[Congressional Record Volume 163, Number 156 (Thursday, September 28, 2017)]
[Senate]
[Pages S6225-S6229]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




          STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS

      By Mr. CARDIN (for himself, Mr. Blunt, and Mr. Nelson):
  S. 1890. A bill to improve the understanding of, and promote access 
to treatment for, chronic kidney disease, and for other purposes; to 
the Committee on Finance.
  Mr. CARDIN. Mr. President, I rise in support of the bipartisan 
Chronic Kidney Disease Improvement in Research and Treatment Act of 
2017, which I am introducing with Senators Blunt and Nelson today. This 
legislation seeks to make a real difference in the lives of Americans 
suffering from kidney disease and end-stage renal disease.
  Kidney disease is the 9th leading cause of death in the United 
States, and unfortunately, more than 1 in 10 Americans today suffer 
from some form of kidney disease. More than 661,000 Americans are 
living with kidney failure or end-stage renal disease, which is an 
irreversible condition that can be fatal without a kidney transplant or 
life-sustaining dialysis. Of these, 468,000 patients in our Country 
rely on life-sustaining dialysis care to survive and roughly 193,000 
live with a functioning kidney transplant.
  This legislation seeks to promote research, expand patient choice, 
and improve care coordination for these hundreds of thousands of 
patients. Specifically, it would identify payment disincentives that 
create barriers to kidney transplants. The bill would require the 
Government Accountability Office (GAO) to submit a comprehensive report 
on how and to what extent palliative care is utilized in treating 
individuals with advanced kidney disease and the effect of palliative 
care on the quality of life and treatment outcomes of individuals with 
ESRD. It would also direct the Department of Health and Human Services 
(HHS) to evaluate and report on the biological, social, and behavioral 
factors related to kidney disease and efforts to slow the progression 
of disease in minority populations disproportionately affected by this 
disease.
  This legislation would improve access to pre-dialysis kidney 
education programs to better manage patients' kidney disease and even 
prevent kidney failure in some cases. Nephrologists and other health 
professionals would be incentivized to work in underserved rural and 
urban areas, and current payment policies would be modified to 
encourage home dialysis, which is not incentivized under the current 
Medicare payment structure. Patients with acute kidney injury would 
also be allowed to receive treatments through dialysis providers, 
therefore reducing costs associated with care provided in the more 
expensive hospital outpatient setting. Perhaps most importantly, our 
legislation would guarantee access to Medigap policies to all ESRD 
Medicare beneficiaries, regardless of age. Currently, Medicare patients 
under 65, whether disabled or ESRD beneficiaries do not have access to 
Medigap plans, even though Medicare is their primary insurance.
  Lastly, the bill would expand the options for patients by allowing 
individuals diagnosed with kidney failure to enroll in the Medicare 
Advantage program starting in plan year 2020 and reauthorizing on a 
permanent basis the Medicare Advantage Special Needs Plan for patients 
with kidney failure.
  I urge my colleagues to join me, Senator Blunt and Senator Nelson in 
supporting the Chronic Kidney Disease Improvement in Research and 
Treatment Act of 2017, which will improve the care of patients who 
suffer from kidney disease and end-stage renal disease.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                S. 1890

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Chronic Kidney Disease 
     Improvement in Research and Treatment Act of 2017''.

     SEC. 2. TABLE OF CONTENTS.

       The table of contents of this Act is as follows:

Sec. 1. Short title.
Sec. 2. Table of contents.

 TITLE I--IMPROVING PATIENT LIVES AND QUALITY OF CARE THROUGH RESEARCH 
                             AND INNOVATION

Sec. 101. Improving patient lives and quality of care through research 
              and innovation.
Sec. 102. Enhancing care through new technologies.
Sec. 103. Understanding current utilization of palliative care 
              services.
Sec. 104. Understanding the progression of kidney disease and treatment 
              of kidney failure in minority populations.

          TITLE II--EMPOWER PATIENT DECISION MAKING AND CHOICE

Sec. 201. Providing individuals with kidney failure access to managed 
              care.
Sec. 202. Medigap coverage for beneficiaries with end-stage renal 
              disease.
Sec. 203. Promoting access to home dialysis treatments.

    TITLE III--IMPROVING PATIENT CARE AND ENSURING QUALITY OUTCOMES

Sec. 301. Maintain an economically stable dialysis infrastructure.
Sec. 302. Improve patient decision making and transparency by 
              consolidating and modernizing quality programs.
Sec. 303. Increasing access to Medicare kidney disease education 
              benefit.
Sec. 304. Certification of new facilities.
Sec. 305. Improving access in under served areas.

 TITLE I--IMPROVING PATIENT LIVES AND QUALITY OF CARE THROUGH RESEARCH 
                             AND INNOVATION

     SEC. 101. IMPROVING PATIENT LIVES AND QUALITY OF CARE THROUGH 
                   RESEARCH AND INNOVATION.

