when we know the path that is much better.
  I am not going to give you another reason to go out there and make 
your claims about the Affordable Care Act, which have no basis in fact.
  With that, I urge my colleagues to pray over it, as I will.
  The SPEAKER pro tempore. The gentleman from Pennsylvania has 10\1/2\ 
minutes remaining. The gentleman from New Jersey has 5 minutes 
remaining.
  Mr. PITTS. Mr. Speaker, may I inquire of the minority how many 
speakers they have left?
  We are prepared to close.
  Mr. PALLONE. At this time, I have one more speaker.
  Mr. PITTS. Mr. Speaker, I continue to reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, I yield 2 minutes to the gentleman from 
Connecticut (Mr. Courtney), a member of the Armed Services Committee.
  Mr. COURTNEY. Mr. Speaker, I just wanted to follow up on a point that 
Leader Pelosi just made regarding the OCO account, the Overseas 
Contingency Operations account, which, at Armed Services, we are 
dealing with actually right now.
  The President came over with his OCO request for this year of $80 
billion. This funds the troops over in Afghanistan, the 34,000 that are 
still fighting courageously to defend our country.
  At the end of this year, the projection is that that troop level will 
be brought down to, at the highest level of 10,000, possibly even 
lower, and combat missions, for all intents and purposes, are going to 
come to an end.
  As the Congressional Budget Office has demonstrated over and over 
again, they will score savings with the OCO drawdown that is going to 
happen at the end of this year. Indeed, the Ryan budget has used those 
OCO savings to help balance its own priorities, so this is not funny 
money. This is not hypothetical.
  Anyone who has been on a CODEL over to Afghanistan knows we are 
spending money over there, and starting next year, we are going to 
spend a lot less money because of the change in our deployments over in 
Afghanistan.
  The cost of the permanent fix to SGR is $135 billion over the next 10 
years. You only need a portion of the OCO account to permanently fix 
SGR, and everybody who has even come close to discussing this issue 
knows that in this building.
  Hopefully, the Senate, when they take this up next week, are going to 
move forward with a permanent fix using totally valid, verified savings 
by the Congressional Budget Office in the OCO account.
  It is a peace dividend, in terms of drawing down from Afghanistan, 
that we can finally stabilize the Medicare system by making sure that 
fees are not going to be subjected to this annual cliff that, again, 
denies access in far too many cases in doctors' offices all across the 
country.

  So, again, I just want to emphasize the point that it is not like we 
are powerless here to come up with an SGR fix for which there is 
bipartisan support, using verifiable, valid savings by the 
Congressional Budget Office in the OCO account.
  Our brave soldiers are going to be drawing down closer to the end of 
this year to zero. We can use those savings to fix America's health 
care system.
  Mr. PITTS. Mr. Speaker, I am prepared to close. I will continue to 
reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, do I still have 3 minutes?

[[Page H2717]]

  The SPEAKER pro tempore. Yes. The gentleman from New Jersey has 3 
minutes remaining.
  Mr. PALLONE. Mr. Speaker, I yield myself such time as I may consume.
  First of all, Mr. Speaker, I would like to point out and I would like 
to enter into the Record a letter from the American Medical Association 
and many, many other physicians' groups, as well as State medical 
societies, in opposition to the legislation.
  Let me just read the first paragraph. It is addressed to the Speaker 
and to the Democratic leader. It says:

       On behalf of the undersigned physician organizations, we 
     are writing to express our strong opposition to H.R. 4302, 
     and we urge you to vote against the bill when it is 
     considered on the floor.

  Again, that is from the AMA, many specialty doctor groups, and a 
number of State medical societies.
  I would also point out that it is my strong belief--and I know that 
my chairman of the subcommittee disagrees on this, but it is my strong 
belief that if this bill passes, that we will not have an opportunity 
to bring up the larger permanent fix. We will not negotiate that. I 
doubt very much that that would be the case.

