HR 6212
110th CONGRESS
2d Session
H. R. 6212
To amend titles XVIII and XIX of the Social Security Act to extend
expiring provisions under the Medicare Program, to improve beneficiary access
to preventive and mental health services, to enhance low-income benefit programs,
and to maintain access to care in rural areas, including pharmacy access,
and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
June 9, 2008
Ms. JACKSON-LEE of Texas (for herself, Mr. TOWNS, Mr. DAVIS of Illinois,
and Mr. RODRIGUEZ) introduced the following bill; which was referred to the
Committee on Energy and Commerce, and in addition to the Committee on Ways
and Means, for a period to be subsequently determined by the Speaker, in each
case for consideration of such provisions as fall within the jurisdiction
of the committee concerned
A BILL
To amend titles XVIII and XIX of the Social Security Act to extend
expiring provisions under the Medicare Program, to improve beneficiary access
to preventive and mental health services, to enhance low-income benefit programs,
and to maintain access to care in rural areas, including pharmacy access,
and for other purposes.
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 `Medicare Efficiency and Development
of Improvement of Care and Services Act (MEDICS Act) of 2008'.
(b) Table of Contents- The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
TITLE I--MEDICARE
Subtitle A--Beneficiary Improvements
Part I--Prevention, Mental Health, and Marketing
Sec. 101. Improvements to coverage of preventive services.
Sec. 102. Elimination of discriminatory copayment rates for Medicare outpatient
psychiatric services.
Sec. 103. Prohibitions and limitations on certain sales and marketing activities
under Medicare Advantage plans and prescription drug plans.
Sec. 104. Improvements to the Medigap program.
Part II--Low-Income Programs
Sec. 111. Extension of qualifying individual (QI) program.
Sec. 112. Application of full LIS subsidy assets test under Medicare Savings
Program.
Sec. 113. Eliminating barriers to enrollment.
Sec. 114. Elimination of Medicare part D late enrollment penalties paid
by subsidy eligible individuals.
Sec. 115. Eliminating application of estate recovery.
Sec. 116. Exemptions from income and resources for determination of eligibility
for low-income subsidy.
Sec. 117. Judicial review of decisions of the Commissioner of Social Security
under the Medicare part D low-income subsidy program.
Sec. 118. Translation of model form.
Sec. 119. Medicare enrollment assistance.
Subtitle B--Provisions Relating to Part A
Sec. 121. Expansion and extension of the Medicare Rural Hospital Flexibility
Program.
Sec. 122. Rebasing for sole community hospitals.
Sec. 123. Demonstration project on community health integration models in
certain rural counties.
Sec. 124. Extension of the reclassification of certain hospitals.
Sec. 125. Revocation of unique deeming authority of the Joint Commission.
Subtitle C--Provisions Relating to Part B
Part I--Physicians' Services
Sec. 131. Physician payment, efficiency, and quality improvements.
Sec. 132. Incentives for electronic prescribing.
Sec. 133. Expanding access to primary care services.
Sec. 134. Extension of floor on Medicare work geographic adjustment under
the Medicare physician fee schedule.
Sec. 135. Imaging provisions.
Sec. 136. Extension of treatment of certain physician pathology services
under Medicare.
Sec. 137. Accommodation of physicians ordered to active duty in the Armed
Services.
Sec. 138. Adjustment for Medicare mental health services.
Sec. 139. Improvements for Medicare anesthesia teaching programs.
Part II--Other Payment and Coverage Improvements
Sec. 141. Extension of exceptions process for Medicare therapy caps.
Sec. 142. Extension of payment rule for brachytherapy and therapeutic radiopharmaceuticals.
Sec. 143. Speech-language pathology services.
Sec. 144. Payment and coverage improvements for patients with chronic obstructive
pulmonary disease and other conditions.
Sec. 145. Revision of payment for power-driven wheelchairs.
Sec. 146. Clinical laboratory tests.
Sec. 147. Improved access to ambulance services.
Sec. 148. Extension and expansion of the Medicare hold harmless provision
under the prospective payment system for hospital outpatient department
(HOPD) services for certain hospitals.
Sec. 149. Clarification of payment for clinical laboratory tests furnished
by critical access hospitals.
Sec. 150. Adding certain entities as originating sites for payment of telehealth
services.
Sec. 151. MedPAC study and report on improving chronic care demonstration
programs.
