[Congressional Record (Bound Edition), Volume 161 (2015), Part 7]
[House]
[Pages 9843-9846]
[From the U.S. Government Publishing Office, www.gpo.gov]




 STRENGTHENING MEDICARE ADVANTAGE THROUGH INNOVATION AND TRANSPARENCY 
                        FOR SENIORS ACT OF 2015

  Mr. BRADY of Texas. Mr. Speaker, I move to suspend the rules and pass 
the bill (H.R. 2570) to establish a demonstration program requiring the 
utilization of Value-Based Insurance Design to demonstrate that 
reducing the copayments or coinsurance charged to Medicare 
beneficiaries for selected high-value prescription medications and 
clinical services can increase their utilization and ultimately improve 
clinical outcomes and lower health care expenditures, as amended.
  The Clerk read the title of the bill.
  The text of the bill is as follows:

                               H.R. 2570

       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 ``Strengthening Medicare 
     Advantage through Innovation and Transparency for Seniors Act 
     of 2015''.

     SEC. 2. TREATMENT OF PATIENT ENCOUNTERS IN AMBULATORY 
                   SURGICAL CENTERS IN DETERMINING MEANINGFUL EHR 
                   USE.

       Section 1848(o)(2) of the Social Security Act (42 U.S.C. 
     1395w-4(o)(2)) is amended by adding at the end of the 
     following new subparagraph:
       ``(D) Treatment of patient encounters at ambulatory 
     surgical centers.--
       ``(i) In general.--Subject to clause (ii), for a payment 
     year after 2015 any patient encounter of an eligible 
     professional occurring at an ambulatory surgical center 
     (described in section 1833(i)(1)(A)) shall not be treated as 
     a patient encounter in determining whether an eligible 
     professional qualifies as a meaningful EHR user. 
     Notwithstanding any other provision of law, the Secretary may 
     implement this clause by program instruction or otherwise.
       ``(ii) Sunset.--Clause (i) shall no longer apply as of the 
     first payment year that begins more than 3 years after the 
     date the Secretary determines, through notice and comment 
     rulemaking, that certified EHR technology is applicable to 
     the ambulatory surgical center setting.''.

     SEC. 3. VALUE-BASED INSURANCE DESIGN DEMONSTRATION PROGRAM.

       (a) In General.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     establish a 3-year demonstration program to test the use of 
     value-based insurance design methodologies (as defined in 
     subsection (c)(1)) under eligible Medicare Advantage plans 
     offered by Medicare Advantage organizations under part C of 
     title XVIII of the Social Security Act (42 U.S.C. 1395w-21 et 
     seq.). The Secretary may extend the program to a duration of 
     4 or 5 years, as determined necessary by the Secretary in 
     coordination with the Centers for Medicare and Medicaid 
     Innovation.
       (b) Demonstration Program Design.--
       (1) Selection of medicare advantage sites and eligible 
     medicare advantage plans.--Not later than two years after the 
     date of the enactment of this Act, the Secretary shall--
       (A) select at least two Medicare Advantage sites with 
     respect to which to conduct the demonstration program under 
     this section; and
       (B) approve eligible Medicare Advantage plans to 
     participate in such demonstration program.

     In selecting Medicare Advantage sites under subparagraph (A), 
     the Secretary shall take into account area differences as 
     well as the availability of health maintenance organization 
     plans and preferred provider organization plans offered in 
     such sites.
       (2) Start of demonstration.--The demonstration program 
     shall begin not later than the third plan year beginning 
     after the date of the enactment of this Act.
       (3) Eligible medicare advantage plans.--For purposes of 
     this section, the term ``eligible Medicare Advantage plan'' 
     means a Medicare Advantage plan under part C of title XVIII 
     of the Social Security Act (42 U.S.C. 1395w-21 et seq.) that 
     meets the following requirements:
       (A) The plan is an Medicare Advantage regional plan (as 
     defined in paragraph (4) of section 1859(b) of such Act (42 
     U.S.C. 1395w-28(b))) or Medicare Advantage local plan (as 
     defined in paragraph (5) of such section) offered in the 
     Medicare Advantage region selected under paragraph (1)(A).
       (B) The plan has--
       (i)(I) a quality rating under section 1853(o) of such Act 
     (42 U.S.C. 1395w-23(o)) of 4 stars