                                                   March 26, 2014.
     Hon. John A. Boehner,
     Speaker, House of Representatives, Washington, DC.
     Hon. Nancy Pelosi,
     Minority Leader, House of Representatives, Washington, DC.
       Dear Speaker Boehner and Representative Pelosi: On behalf 
     of the undersigned physician organizations, we are writing to 
     express our strong opposition to H.R. 4302, the ``Protecting 
     Access to Medicare Act of 2014,'' and we urge you to vote 
     against the bill when it is considered on the floor.
       Instead of reforming the Medicare physician payment system, 
     Congress seems intent on imposing yet another round of 
     arbitrary provider payment reductions to maintain a corrosive 
     policy that essentially every Member of Congress says should 
     be scrapped. Importantly, by selectively choosing cost 
     savings proposals that were included in the bipartisan, 
     bicameral policy framework set forth in H.R. 4015 and S. 
     2000, the bill being considered would undermine future 
     passage of that framework and add to the instability that now 
     impedes the development and adoption of health care delivery 
     and payment innovations that can strengthen the Medicare 
     program.
       It appears that an unprecedented, bipartisan agreement on 
     Medicare reform is on the verge of being cast aside because 
     elected leaders are unwilling to make tough choices to 
     strengthen programs serving 50 million Americans. We strongly 
     urge Members to vote against this legislation and renew our 
     call for all parties to engage in good faith, bipartisan 
     efforts to enact the physician payment and delivery system 
     reform policy contained in H.R. 4015/S. 2000, the SGR Repeal 
     and Medicare Provider Payment Modernization Act. The endless 
     cycle of short-term remedies that serve to support a failed 
     policy are no longer acceptable.
           Sincerely,
       American Medical Association; American Academy of Allergy, 
     Asthma & Immunology; American Academy of Dermatology 
     Association; American Academy of Neurology; American Academy 
     of Ophthalmology; American Academy of Otolaryngology--Head 
     and Neck Surgery; American Academy of Physical Medicine & 
     Rehabilitation; American Academy of Sleep Medicine; American 
     Association for Geriatric Psychiatry; American Association of 
     Hip and Knee Surgeons; American Association of Orthopaedic 
     Surgeons; American College of Emergency Physicians; American 
     College of Gastroenterology; American College of Mohs 
     Surgery; American College of Occupational and Environmental 
     Medicine; American College of Osteopathic Family Physicians; 
     American College of Osteopathic Internists; American College 
     of Osteopathic Surgeons; American College of Phlebology; 
     American College of Physicians.
       American College of Surgeons; American Congress of 
     Obstetricians and Gynecologists; American Gastroenterological 
     Association; American Geriatrics Society; American 
     Orthopaedic Foot and Ankle Society; American Osteopathic 
     Association; American Pediatric Surgical Association; 
     American Society for Dermatologic Surgery Association; 
     American Society for Gastrointestinal Endoscopy; American 
     Society for Reproductive Medicine; American Society of 
     Cataract and Refractive Surgery; American Society of 
     Disability Evaluating Physicians; American Society of General 
     Surgeons; American Society of Hematology; American Society of 
     Nephrology; American Urogynecologic Society; American 
     Urological Association; College of American Pathologists; 
     Infectious Diseases Society of America; Medical Group 
     Management Association.
       National Association of Medical Examiners; North American 
     Spine Society; National Association of Spine Specialists; 
     Renal Physicians Association; Society of Cardiovascular 
     Angiography and Interventions; Society of Critical Care 
     Medicine; Society of Gynecologic Oncology; Society of 
     Hospital Medicine; Society of Thoracic Surgeons; Alaska State 
     Medical Association; Arkansas Medical Society; Connecticut 
     State Medical Society; Medical Society of the District of 
     Columbia; Medical Association of Georgia; Hawaii Medical 
     Association; Idaho Medical Association; Illinois State 
     Medical Society; Indiana State Medical Association; Iowa 
     Medical Society; Kentucky Medical Association; Maine Medical 
     Association.
       Massachusetts Medical Society; Michigan State Medical 
     Society; Minnesota Medical Association; Mississippi State 
     Medical Association; Missouri State Medical Association; 
     Montana Medical Association; Nebraska Medical Association; 
     Nevada State Medical Association; Medical Society of the 
     State of New York; North Dakota Medical Association; Ohio 
     State Medical Association; Oregon Medical Association; 
     Pennsylvania Medical Society; Rhode Island Medical Society; 
     South Dakota State Medical Association; Utah Medical 
     Association; Vermont Medical Society; Medical Society of 
     Virginia; Washington State Medical Association; Wisconsin 
     Medical Society; Wyoming Medical Society.