       (a) Study.--The Secretary of Health and Human Services (in 
     this section referred to as the ``Secretary'') shall conduct 
     a study on increasing kidney transplantation rates. Such 
     study shall include an analysis of each of the following:
       (1) Any disincentives in the payment systems under the 
     Medicare program under title XVIII of the Social Security Act 
     that create barriers to kidney transplants and post-
     transplant care for beneficiaries with end-stage renal 
     disease.
       (2) The practices used by States with higher than average 
     donation rates and whether those practices and policies could 
     be successfully utilized in other States.
       (3) Practices and policies that could increase deceased 
     donation rates of minority populations.
       (4) Whether cultural and policy barriers exist to 
     increasing living donation rates, including an examination of 
     how to better facilitate chained donations.
       (5) Other areas determined appropriate by the Secretary.
       (b) Report.--Not later than 18 months after the date of the 
     enactment of this Act, the Secretary shall submit to Congress 
     a report on the study conducted under subsection (a), 
     together with such recommendations as the Secretary 
     determines to be appropriate.

     SEC. 102. ENHANCING CARE THROUGH NEW TECHNOLOGIES.

       (a) Agreement With National Academy of Sciences.--The 
     Secretary of Health and Human Services shall seek to enter 
     into an agreement with the National Academy of Sciences 
     within six months of the date of the enactment of this Act 
     under which the National Academy of Sciences will conduct a 
     study on the design of payments for renal dialysis services 
     under the Medicare program

[[Page S6226]]

     under title XVIII of the Social Security Act, including an 
     analysis of whether adjustments to such payments are needed 
     to allow for the incorporation of new technologies and 
     therapies.
       (b) Contents.--In conducting the study under subsection 
     (a), the National Academy of Sciences shall evaluate the 
     current payment system for renal dialysis services under the 
     Medicare program, identify barriers to adopting innovative 
     items, services, and therapies, and make recommendations as 
     to how to eliminate such barriers.

     SEC. 103. UNDERSTANDING CURRENT UTILIZATION OF PALLIATIVE 
                   CARE SERVICES.

       (a) Study.--
       (1) In general.--The Comptroller General of the United 
     States (in this section referred to as the ``Comptroller 
     General'') shall conduct a study on the utilization of 
     palliative care in treating individuals with advanced kidney 
     disease, from stage 4 through stage 5, including individuals 
     with kidney failure on dialysis through any progression of 
     the disease. Such study shall include an analysis of--
       (A) how palliative care can be utilized to improve the 
     quality of life of those with kidney disease and facilitate 
     care tailored to their individual goals and values;
       (B) the successful use of palliative care in the care of 
     patients with other chronic diseases and serious illnesses;
       (C) the utilization of palliative care at any point in an 
     illness, including when used at the same time as curative 
     treatment; and
       (D) other areas determined appropriate by the Comptroller 
     General.
       (2) Definition of palliative care.--In this section, the 
     term ``palliative care'' means patient and family centered 
     care that optimizes quality of life by anticipating, 
     preventing, and treating suffering. Such term includes care 
     that is furnished throughout the continuum of the illness 
     that addresses physical, intellectual, emotional, social, and 
     spiritual needs and that facilitates patient autonomy, access 
     to information and choice.
       (b) Report.--Not later than 1 year after the date of the 
     enactment of this Act, the Comptroller General shall submit 
     to the Congress a report on the study conducted under 
     subsection (a), together with such recommendations as the 
     Comptroller General determines to be appropriate.

     SEC. 104. UNDERSTANDING THE PROGRESSION OF KIDNEY DISEASE AND 
                   TREATMENT OF KIDNEY FAILURE IN MINORITY 
                   POPULATIONS.

       (a) Study.--The Secretary of Health and Human Services (in 
     this section referred to as the ``Secretary'') shall conduct 
     a study on--
       (1) the social, behavioral, and biological factors leading 
     to kidney disease;
       (2) efforts to slow the progression of kidney disease in 
     minority populations that are disproportionately affected by 
     such disease; and
       (3) treatment patterns associated with providing care, 
     under the Medicare program under title XVIII of the Social 
     Security Act, the Medicaid program under title XIX of such 
     Act, and through private health insurance, to minority 
     populations that are disproportionately affected by kidney 
     failure.
       (b) Report.--Not later than 1 year after the date of the 
     enactment of this Act, the Secretary shall submit to Congress 
     a report on the study conducted under subsection (a), 
     together with such recommendations as the Secretary 
     determines to be appropriate.

          TITLE II--EMPOWER PATIENT DECISION MAKING AND CHOICE

     SEC. 201. PROVIDING INDIVIDUALS WITH KIDNEY FAILURE ACCESS TO 
                   MANAGED CARE.