[[Page 9844]]

     or higher based on the most recent data available for such 
     year, or (II) in the case of a specialized Medicare Advantage 
     plan for special needs individuals, as defined in section 
     1859(b)(6)(A) of such Act (42 U.S.C. 1395w-28(b)(6)(A)), a 
     quality rating under section 1853(o) of such Act (42 U.S.C. 
     1395w-23(o)) equal to or higher than the national average for 
     special needs plans (excluding Institutional-Special needs 
     plans) based on the most recent data available for such year; 
     and
       (ii) at least 20 percent of the population to whom the plan 
     is offered in a service area consists of subsidy eligible 
     individuals (as defined in section 1860D-14(a)(3)(A) of the
     Social Security Act (42 U.S.C. 1395w-114(a)(3)(A))).
       (4) Disclosure to beneficiaries.--The Secretary shall 
     provide to each individual eligible to enroll under a 
     Medicare Advantage plan approved to participate under the 
     demonstration program during a plan year for which the plan 
     is so selected--
       (A) notification that the plan is participating in such 
     demonstration program;
       (B) background information on the demonstration program;
       (C) clinical data derived from the studies resulting from 
     the demonstration program; and
       (D) notification of the potential benefits that the 
     individual will receive, and of the other potential impacts 
     that the individual will experience, on account of the 
     participation of the plan in the demonstration program.
       (c) Value-Based Insurance Design Methodologies.--
       (1) Definition.--For purposes of this section, the term 
     ``value-based insurance design methodology'' means a 
     methodology for identifying specific prescription 
     medications, and clinical services that are payable under 
     title XVIII of the Social Security Act, for which the 
     reduction of copayments, coinsurance, or both, would improve 
     the management of specific chronic clinical conditions 
     because of the high value and effectiveness of such 
     medications and services for such specific chronic clinical 
     conditions, as approved by the Secretary.
       (2) Use of methodologies to reduce copayments and 
     coinsurance.--A Medicare Advantage organization offering an 
     eligible Medicare Advantage plan approved to participate 
     under the demonstration program, for each plan year for which 
     the plan is so selected and using value-based insurance 
     design methodologies--
       (A) shall identify each prescription medication and 
     clinical service covered under such plan for which the plan 
     proposes to reduce or eliminate the copayment or coinsurance, 
     with respect to the management of specific chronic clinical 
     conditions (as specified by the Secretary) of Medicare 
     Advantage eligible individuals (as defined in section 
     1851(a)(3) of the Social Security Act (42 U.S.C. 1395w-
     21(a)(3))) enrolled under such plans, for such plan year;
       (B) may, for such plan year, reduce or eliminate 
     copayments, coinsurance, or both for such prescription 
     medication and clinical services so identified with respect 
     to the management of such conditions of such individuals--
       (i) if such reduction or elimination is evidence-based and 
     for the purpose of encouraging such individuals in such plan 
     to use such prescription medications and clinical services 
     (such as preventive care, primary care, specialty visits, 
     diagnostic tests, procedures, and durable medical equipment) 
     with respect to such conditions; and
       (ii) for the purpose of encouraging such individuals in 
     such plan to use health care providers that such organization 
     has identified with respect to such plan year as being high 
     value providers; and
       (C) if a reduction or elimination is applied pursuant to 
     subparagraph (B), with respect to such medication and 
     clinical services, shall, for such plan year, count toward 
     the deductible applicable to such individual under such plan 
     amounts that would have been payable by the individual as 
     copayment or coinsurance for such medication and services if 
     the reduction or elimination had not been applied.
       (3) Prohibition of increases of copayments and 
     coinsurance.--In no case may any Medicare Advantage plan 
     participating in the demonstration program increase, for any 
     plan year for which the plan is so participating, the amount 
     of copayments or coinsurance for any item or service covered 
     under such plan for purposes of discouraging the use of such 
     item or service.
       (d) Report on Implementation.--
       (1) In general.--Not later than 1 year after the date on 
     which the demonstration program under this section begins 
     under subsection (b)(2), the Secretary shall submit to 
     Congress a report on the status of the implementation of the 
     demonstration program.
       (2) Elements.--The report required by paragraph (1) shall, 
     with respect to eligible Medicare Advantage plans 
     participating in the demonstration program for the first plan 
     year of such program, include the following:
       (A) A list of each medication and service identified 
     pursuant to subsection (c)(2)(A) for such plan with respect 
     to such plan year.
       (B) For each such medication or service so identified, the 
     amount of the copayment or coinsurance required under such 