Sec. 152. Increase of FQHC payment limits.
Sec. 153. Kidney disease education and awareness provisions.
Sec. 154. Renal dialysis provisions.
Subtitle D--Provisions Relating to Part C
Sec. 161. Phase-out of indirect medical education (IME).
Sec. 162. Revisions to requirements for Medicare Advantage private fee-for-service
plans.
Sec. 163. Revisions to quality improvement programs.
Sec. 164. Revisions relating to specialized Medicare Advantage plans for
special needs individuals.
Sec. 165. Limitation on out-of-pocket costs for dual eligibles and qualified
medicare beneficiaries enrolled in a specialized Medicare Advantage plan
for special needs individuals.
Sec. 166. Adjustment to the Medicare Advantage stabilization fund.
Sec. 167. Access to Medicare reasonable cost contract plans.
Sec. 168. MedPAC study and report on quality measures.
Sec. 169. MedPAC study and report on Medicare Advantage payments.
Subtitle E--Provisions Relating to Part D
Part I--Improving Pharmacy Access
Sec. 171. Prompt payment by prescription drug plans and MA-PD plans under
part D.
Sec. 172. Submission of claims by pharmacies located in or contracting with
long-term care facilities.
Sec. 173. Regular update of prescription drug pricing standard.
Part II--Other Provisions
Sec. 175. Inclusion of barbiturates and benzodiazepines as covered part
D drugs.
Sec. 176. Formulary requirements with respect to certain categories or classes
of drugs.
Subtitle F--Other Provisions
Sec. 181. Use of part D data.
Sec. 182. Revision of definition of medically accepted indication for drugs.
Sec. 183. Contract with a consensus-based entity regarding performance measurement.
Sec. 184. Cost-sharing for clinical trials.
Sec. 185. Addressing health care disparities.
Sec. 186. Demonstration to improve care to previously uninsured.
Sec. 187. Office of the Inspector General report on compliance with and
enforcement of national standards on culturally and linguistically appropriate
services (CLAS) in Medicare.
Sec. 188. Medicare Improvement Funding.
TITLE II--MEDICAID
Sec. 201. Extension of transitional medical assistance (TMA).
Sec. 202. Medicaid DSH extension.
Sec. 203. Pharmacy reimbursement under Medicaid.
Sec. 204. Review of administrative claim determinations.
TITLE III--MISCELLANEOUS
Sec. 301. Extension of TANF supplemental grants.
Sec. 302. 70 percent federal matching for foster care and adoption assistance
for the District of Columbia.
Sec. 303. Extension of Special Diabetes Grant Programs.
Sec. 304. IOM reports on best practices for conducting systematic reviews
of clinical effectiveness research and for developing clinical protocols.
Sec. 305. Increasing number of primary care physicians.
TITLE I--MEDICARE
Subtitle A--Beneficiary Improvements
PART I--PREVENTION, MENTAL HEALTH, AND MARKETING
SEC. 101. IMPROVEMENTS TO COVERAGE OF PREVENTIVE SERVICES.
(a) Coverage of Additional Preventive Services-
(1) COVERAGE- Section 1861 of the Social Security Act (42 U.S.C. 1395x),
as amended by section 114 of the Medicare, Medicaid, and SCHIP Extension
Act of 2007 (Public Law 110-173), is amended--
(A) in subsection (s)(2)--
(i) in subparagraph (Z), by striking `and' after the semicolon at the
end;
(ii) in subparagraph (AA), by adding `and' after the semicolon at the
end; and
(iii) by adding at the end the following new subparagraph:
`(BB) additional preventive services (described in subsection (ddd)(1));';
and
(B) by adding at the end the following new subsection:
`Additional Preventive Services
`(ddd)(1) The term `additional preventive services' means services not otherwise
described in this title that identify medical conditions or risk factors and
that the Secretary determines are--
`(A) reasonable and necessary for the prevention or early detection of an
illness or disability;
`(B) recommended with a grade of A or B by the United States Preventive
Services Task Force; and
`(C) appropriate for individuals entitled to benefits under part A or enrolled
under part B.
`(2) In making determinations under paragraph (1) regarding the coverage of
a new service, the Secretary shall use the process for making national coverage
determinations (as defined in section 1869(f)(1)(B)) under this title. As
part of the use of such process, the Secretary may conduct an assessment of
the relation between predicted outcomes and the expenditures for such service
and may take into account the results of such assessment in making such determination.'.