       (a) Permanent Extension of Medicare Advantage ESRD Special 
     Needs Plans Authority.--Section 1859(f)(1) of the Social 
     Security Act (42 U.S.C. 1395w-28(f)(1)) is amended by 
     inserting ``, in the case of a specialized MA plan for 
     special needs individuals who have not been determined to 
     have end stage renal disease,'' before ``for periods before 
     January 1, 2019''.
       (b) Accelerated Access to Medicare Advantage.--Section 
     17006(a)(3) of the 21st Century Cures Act (Public Law 114-
     255) is amended by striking ``2021'' and inserting ``2020.''
       (c) Accelerated MedPAC Risk Adjustment Report.--Section 
     17006(f)(2)(A)(i)(II) of the 21st Century Cures Act (Public 
     Law 114-255) is amended by striking ``2020'' and inserting 
     ``2019.''

     SEC. 202. MEDIGAP COVERAGE FOR BENEFICIARIES WITH END-STAGE 
                   RENAL DISEASE.

       (a) Guaranteed Availability of Medigap Policies to All ESRD 
     Medicare Beneficiaries.--
       (1) In general.--Section 1882(s) of the Social Security Act 
     (42 U.S.C. 1395ss(s)) is amended--
       (A) in paragraph (2)--
       (i) in subparagraph (A), by striking ``is 65'' and 
     inserting the following: ``is--
       ``(i) 65 years of age or older and is enrolled for benefits 
     under part B; or
       ``(ii) is entitled to benefits under 226A(b) and is 
     enrolled for benefits under part B.''; and
       (ii) in subparagraph (D), in the matter preceding clause 
     (i), by inserting ``(or is entitled to benefits under 
     226A(b))'' after ``is 65 years of age or older''; and
       (B) in paragraph (3)(B)--
       (i) in clause (ii), by inserting ``(or is entitled to 
     benefits under 226A(b))'' after ``is 65 years of age or 
     older''; and
       (ii) in clause (vi), by inserting ``(or under 226A(b))'' 
     after ``at age 65''.
       (2) Effective date.--The amendments made by paragraph (1) 
     shall apply to medicare supplemental policies effective on or 
     after January 1, 2020.
       (b) Additional Enrollment Period for Certain Individuals.--
       (1) One-time enrollment period.--
       (A) In general.--In the case of an individual described in 
     subparagraph (B), the Secretary of Health and Human Services 
     shall establish a one-time enrollment period during which 
     such an individual may enroll in any medicare supplemental 
     policy under section 1882 of the Social Security Act (42 
     U.S.C. 1395ss) of the individual's choosing.
       (B) Enrollment period.--The enrollment period established 
     under subparagraph (A) shall begin on January 1, 2020, and 
     shall end June 30, 2020.
       (2) Individual described.--An individual described in this 
     paragraph is an individual who--
       (A) is entitled to hospital insurance benefits under part A 
     of title XVIII of the Social Security Act under section 
     226A(b) of such Act (42 U.S.C. 426-1);
       (B) is enrolled for benefits under part B of such title 
     XVIII; and
       (C) would not, but for the provisions of, and amendments 
     made by, subsection (a) be eligible for the guaranteed issue 
     of a medicare supplemental policy under paragraph (2) or (3) 
     of section 1882(s) of such Act (42 U.S.C. 1395ss(s).

     SEC. 203. PROMOTING ACCESS TO HOME DIALYSIS TREATMENTS.

       (a) In General.--Section 1881(b)(3) of the Social Security 
     Act (42 U.S.C. 1395rr(b)(3)) is amended--
       (1) by redesignating subparagraphs (A) and (B) as clauses 
     (i) and (ii), respectively;
       (2) in clause (ii), as redesignated by subparagraph (A), 
     strike ``on a comprehensive'' and insert ``subject to 
     subparagraph (B), on a comprehensive'';
       (3) by striking ``With respect to'' and inserting ``(A) 
     With respect to''; and
       (4) by adding at the end the following new subparagraph:
       ``(B) For purposes of subparagraph (A)(ii), an individual 
     determined to have end-stage renal disease receiving home 
     dialysis may choose to receive the monthly end-stage renal 
     disease-related visits furnished on or after January 1, 2018, 
     via telehealth if the individual receives a face-to-face 
     visit, without the use of telehealth, at least once every 
     three consecutive months.''.
       (b) Originating Site Requirements.--
       (1) In general.--Section 1834(m) of the Social Security Act 
     (42 U.S.C. 1395m(m)) is amended--
       (A) in paragraph (4)(C)(ii), by adding at the end the 
     following new subclauses:

       ``(IX) A renal dialysis facility, but only for purposes of 
     section 1881(b)(3)(B).
       ``(X) The home of an individual, but only for purposes of 
     section 1881(b)(3)(B).''; and