     plan with respect to such plan year for such medication or 
     service and the amount of the reduction of such copayment or 
     coinsurance from a previous plan year.
       (C) For each provider identified pursuant to subsection 
     (c)(2)(B)(ii) for such plan with respect to such plan year, a 
     statement of the amount of the copayment or coinsurance 
     required under such plan with respect to such plan year and 
     the amount of the reduction of such copayment or coinsurance 
     from the previous plan year.
       (e) Review and Assessment of Utilization of Value-Based 
     Insurance Design Methodologies.--
       (1) In general.--The Secretary shall enter into a contract 
     or agreement with an independent entity to review and assess 
     the implementation of the demonstration program under this 
     section. The review and assessment shall include the 
     following:
       (A) An assessment of the utilization of value-based 
     insurance design methodologies by Medicare Advantage plans 
     participating under such program.
       (B) An analysis of whether reducing or eliminating the 
     copayment or coinsurance for each medication and clinical 
     service identified pursuant to subsection (c)(2)(A) resulted 
     in increased adherence to medication regimens, increased 
     service utilization, improvement in quality metrics, better 
     health outcomes, and enhanced beneficiary experience.
       (C) An analysis of the extent to which costs to Medicare 
     Advantage plans under part C of title XVIII of the Social 
     Security Act participating in the demonstration program is 
     less than costs to Medicare Advantage plans under such part 
     that are not participating in the demonstration program.
       (D) An analysis of whether reducing or eliminating the 
     copayment or coinsurance for providers identified pursuant to 
     subsection (c)(2)(B)(ii) resulted in improvement in quality 
     metrics, better health outcomes, and enhanced beneficiary 
     experience.
       (E) An analysis, for each provider so identified, the 
     extent to which costs to Medicare Advantage plans under part 
     C of title XVIII of the Social Security Act participating in 
     the demonstration program is less than costs to Medicare 
     Advantage plans under such part that are not participating in 
     the demonstration program.
       (F) Such other matters as the Secretary considers 
     appropriate.
       (2) Report.--The contract or agreement entered into under 
     paragraph (1) shall require such entity to submit to the 
     Secretary a report on the review and assessment conducted by 
     the entity under such paragraph in time for the inclusion of 
     the results of such report in the report required by 
     paragraph (3). Such report shall include a description, in 
     clear language, of the manner in which the entity conducted 
     the review and assessment.
       (3) Report to congress.--Not later than 4 years after the 
     date on which the demonstration program begins under 
     subsection (b)(2), the Secretary shall submit to Congress a 
     report on the review and assessment of the demonstration 
     program conducted under this subsection. The report shall 
     include the following:
       (A) A description of the results of the review and 
     assessment included in the report submitted pursuant to 
     paragraph (2).
       (B) Such recommendations as the Secretary considers 
     appropriate for enhancing the utilization of the 
     methodologies applied under the demonstration program to all 
     Medicare Advantage plans under part C of title XVIII of the 
     Social Security Act so as to reduce copayments and 
     coinsurance under such plans paid by Medicare beneficiaries 
     for high-value prescription medications and clinical services 
     for which coverage is provided under such plans and to 
     otherwise improve the quality of health care provided under 
     such plans.
       (4) Oversight report.--Not later than three years after the 
     date of the enactment of this Act, the Comptroller General of 
     the United States shall submit to Congress a report on the 
     demonstration program that includes an assessment, with 
     respect to individuals enrolled under Medicare Advantage 
     plans approved to participate under the demonstration 
     program, of the impact that the age, co-morbidities, and 
     geographic regions of such individuals had upon the 
     implementation of the demonstration program by the plans with 
     respect to such individuals.
       (f) Savings.--In no case may any reduction in beneficiary 
     copayments or coinsurance resulting from the implementation 
     of the demonstration program under this section result in 
     expenditures under parts A, B, and D of the title XVIII of 
     the Social Security Act that are greater than such 
     expenditures without application of this section.
       (g) Expansion of Demonstration Program.--Taking into 
     account the review and assessment conducted under subsection 
     (e), the Secretary may, through notice and comment 
     rulemaking, expand (including implementation on a nationwide 
     basis) the duration and scope of the demonstration program 
     under title XVIII of the Social Security Act, other than 
     under the original medicare fee-for-service program under 
     parts A and B of such title, to the extent determined 
     appropriate by the Secretary, if the requirements of 
     paragraphs (1), (2) and (3) of subsection (c) of section 
     1115A of the Social Security Act