(2) PAYMENT AND COINSURANCE FOR ADDITIONAL PREVENTIVE SERVICES- Section
1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended--
(A) by striking `and' before `(V)'; and
(B) by inserting before the semicolon at the end the following: `, and
(W) with respect to additional preventive services (as defined in section
1861(ddd)(1)), the amount paid shall be (i) in the case of such services
which are clinical diagnostic laboratory tests, the amount determined
under subparagraph (D), and (ii) in the case of all other such services,
80 percent of the lesser of the actual charge for the service or the amount
determined under a fee schedule established by the Secretary for purposes
of this subparagraph'.
(3) CONFORMING AMENDMENT REGARDING COVERAGE- Section 1862(a)(1)(A) of the
Social Security Act (42 U.S.C. 1395y(a)(1)(A)) is amended by inserting `or
additional preventive services (as described in section 1861(ddd)(1))' after
`succeeding subparagraph'.
(4) RULE OF CONSTRUCTION- Nothing in the provisions of, or amendments made
by, this subsection shall be construed to provide coverage under title XVIII
of the Social Security Act of items and services for the treatment of a
medical condition that is not otherwise covered under such title.
(b) Revisions to Initial Preventive Physical Examination-
(1) IN GENERAL- Section 1861(ww) of the Social Security Act (42 U.S.C. 1395x(ww))
is amended--
(i) by inserting `body mass index,' after `weight';
(ii) by striking `, and an electrocardiogram'; and
(iii) by inserting `and end-of-life planning (as defined in paragraph
(3)) upon the agreement with the individual' after `paragraph (2)';
(B) in paragraph (2), by adding at the end the following new subparagraphs:
`(M) An electrocardiogram.
`(N) Additional preventive services (as defined in subsection (ddd)(1)).';
and
(C) by adding at the end the following new paragraph:
`(3) For purposes of paragraph (1), the term `end-of-life planning' means
verbal or written information regarding--
`(A) an individual's ability to prepare an advance directive in the case
that an injury or illness causes the individual to be unable to make health
care decisions; and
`(B) whether or not the physician is willing to follow the individual's
wishes as expressed in an advance directive.'.
(2) WAIVER OF APPLICATION OF DEDUCTIBLE- The first sentence of section 1833(b)
of the Social Security Act (42 U.S.C. 1395l(b)) is amended--
(A) by striking `and' before `(8)'; and
(B) by inserting `, and (9) such deductible shall not apply with respect
to an initial preventive physical examination (as defined in section 1861(ww))'
before the period at the end.
(3) EXTENSION OF ELIGIBILITY PERIOD FROM SIX MONTHS TO ONE YEAR- Section
1862(a)(1)(K) of the Social Security Act (42 U.S.C. 1395y(a)(1)(K)) is amended
by striking `6 months' and inserting `1 year'.
(4) TECHNICAL CORRECTION- Section 1862(a)(1)(K) of the Social Security Act
(42 U.S.C. 1395y(a)(1)(K)) is amended by striking `not later' and inserting
`more'.
(c) Effective Date- The amendments made by this section shall apply to services
furnished on or after January 1, 2009.
SEC. 102. ELIMINATION OF DISCRIMINATORY COPAYMENT RATES FOR MEDICARE OUTPATIENT
PSYCHIATRIC SERVICES.
Section 1833(c) of the Social Security Act (42 U.S.C. 1395l(c)) is amended
to read as follows:
`(c)(1) Notwithstanding any other provision of this part, with respect to
expenses incurred in a calendar year in connection with the treatment of mental,
psychoneurotic, and personality disorders of an individual who is not an inpatient
of a hospital at the time such expenses are incurred, there shall be considered
as incurred expenses for purposes of subsections (a) and (b)--
`(A) for expenses incurred in years prior to 2010, only 62 1/2 percent of
such expenses;
`(B) for expenses incurred in 2010 or 2011, only 68 3/4 percent of such
expenses;
`(C) for expenses incurred in 2012, only 75 percent of such expenses;
`(D) for expenses incurred in 2013, only 81 1/4 percent of such expenses;
and
`(E) for expenses incurred in 2014 or any subsequent calendar year, 100
percent of such expenses.