       (B) by adding at the end the following new paragraph:
       ``(5) Treatment of home dialysis monthly esrd-related 
     visit.--The geographic requirements described in paragraph 
     (4)(C)(i) shall not apply with respect to telehealth services 
     furnished on or after January 1, 2018, for purposes of 
     section 1881(b)(3)(B), at an originating site described in 
     subclause (VI), (IX), or (X) of paragraph (4)(C)(ii).''.
       (2) No facility fee if originating site for home dialysis 
     therapy is the home.--Section 1834(m)(2)(B) of the Social 
     Security (42 U.S.C. 1395m(m)(2)(B)) is amended--
       (A) by redesignating clauses (i) and (ii) as subclauses (I) 
     and (II), and indenting appropriately;
       (B) in subclause (II), as redesignated by subparagraph (A), 
     by striking ``clause (i) or this clause'' and inserting 
     ``subclause (I) or this subclause'';
       (C) by striking ``site.--With respect to'' and inserting 
     ``site.--
       ``(i) In general.--Subject to clause (ii), with respect 
     to''; and
       (D) by adding at the end the following new clause:
       ``(ii) No facility fee if originating site for home 
     dialysis therapy is the home.--No facility fee shall be paid 
     under this subparagraph to an originating site described in 
     paragraph (4)(C)(ii)(X).''.
       (c) Conforming Amendment.--Section 1881(b)(1) of the Social 
     Security Act (42 U.S.C. 1395rr(b)(1)) is amended by striking 
     ``paragraph (3)(A)'' and inserting ``paragraph (3)(A)(i)''.
       (d) Exclusion From Remuneration for Purposes of Applying 
     Civil Monetary Penalties.--
       (1) In general.--Section 1128A(i)(6) of the Social Security 
     Act (42 U.S.C. 1320a-7a(i)(6)) is amended--
       (A) in subparagraph (H)(iv), by striking ``; or'' at the 
     end;
       (B) in subparagraph (I), by striking the period at the end 
     and inserting ``; or''; and
       (C) by adding at the end the following new subparagraph:
       ``(J) the provision of telehealth or remote patient 
     monitoring technologies to individuals under title XVIII by a 
     health care provider for the purpose of furnishing telehealth 
     or remote patient monitoring services.''.
       (2) Effective date.--The amendments made by this subsection 
     shall apply to services furnished on or after the date of the 
     enactment of this Act.

    TITLE III--IMPROVING PATIENT CARE AND ENSURING QUALITY OUTCOMES

     SEC. 301. MAINTAIN AN ECONOMICALLY STABLE DIALYSIS 
                   INFRASTRUCTURE.

       (a) In General.--Section 1881(b)(14) of the Social Security 
     Act (42 U.S.C. 1395rr(b)(14)) is amended--

[[Page S6227]]

       (1) in subparagraph (D), in the matter preceding clause 
     (i), by striking ``Such system'' and inserting ``Subject to 
     subparagraph (J), such system''; and
       (2) by adding at the end the following new subparagraph:
       ``(J) For payment for renal dialysis services furnished on 
     or after January 1, 2018, under the system under this 
     paragraph--
       ``(i) the payment adjustment described in clause (i) of 
     subparagraph (D)--

       ``(I) shall not take into account comorbidities; and
       ``(II) shall only take into account age for purposes of 
     distinguishing between individuals who are under 18 years of 
     age and those who are 18 years of age and older but shall not 
     include any other adjustment for age;

       ``(ii) the Secretary shall reassess any adjustments related 
     to patient weight under such clause;
       ``(iii) the payment adjustment described in clause (ii) of 
     such subparagraph shall not be included;
       ``(iv) the standardization factor described in the final 
     rule published in the Federal Register on November 8, 2012 
     (77 Fed. Reg. 67470), shall be established using the most 
     currently available data (and not historical data) and 
     adjusted on an annual basis, based on such available data, to 
     account for any change in utilization of drugs and any 
     modification in adjustors applied under this paragraph; and
       ``(v) take into account reasonable costs for determining 
     the payment rate consistent with paragraph (2)(B).''.
       (b) Inclusion of Network Fee as an Allowable Cost.--Section 
     1881(b)(14) of the Social Security Act (42 U.S.C. 
     1395rr(b)(14)), as amended by subsection (a), is amended by 
     adding at the end the following new subparagraph:
       ``(K) Not later than January 1, 2018, the Secretary shall 
     amend the ESRD facility cost report to include the per 
     treatment network fee (as described in paragraph (7)) as an 
     allowable cost or offset to revenue.''.

     SEC. 302. IMPROVE PATIENT DECISION MAKING AND TRANSPARENCY BY 
                   CONSOLIDATING AND MODERNIZING QUALITY PROGRAMS.