[[Page 9845]]

     (42 U.S.C. 1315a), as applied to the testing of a model under 
     subsection (b) of such section, applied to the demonstration 
     under this section.
       (h) Waiver Authority.--The Secretary may waive such 
     provisions of titles XI and XVIII of the Social Security Act 
     as may be necessary to carry out the demonstration program 
     under this section.
       (i) Implementation Funding.--For purposes of carrying out 
     the demonstration program under this section, the Secretary 
     shall provide for the transfer from the Federal Hospital 
     Insurance Trust Fund under section 1817 of the Social 
     Security Act (42 U.S.C. 1395i) and the Federal Supplementary 
     Insurance Trust Fund under section 1841 of the Social 
     Security Act (42 U.S.C. 1395t), including the Medicare 
     Prescription Drug Account in such Trust Fund, in such 
     proportion as determined appropriate by the Secretary, of 
     such sums as may be necessary.

     SEC. 4. TREATMENT OF INFUSION DRUGS FURNISHED THROUGH DURABLE 
                   MEDICAL EQUIPMENT.

       Section 1842(o)(1) of the Social Security Act (42 U.S.C. 
     1395u(o)(1)) is amended--
       (1) in subparagraph (C), by inserting ``(and including a 
     drug or biological described in subparagraph (D)(i) furnished 
     on or after January 1, 2017)'' after ``2005''; and
       (2) in subparagraph (D)--
       (A) by striking ``infusion drugs'' and inserting ``infusion 
     drugs or biologicals'' each place it appears; and
       (B) in clause (i)--
       (i) by striking ``2004'' and inserting ``2004, and before 
     January 1, 2017''; and
       (ii) by striking ``for such drug''.

     SEC. 5. SENSE OF CONGRESS REGARDING THE IMPLEMENTATION AND 
                   DISTRIBUTION OF QUALITY INCENTIVE PAYMENTS TO 
                   MEDICARE ADVANTAGE PLANS.

       It is the sense of Congress that--
       (1) the Secretary of Health and Human Services has 
     incorrectly interpreted subsection (n) of section 1853 of the 
     Social Security Act (42 U.S.C. 1395w-23) as prohibiting the 
     provision of any Medicare quality incentive payments under 
     subsection (o) of such section with respect to Medicare 
     Advantage plans that exceed the payment benchmark cap under 
     such subsection (n) for the area served by such plans; and
       (2) the Secretary should immediately apply quality 
     incentive payments under such subsection (o) with respect to 
     such Medicare Advantage plans without regard to the limits 
     set forth in such subsection (n).