  Mr. Speaker, I yield 1 minute to the gentleman from Maryland (Mr. 
Hoyer), our Democratic whip.
  Mr. HOYER. I thank the gentleman for yielding.
  Mr. Speaker, perhaps we ought to have a criteria of everybody who has 
read this bill can vote on it. My bet is there would be very few 
Members who would be able to vote on this bill.
  This is an 8-page summary of this bill with probably 50 paragraphs in 
it about changes that have been effected in the Medicare system. None 
of us know what the substance of this bill is.
  We had a lot of rhetoric in 2010 about reading the bills. I challenge 
any Member to come up here and say: I have read this bill.
  I am for a permanent fix in the sustainable growth rate for doctors. 
I have pledged that for the last 4 or 5 years. We have a bipartisan 
agreement to effect that exact end; but, as so often is the case, we do 
not have the courage to rationally fund that agreement. That is why 
America is in trouble fiscally. This is a game unworthy of this 
institution and of the American people.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. PALLONE. Mr. Speaker, I yield the balance of my time to the 
Democratic whip.
  Mr. HOYER. It is unfortunate that we have been put in this position 
with less than 48 hours' notice of what is in this bill to do something 
that all of us know needs to be done.
  The doctors of America, at least the organized doctors of America, 
have said vote ``no'' on this bill because they know, we know, The Wall 
Street Journal knows, we have to fix this permanently, not patch it 
every year. It is a fraud. Both sides have committed that fraud, and we 
ought to stop it.
  We ought to fix this. Americans ought to expect us to fix it. The 
doctors expect us to fix it. Seniors expect us to fix it. What a 
lamentable fact that we cannot summon the courage and the judgment and 
the wisdom to do just that.
  Mr. PITTS. Mr. Speaker, I yield myself such time as I may consume.
  I want to read out the title of a blast that I just received from The 
Heritage Foundation. Some of our Members might be interested in this. 
``A temporary SGR patch is better than permanent deficits in support of 
the bill.''
  My colleagues, this morning, seniors are watching. This is not a 
game. We are thinking of seniors and certainty for them. A vote ``no'' 
today is a vote against seniors. We are not voting for the AMA today. 
We are voting for or against seniors today.
  We will continue to work with all of our might for a permanent repeal 
of SGR. We have worked on this for 3 years. We must get there as soon 
as possible, but we are at a deadline, and this is the last vote we 
will have.
  If you vote ``no'' on this bill, you are voting for more uncertainty. 
You are voting for a cut to doctor reimbursement. You are voting 
against seniors.
  Let us vote for seniors this morning. Vote for H.R. 4302.
  Mr. Speaker, I yield back the balance of my time.
  Mr. DINGELL. Mr. Speaker, I rise in opposition to H.R. 4302, the 
Protecting Access to Medicare Act of 2014. It is embarrassing that a 
year of hard work on a permanent replacement for the Sustainable Growth 
Rate is being thrown in the trash can for yet another politically 
motivated short-term fix. The American people sent us here to solve our 
nation's problems, not kick the can down the road yet again. Now is the 
time for a permanent solution to this annual problem, and the 
legislation before us today does nothing to give our seniors and our 
doctors any certainty moving forward.

[[Page H2718]]