       (a) Measures.--Section 1881(h)(2) of the Social Security 
     Act (42 U.S.C. 1395rr(h)(2)) is amended by adding at the end 
     the following new subparagraphs:
       ``(F) Weighting limitation.--No single measure specified by 
     the Secretary or individual measure within a composite 
     measure so specified may be weighted less than 10 percent of 
     the total performance score.
       ``(G) Statistically valid and reliable.--In specifying 
     measures under subparagraph (A), the Secretary shall only 
     specify measures that have been shown to be statistically 
     valid and reliable through testing.''.
       (b) Endorsement.--Section 1881(h)(2)(B) of the Social 
     Security Act (42 U.S.C. 1395rr(h)(2)(B)) is amended--
       (1) in clause (ii), by adding at the end the following new 
     sentence: ``The exception under the preceding sentence shall 
     not apply to a measure that the entity with a contract under 
     section 1890(a) (or a similar entity) considered but failed 
     to endorse.''; and
       (2) by adding at the end the following new clause:
       ``(iii) Composite measures.--Clauses (i) and (ii) shall 
     apply to composite measures in the same manner as such 
     clauses apply to individual measures.''.
       (c) Requirements for Dialysis Facility Compare Star Rating 
     Program.--Section 1881(h)(6) of the Social Security Act (42 
     U.S.C. 1395rr(h)(6)) is amended by adding at the end the 
     following new subparagraph:
       ``(E) Requirements for any dialysis facility compare star 
     rating program.--To the extent that the Secretary maintains a 
     dialysis facility compare star rating program, under such a 
     program the Secretary--
       ``(i) shall assign stars using the same methodology and 
     total performance score results from the quality incentive 
     program under this subsection;
       ``(ii) shall determine the stars using the same methodology 
     used under such quality incentive program; and
       ``(iii) shall not use a forced bell curve when determining 
     the stars or rebaselining the stars.''.
       (d) Hospitals Required to Provide Information.--Section 
     1881 of the Social Security Act (42 U.S.C. 1395rr) is amended 
     by adding at the end the following new subsection:
       ``(i) Hospitals Required to Provide Information.--
       ``(1) In general.--The Secretary shall establish a process 
     under which a hospital or a critical access hospital shall 
     provide a renal dialysis facility with health and treatment 
     information with respect to an individual who is discharged 
     from the hospital or critical access hospital and who 
     subsequently receives treatment at facility.
       ``(2) Elements.--Under the process established under 
     paragraph (1)--
       ``(A) the request for the health information may be 
     initiated by the individual prior to discharge or upon 
     request by the renal dialysis facility after the patient is 
     discharged; and
       ``(B) the information must be provided to the facility 
     within 7 days of the request being made.''.
       (e) Incentive Payments.--Section 1881(h)(1) of the Social 
     Security Act (42 U.S.C. 1395rr(h)(1)) is amended by adding at 
     the end the following new subparagraph:
       ``(D) Incentive payments.--
       ``(i) In general.--In the case of a provider of services or 
     a renal dialysis facility that the Secretary determines 
     exceeds the attainment performance standards under paragraph 
     (4) with respect to a year, the Secretary may make a bonus 
     payment to the provider or facility (pursuant to a process 
     established by the Secretary).
       ``(ii) Funding.--The total amount of bonus payments under 
     clause (i) in a year shall be equal to the total amount of 
     reduced payments in a year under subparagraph (A).
       ``(iii) No effect in subsequent years.--The provisions of 
     subparagraph (C) shall apply to a bonus payment under this 
     subparagraph in the same manner subparagraph (C) applies to a 
     reduction under such subparagraph.''.
       (f) Effective Date.--The amendments made by this section 
     shall apply to items and services furnished on or after 
     January 1, 2019.

     SEC. 303. INCREASING ACCESS TO MEDICARE KIDNEY DISEASE 
                   EDUCATION BENEFIT.

       (a) In General.--Section 1861(ggg) of the Social Security 
     Act (42 U.S.C. 1395x(ggg)) is amended--
       (1) in paragraph (1)--
       (A) in subparagraph (A), by inserting ``or stage V'' after 
     ``stage IV''; and
       (B) in subparagraph (B), by inserting ``or of a physician 
     assistant, nurse practitioner, or clinical nurse specialist 
     (as defined in section 1861(aa)(5)) assisting in the 
     treatment of the individual's kidney condition'' after 
     ``kidney condition''; and
       (2) in paragraph (2)--
       (A) by striking subparagraph (B); and
       (B) in subparagraph (A)--
       (i) by striking ``(A)'' after ``(2)'';
       (ii) by striking ``and'' at the end of clause (i);
       (iii) by striking the period at the end of clause (ii) and 
     inserting ``; and'';
       (iv) by redesignating clauses (i) and (ii) as subparagraphs 
     (A) and (B), respectively; and
       (v) by adding at the end the following:
       ``(C) a renal dialysis facility subject to the requirements 
     of section 1881(b)(1) with personnel who--
       ``(i) provide the services described in paragraph (1); and
       ``(ii) is a physician (as defined in subsection (r)(1)) or 
     a physician assistant, nurse practitioner, or clinical nurse 
     specialist (as defined in subsection (aa)(5)).''.
       (b) Payment to Renal Dialysis Facilities.--Section 1881(b) 
     of the Social Security Act (42 U.S.C. 1395rr(b)) is amended 
     by adding at the end the following new paragraph:
       ``(15) For purposes of paragraph (14), the single payment 
     for renal dialysis services under such paragraph shall not 
     take into account the amount of payment for kidney disease 
     education services (as defined in section 1861(ggg)). 
     Instead, payment for such services shall be made to the renal 
     dialysis facility on an assignment-related basis under 
     section 1848.''.
       (c) Effective Date.--The amendments made by this section 
     apply to kidney disease education services furnished on or 
     after January 1, 2018.