     SEC. 6. MEDICARE IMPROVEMENT FUND.

       Section 1898(b)(1) of the Social Security Act (42 U.S.C. 
     1395iii(b)(1)) is amended by striking ``during and after 
     fiscal year 2020, $0'' and inserting ``after fiscal year 
     2020, $220,000,000''.

     SEC. 7. NON-INCLUSION OF DME INFUSION DRUGS UNDER DME 
                   COMPETITIVE ACQUISITION PROGRAMS.

       (a) In General.--Section 1847(a)(2)(A) of the Social 
     Security Act (42 U.S.C. 1395w-3(a)(2)(A)) is amended--
       (1) by striking ``and excluding'' and inserting ``, 
     excluding''; and
       (2) by inserting before the period at the end the 
     following: ``, and excluding drugs and biologicals described 
     in section 1842(o)(1)(D)''.
       (b) Conforming Amendment.--Section 1842(o)(1)(D)(ii) of the 
     Social Security Act (42 U.S.C. 1395u(o)(1)(D)(ii)) is amended 
     by striking ``2007'' and inserting ``2007, and before the 
     date of the enactment of the Strengthening Medicare Advantage 
     through Innovation and Transparency for Seniors Act of 
     2015''.

  The SPEAKER pro tempore (Mr. Hardy). Pursuant to the rule, the 
gentleman from Texas (Mr. Brady) and the gentleman from New York (Mr. 
Rangel) each will control 20 minutes.
  The Chair recognizes the gentleman from Texas.


                             General Leave

  Mr. BRADY of Texas. Mr. Speaker, I ask unanimous consent that all 
Members may have 5 legislative days within which to revise and extend 
their remarks and to include extraneous material on H.R. 2570, 
currently under consideration.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Texas?
  There was no objection.
  Mr. BRADY of Texas. Mr. Speaker, I yield myself such time as I may 
consume.
  I stand in strong support of H.R. 2570, the Strengthening Medicare 
Advantage through Innovation and Transparency for Seniors Act.
  This package is comprised of two policies, and I will let the 
sponsors, who have worked so hard, speak to them in more depth.
  The Electronic Health Fairness Act of 2015, as marked up by the 
committee back in February, brings fairness to physicians who are 
practicing in the ASC setting by reducing meaningful use burdens for 
sites of service that were left out of the EHR technology requirements. 
This exemption only lasts until the ASCs are able to catch up, and then 
everybody will be on an equal footing regarding meaningful use 
requirements.
  The bill then establishes a new demonstration program based on value-
based insurance design. This proposal would give plans the ability to 
adjust benefits based on their enrollees' needs. The one-size-fits-all 
policies in Medicare Advantage create the need for different types of 
plans that wouldn't be necessary if regular Medicare Advantage plans 
could adjust their benefit structures to better serve our seniors.
  Reducing copays or cost sharing for beneficiaries for the sake of 
better healthcare outcomes is right in line with the principles that I 
support as all seniors are different and should be served as such, so 
that all have an opportunity for positive health outcomes.
  The bill also includes a policy that changes the way Medicare pays 
for drugs that doctors prescribe that are infused through durable 
medical equipment items. This change means that Medicare payments will 
be more market based.
  The policy does take away the potential that these rates could change 
significantly in the future by exempting the drugs from DME competitive 
bidding. I am committed to ensuring that beneficiaries who need these 
drugs are able to continue to get them in their homes, and I will 
certainly monitor the impact.
  I want to thank Ways and Means members Mrs. Black of Tennessee and 
Mr. Blumenauer of Oregon for their continued leadership in improving 
Medicare Advantage. Their very hard work will ensure that seniors, for 
years to come, will enjoy better healthcare choices and more options at 
that.
  Mr. Speaker, I reserve the balance of my time.
  Mr. RANGEL. Mr. Speaker, I yield myself such time as I may consume.
  I join with the gentleman from Texas in supporting H.R. 2570. 
Representative Diane Black and Representative Earl Blumenauer have 
worked hard on this issue.
  This legislation will allow the Secretary of HHS to conduct a 
demonstration, giving managed care organizations the ability to offer 
plans with a variety of benefit structures that would lower the cost 
sharing for high-value service. We think it makes a lot of sense, and I 
concur.
  I reserve the balance of my time.