  Everyone in this body agrees that we need to start rewarding our 
doctors for the quality of their work rather than the quantity of their 
work. After months of hearings in the House Committee on Energy and 
Commerce, and in conjunction with our colleagues on the House Committee 
on Ways and Means and the Senate Committee on Finance, we put our heads 
together and came up with a common-sense proposal to pay our doctors 
under Medicare for the next decade. Everyone agrees that this policy 
makes sense and should be adopted. We have work to do to find pay-fors 
for the legislation, but that is not an insurmountable task. Congress 
should be moving full steam ahead to find offsets for the policy we all 
agree on, rather than doing yet another short-term patch that will make 
a permanent fix more expensive and ultimately harder to attain.
  Our constituents are tired of gimmickry and want real results. We 
should not have to deal with this issue on an annual basis. I urge my 
colleagues to join me in voting against H.R. 4302 and instead come 
together to find the necessary offsets to make a permanent fix to the 
Sustainable Growth Rate a reality.
  Mr. HARRIS. Mr. Speaker, I oppose this bill because we need to 
provide a permanent solution rather than just a band-aid approach to 
maintaining seniors' access to quality health care.
  Ms. JACKSON LEE. Mr. Speaker, I rise to speak in opposition to H.R. 
4302, the so-called ``Protecting Access to Medicare Act,'' which 
extends current Medicare physician reimbursement rates for one year.
  I strongly support providing adequate compensation to our physicians 
who serve Medicare patients. Medicare patients in every state make up 
10% or more of those who have health insurance.
  I oppose H.R. 4302 because it does not provide a long-term fix for 
Medicare payments to physicians, and the misvalued services under the 
physician payment system has not been addressed.
  The core purpose of the bill is found in its name, the ``Sustainable 
Growth Rate,'' but that purpose is not being met because the 
reimbursement rate to physicians is not sustainable for a robust 
medical care safety net for our nation's seniors.
  CMS has made changes to the Medicare Physician Fee Schedule and other 
Medicare payment policies to improve efficiency and accuracy in 
Medicare payment and the quality of care for our beneficiaries.
  CMS has improved payment for primary care services, while enhancing 
efforts to address payment for misvalued services under the physician 
payment system.
  CMS has begun to implement important delivery system reforms included 
in the Affordable Care Act, which includes the value-based payment 
modifier that provides incentives for physicians and physician groups 
to furnish high-quality, efficient care.
  Congress needs to do its part in implementing a reimbursement rate 
that reflects the reality of providing the care our nation's seniors 
need and expect.
  Medicare patients and the medical payments made to their physicians 
and medical service providers' is critical to our nation's health care 
economy.
  It is important for our seniors to know that Medicare will be there 
when they need it. But it is equally important that there are 
physicians who are willing to attend to them without going broke.
  That is why we have a Sustainable Growth Rate or ``SGR.'' Medicare 
reimbursement enables rural physicians and hospitals to remain open for 
business.
  This bill should not impose another round of arbitrary provider 
payment reductions to maintain a dysfunctional policy that many member 
of this House knows should be ended.
  This bill undermines the future passage of the framework that was 
part of the original bipartisan SGR bill that the House had the chance 
to vote on earlier this month.
  We should return to that bill and pass it without any gimmicks so 
that the modernization of the Medicare health care delivery and payment 
innovations that can strengthen the program can be implemented.
  Mr. Speaker, I have always strongly supported providing adequate 
compensation to our physicians who serve Medicare patients because it 
is important for our seniors to know that Medicare will be there when 
they need it.
  Thus, it is critical that we not disrupt timely and adequate payment 
to Medicare providers.
  The bill before us will provide payment certainty for one year, but 
only for one year. This is not acceptable--if we do not press the issue 
of reform now--when will it be addressed?
  This is better than nothing but what must really be done to provide 
our seniors and physicians the certainty and security they deserve is 
to reach an agreement on a permanent replacement for the SGR that is 
fair, responsible, and fiscally sustainable.
  Instead of wasting time trying to repeal, impede, or undermine the 
Affordable Care Act, or making it more difficult for physicians who 
care for the elderly we should be working together to reach an 
agreement on a permanent replacement for the SGR and the $138 billion 
in offsets needed to pay for that legislation.
  That is what the American people sent us here to do.

                              {time}  1030

  The SPEAKER pro tempore. The question is on the motion offered by the 
gentleman from Pennsylvania (Mr. Pitts) that the House suspend the 
rules and pass the bill, H.R. 4302, as amended.
  The question was taken.
  The SPEAKER pro tempore. In the opinion of the Chair, two-thirds 
being in the affirmative, the ayes have it.
  Mr. PITTS. Mr. Speaker, I object to the vote on the ground that a 
quorum is not present and make the point of order that a quorum is not 
present.
  The SPEAKER pro tempore. Pursuant to clause 8 of rule XX, further 
proceedings on this question will be postponed.
  The point of no quorum is considered withdrawn.

                          ____________________