     SEC. 304. CERTIFICATION OF NEW FACILITIES.

       (a) Certification.--
       (1) In general.--Section 1865(a)(1) of the Social Security 
     Act (42 U.S.C. 1395bb(a)(1)) is amended by striking ``or the 
     conditions and requirements under section 1881(b)''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall take effect on the date of enactment of this Act and 
     apply to a finding made on or after such date.
       (b) Timing for Acceptance of Requests From Accreditation 
     Organizations.--Not later than 6 months after the date of the 
     enactment of this Act, the Secretary of Health and Human 
     Services shall accept a completed application from any 
     national accreditation body for providers and facilities that 
     provide services under 1881(b), in accordance with section 
     1865(3)(A)). Any application received pursuant to the 
     preceding sentence shall be deemed approved unless the 
     Secretary, within 90 days after the date of the submission of 
     the application to the Secretary, either denies such request 
     in writing or informs the applicant in writing with respect 
     to any additional information that is needed in order to make 
     a final determination with respect to the application. If the 
     Secretary requests additional information pursuant to the 
     preceding sentence and the applicant submits such 
     information, the application shall be deemed approved unless 
     the Secretary, within 90 days of date of receiving such 
     information, denies such request.

     SEC. 305. IMPROVING ACCESS IN UNDER SERVED AREAS.

       (a) Definition of Primary Care Services.--Section 
     331(a)(3)(D) of the Public Health Service Act (42 U.S.C. 
     254d(a)(3)(D)) is amended by inserting ``and includes renal 
     dialysis services'' before the period at the end.
       (b) National Health Service Corps Scholarship Program.--
     Section 338A(a)(2) of the Public Health Service Act (42 
     U.S.C. 254l(a)(2)) is amended by inserting ``, including 
     nephrology health professionals'' before the period at the 
     end.
       (c) National Health Service Corps Loan Repayment Program.--
     Section 338B(a)(2) of the Public Health Service Act (42 
     U.S.C. 254l-1(a)(2)) is amended by inserting ``, including 
     nephrology health professionals'' before the period at the 
     end.
                                 ______
                                 
      By Mr. McCAIN (for himself, Mr. Lee, Mr. Lankford, and Mr. 
        Flake):
  S. 1894. A bill to exempt Puerto Rico from the coastwise laws of the 
United

[[Page S6228]]

States (commonly known as the ``Jones Act'' ); read the first time.

                                S. 1894

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

     SECTION 1. EXCEPTIONS TO APPLICATION OF COASTWISE LAWS FOR 
                   PUERTO RICO.

       Section 55101(b) of title 46, United States Code, is 
     amended--
       (1) by redesignating paragraphs (1), (2), and (3) as 
     paragraphs (2), (3), and (4), respectively; and
       (2) by inserting before paragraph (2), as redesignated, the 
     following:
       ``(1) the Commonwealth of Puerto Rico;''.
                                 ______
                                 
      By Mr. DAINES:
  S. 1898. A bill to amend the Internal Revenue Code of 1986 to 
retroactively repeal the individual mandate for health insurance; to 
the Committee on Finance.
  Mr. DAINES. Mr. President, I ask unanimous consent that the text of 
the bill be printed in the Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                S. 1898

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Repeal and Refund Act''.

     SEC. 2. REPEAL OF INDIVIDUAL MANDATE.

       (a) Repeal of Requirement to Maintain Minimum Essential 
     Coverage.--
       (1) In general.--The Internal Revenue Code of 1986 is 
     amended by striking chapter 48.
       (2) Conforming amendments.--
       (A) Amendments related to the internal revenue code of 
     1986.--
       (i) Section 36B of the Internal Revenue Code of 1986 is 
     amended by redesignating subsection (g) as subsection (h) and 
     by inserting after subsection (g) the following new 
     subsection:
       ``(g) Minimum Essential Coverage.--For purposes of this 
     section--
       ``(1) In general.--The term `minimum essential coverage' 
     means any of the following:
       ``(A) Government sponsored programs.--Coverage under--
       ``(i) the Medicare program under part A of title XVIII of 
     the Social Security Act,
       ``(ii) the Medicaid program under title XIX of the Social 
     Security Act,
       ``(iii) the CHIP program under title XXI of the Social 
     Security Act,
       ``(iv) medical coverage under chapter 55 of title 10, 
     United States Code, including coverage under the TRICARE 
     program,
       ``(v) a health care program under chapter 17 or 18 of title 
     38, United States Code, as determined by the Secretary of 
     Veterans Affairs, in coordination with the Secretary of 
     Health and Human Services and the Secretary,
       ``(vi) a health plan under section 2504(e) of title 22, 
     United States Code (relating to Peace Corps volunteers), or
       ``(vii) the Nonappropriated Fund Health Benefits Program of 
     the Department of Defense, established under section 349 of 
     the National Defense Authorization Act for Fiscal Year 1995 
     (Public Law 103-337; 10 U.S.C. 1587 note).
       ``(B) Employer-sponsored plan.--Coverage under an eligible 
     employer-sponsored plan.
       ``(C) Plans in the individual market.--Coverage under a 
     health plan offered in the individual market within a State.
       ``(D) Grandfathered health plan.--Coverage under a 
     grandfathered health plan.
       ``(E) Other coverage.--Such other health benefits coverage, 
     such as a State health benefits risk pool, as the Secretary 
     of Health and Human Services, in coordination with the 
     Secretary, recognizes for purposes of this subsection.
       ``(2) Eligible employer-sponsored plan.--The term `eligible 
     employer-sponsored plan' means, with respect to any employee, 
     a group health plan or group health insurance coverage 
     offered by an employer to the employee which is--
       ``(A) a governmental plan (within the meaning of section 
     2791(d)(8) of the Public Health Service Act), or
       ``(B) any other plan or coverage offered in the small or 
     large group market within a State.