                              {time}  1730

  Mr. BRADY of Texas. Mr. Speaker, I yield 2 minutes to the gentlewoman 
from Tennessee (Mrs. Black), a key member of the Committee on Ways and 
Means and a healthcare professional herself.
  Mrs. BLACK. Mr. Speaker, as a nurse for over 40 years, I understand 
the challenge of helping Americans find affordable healthcare coverage, 
but the sad truth is, even for those who do have health coverage, high 
deductibles and out-of-pocket costs can leave too many Americans 
functionally uninsured.
  When families are forced to choose between buying groceries and 
filling a prescription, their health is sidelined, and they risk facing 
even higher medical costs down the road. That is why I authored H.R. 
2570, the Strengthening Medicare Advantage Through Innovation and 
Transparency for Seniors Act. Our bill directs CMS to set up a pilot 
project for what is known as Value-Based Insurance Design, or otherwise 
known as VBID.
  Instead of the current one-size-fits-all approach to cost sharing, 
VBID embraces the idea that by lowering a patient's out-of-pocket costs 
for essential prescription drugs and services, customers will then be 
motivated to stick with their regimen and stay healthier. This will, in 
turn, decrease the overall long-term costs to our healthcare system and 
provide a higher quality of care for our patients.
  My bill also helps our providers by offering ambulatory surgical 
centers relief from the electronic health records' meaningful use 
mandate. While this recordkeeping system may make sense in a hospital 
setting, it doesn't always work for a small, outpatient surgical 
facility. Providers who practice medicine in these settings should not 
be penalized as a result.

[[Page 9846]]

  I thank Congressman Blumenauer and Congresswoman Cathy McMorris 
Rodgers for their strong commitment to VBID policy.
  I urge a ``yes'' vote on H.R. 2570.
  Mr. RANGEL. I yield myself the balance of my time to close.
  Mr. Speaker, at this time I concur with the gentleman from Texas. 
Members have worked hard in perfecting these bills, and I support H.R. 
2570.
  I yield back the balance of my time.
  Mr. BRADY of Texas. Mr. Speaker, I yield myself such time as I may 
consume.
  This is a very good bill. It is a good improvement to Medicare 
Advantage, and it is really a case of Republicans and Democrats finding 
common ground and doing it in a way that helps seniors with their 
choices and really tailoring health care to them.
  I strongly urge support for this bill.
  Mr. Speaker, I yield back the balance of my time.
  The SPEAKER pro tempore. The question is on the motion offered by the 
gentleman from Texas (Mr. Brady) that the House suspend the rules and 
pass the bill, H.R. 2570, as amended.
  The question was taken; and (two-thirds being in the affirmative) the 
rules were suspended and the bill, as amended, was passed.
  The title of the bill was amended so as to read: ``A bill to amend 
title XVIII of the Social Security Act with respect to the treatment of 
patient encounters in ambulatory surgical centers in determining 
meaningful EHR use, establish a demonstration program requiring the 
utilization of Value-Based Insurance Design to demonstrate that 
reducing the copayments or coinsurance charged to Medicare 
beneficiaries for selected high-value prescription medications and 
clinical services can increase their utilization and ultimately improve 
clinical outcomes and lower health care expenditures, and for other 
purposes.''.
  A motion to reconsider was laid on the table.

                          ____________________