[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.
____________________