     Such term shall include a grandfathered health plan described 
     in paragraph (1)(D) offered in a group market.
       ``(3) Excepted benefits not treated as minimum essential 
     coverage.--The term `minimum essential coverage' shall not 
     include health insurance coverage which consists of coverage 
     of excepted benefits--
       ``(A) described in paragraph (1) of subsection (c) of 
     section 2791 of the Public Health Service Act; or
       ``(B) described in paragraph (2), (3), or (4) of such 
     subsection if the benefits are provided under a separate 
     policy, certificate, or contract of insurance.
       ``(4) Individuals residing outside united states or 
     residents of territories.--Any applicable individual shall be 
     treated as having minimum essential coverage for any month--
       ``(A) if such month occurs during any period described in 
     subparagraph (A) or (B) of section 911(d)(1) which is 
     applicable to the individual, or
       ``(B) if such individual is a bona fide resident of any 
     possession of the United States (as determined under section 
     937(a)) for such month.
       ``(5) Insurance-related terms.--Any term used in this 
     section which is also used in title I of the Patient 
     Protection and Affordable Care Act shall have the same 
     meaning as when used in such title.''.
       (ii) Section 36B(c)(2)(B) of such Code is amended to read 
     as follows:
       ``(B) Exception for minimum essential coverage.--The term 
     `coverage month' shall not include any month with respect to 
     an individual if for such month the individual is eligible 
     for minimum essential coverage other than eligibility for 
     coverage described in subsection (g)(1)(C) (relating to 
     coverage in the individual market).''.
       (iii) Clauses (i)(I) and (ii) of section 36B(c)(2)(C) of 
     such Code are each amended by striking ``section 
     5000A(f)(2)'' and inserting ``subsection (g)(2)''.
       (iv)(I) Subclause (II) of section 36B(c)(2)(C)(i) of such 
     Code is amended by striking ``(within the meaning of section 
     5000A(e)(1)(B))''.
       (II) Paragraph (2) of section 36B(c) of such Code is 
     amended by adding at the end the following new subparagraph:
       ``(D) Required contribution.--For purposes of subparagraph 
     (C)(i)(II), the term `required contribution' means--
       ``(i) in the case of an individual eligible to purchase 
     minimum essential coverage consisting of coverage through an 
     eligible-employer-sponsored plan, the portion of the annual 
     premium which would be paid by the individual (without regard 
     to whether paid through salary reduction or otherwise) for 
     self-only coverage, or
       ``(ii) in the case of an individual eligible only to 
     purchase minimum essential coverage described in subsection 
     (g)(1)(C), the annual premium for the lowest cost bronze plan 
     available in the individual market through the Exchange in 
     the State in the rating area in which the individual resides 
     (without regard to whether the individual purchased a 
     qualified health plan through the Exchange), reduced by the 
     amount of the credit allowable under subsection (a) for the 
     taxable year (determined as if the individual was covered by 
     a qualified health plan offered through the Exchange for the 
     entire taxable year).''.
       (v) Section 162(m)(6)(C)(i) of such Code is amended by 
     striking ``section 5000A(f)'' and inserting ``section 
     36B(g)''.
       (vi) Subsections (a)(1) and (b)(1) of section 4980H of such 
     Code are each amended by striking ``section 5000A(f)(2)'' and 
     inserting ``section 36B(g)(2)''.
       (vii) Section 4980I(f)(1)(B) of such Code is amended by 
     striking ``section 5000A(f)'' and inserting ``section 
     36B(g)''.
       (viii) Section 6056(b)(2)(b) of such Code is amended by 
     striking ``section 5000A(f)(2)'' and inserting ``section 
     36B(g)(2)''.
       (ix) The table of chapters of the Internal Revenue Code of 
     1986 is amended by striking the item relating to chapter 48.
       (B) Amendments related to the patient protection and 
     affordable care act.--
       (i) Section 1251(a)(4)(B)(ii) of the Patient Protection and 
     Affordable Care Act is amended by striking ``section 
     500A(f)(2)'' and inserting ``section 36B(g)(2)''.
       (ii) Section 1302(e)(2) of such Act is amended to read as 
     follows:
       ``(2) Individuals eligible for enrollment.--An individual 
     is described in this paragraph for any plan year if the 
     individual has not attained the age of 30 before the 
     beginning of the plan year.''.
       (iii) Section 1311(d)(4) of such Act is amended by striking 
     subparagraph (H).
       (iv) Section 1312(d)(4) of such Act is amended by striking 
     ``section 5000A(f)'' and inserting ``section 36B(g)''.
       (v) Section 1363(e)(1)(C) of such Act is amended--

       (I) by striking ``section 5000A(f)'' and inserting 
     ``section 36B(g)'', and
       (II) by striking ``or is eligible for an employer-sponsored 
     plan that is not affordable coverage (as determined under 
     section 5000A(e)(2) of such Code)'' and inserting ``or who is 
     eligible for an employer-sponsored plan and whose household 
     income for the taxable year described in section 
     1412(b)(1)(B) is less than the amount of gross income 
     specified in section 6012(a)(1) of the Internal Revenue Code 
     of 1986 with respect tot he taxpayer''.

       (vi) Section 1332(a)(2)(D) of such Act is amended by 
     striking ``36B, 4980H, and 5000A'' and inserting ``36B and 
     4980H''.
       (vii) Section 1401(c)(1)(A)(iii) of such Act is amended by 
     striking ``section 5000A(f)'' and inserting ``section 
     36B(g)''.
       (viii) Section 1411(a) of such Act is amended--

       (I) by inserting ``and'' at the end of paragraph (2),
       (II) in paragraph (3)--

       (aa) by striking ``and section 5000A(e)(2)'', and
       (bb) by striking ``, and'' and inserting a period, and

       (III) by striking paragraph (4).

       (ix) Section 1411(b)(4)(C) of such Act is amended by 
     striking ``5000A(e)(1)(B)'' and inserting ``36B(c)(2)(D)''.
       (x) Section 1411(b) of such Act is amended by striking 
     paragraph (5).
       (xi) Section 1411(e)(4)(B) of such Act is amended by 
     striking clause (iv).

[[Page S6229]]

       (C) Other conforming amendments.--Section 2715(b)(3)(G)(i) 
     of the Public Health Service Act is amended by striking 
     ``section 5000A(f)'' and inserting ``section 36B(g)''.
       (3) Effective date.--The amendments made by this subsection 
     shall apply to taxable years beginning after December 31, 
     2013.
       (b) Repeal of Reporting of Health Insurance Coverage.--
       (1) In general.--Part III of subchapter A of chapter 61 of 
     the Internal Revenue Code of 1986 is amended by striking 
     subpart D.
       (2) Conforming amendments.--
       (A) Section 6056(d) of the Internal Revenue Code of 1986 is 
     amended to read as follows:
       ``(d) Coordination With Other Requirements.--To the maximum 
     extent feasible, the Secretary may provide that any return or 
     statement required to be provided under this section may be 
     provided as part of any return or statement required under 
     section 6051.''.
       (B) Section 6724(d)(1)(B) of such Code is amended by 
     inserting ``or'' at the end of clause (xxiii), by striking 
     clause (xxiv), and by redesignating clause (xxv) as clause 
     (xxiv).
       (C) Section 6724(d)(2) of such Code is amended by inserting 
     ``or'' at the end of subparagraph (FF), by striking 
     subparagraph (GG), and by redesignating subparagraph (HH) as 
     subparagraph (GG).
       (D) Subsection (c) of section 1502 of the Patient 
     Protection and Affordable Care Act is repealed.
       (E) The table of subparts for part III of subchapter A of 
     chapter 61 of the Internal Revenue Code of 1986 is amended by 
     striking the item relating to subpart D.
       (3) Effective date.--The amendments made by this subsection 
     shall apply to calendar years beginning after December 31, 
     2013.
       (c) Taxpayer Refund Program.--
       (1) In general.--The Secretary of the Treasury shall 
     implement a program under which taxpayers who have paid a 
     penalty under section 5000A of the Internal Revenue Code of 
     1986 for any taxable year receive 1 payment in refund of all 
     such penalties paid, without regard to whether or not an 
     amended return is filed. Such payment shall be made not later 
     than April 15, 2018.
       (2) Waiver of statute of limitations.--Solely for purposes 
     of claiming the refund under paragraph (1), the period 
     prescribed by section 6511(a) of the Internal Revenue Code of 
     1986 with respect to any payment of a penalty under section 
     5000A shall be extended until the date prescribed by law 
     (including extensions) for filing the return of tax for the 
     taxable year that includes December 31, 2017.

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