`(2) For purposes of subparagraphs (A) through (D) of paragraph (1), the term
`treatment' does not include brief office visits (as defined by the Secretary)
for the sole purpose of monitoring or changing drug prescriptions used in
the treatment of such disorders or partial hospitalization services that are
not directly provided by a physician.'.
SEC. 103. PROHIBITIONS AND LIMITATIONS ON CERTAIN SALES AND MARKETING ACTIVITIES
UNDER MEDICARE ADVANTAGE PLANS AND PRESCRIPTION DRUG PLANS.
(1) MEDICARE ADVANTAGE PROGRAM-
(A) IN GENERAL- Section 1851 of the Social Security Act (42 U.S.C. 1395w-21)
is amended--
(i) in subsection (h)(4)--
(I) in subparagraph (A)--
(aa) by striking `cash or other monetary rebates' and inserting
`, subject to subsection (j)(2)(C), cash, gifts, prizes, or other monetary
rebates'; and
(bb) by striking `, and' at the end and inserting a semicolon;
(II) in subparagraph (B), by striking the period at the end and inserting
a semicolon; and
(III) by adding at the end the following new subparagraph:
`(C) shall not permit a Medicare Advantage organization (or the agents,
brokers, and other third parties representing such organization) to conduct
the prohibited activities described in subsection (j)(1); and'; and
(ii) by adding at the end the following new subsection:
`(j) Prohibited Activities Described and Limitations on the Conduct of Certain
Other Activities-
`(1) PROHIBITED ACTIVITIES DESCRIBED- The following prohibited activities
are described in this paragraph:
`(A) UNSOLICITED MEANS OF DIRECT CONTACT- Any unsolicited means of direct
contact of prospective enrollees, including soliciting door-to-door or
any outbound telemarketing without the prospective enrollee initiating
contact.
`(B) CROSS-SELLING- The sale of other non-health related products (such
as annuities and life insurance) during any sales or marketing activity
or presentation conducted with respect to a Medicare Advantage plan.
`(C) MEALS- The provision of meals of any sort, regardless of value, to
prospective enrollees at promotional and sales activities.
`(D) SALES AND MARKETING IN HEALTH CARE SETTINGS AND AT EDUCATIONAL EVENTS-
Sales and marketing activities for the enrollment of individuals in Medicare
Advantage plans that are conducted--
`(i) in health care settings in areas where health care is delivered
to individuals (such as physician offices and pharmacies), except in
the case where such activities are conducted in common areas in health
care settings; and
`(ii) at educational events.'.
(2) MEDICARE PRESCRIPTION DRUG PROGRAM- Section 1860D-4 of the Social Security
Act (42 U.S.C. 1395w-104) is amended by adding at the end the following
new subsection:
`(l) Requirements With Respect to Sales and Marketing Activities- The following
provisions shall apply to a PDP sponsor (and the agents, brokers, and other
third parties representing such sponsor) in the same manner as such provisions
apply to a Medicare Advantage organization (and the agents, brokers, and other
third parties representing such organization):
`(1) The prohibition under section 1851(h)(4)(C) on conducting activities
described in section 1851(j)(1).'.
(3) EFFECTIVE DATE- The amendments made by this subsection shall apply to
plan years beginning on or after January 1, 2009.
(1) MEDICARE ADVANTAGE PROGRAM- Section 1851 of the Social Security Act
(42 U.S.C. 1395w-21), as amended by subsection (a)(1), is amended--
(A) in subsection (h)(4), by adding at the end the following new subparagraph:
`(D) shall only permit a Medicare Advantage organization (and the agents,
brokers, and other third parties representing such organization) to conduct
the activities described in subsection (j)(2) in accordance with the limitations
established under such subsection.'; and
(B) in subsection (j), by adding at the end the following new paragraph:
`(2) LIMITATIONS- The Secretary shall establish limitations with respect
to at least the following:
`(A) SCOPE OF MARKETING APPOINTMENTS- The scope of any appointment with
respect to the marketing of a Medicare Advantage plan. Such limitation
shall require advance agreement with a prospective enrollee on the scope
of the marketing appointment and documentation of such agreement by the
Medicare Advantage organization. In the case where the marketing appointment
is in person, such documentation shall be in writing.
`(B) CO-BRANDING- The use of the name or logo of a co-branded network
provider on Medicare Advantage plan membership and marketing materials.
`(C) LIMITATION OF GIFTS TO NOMINAL DOLLAR VALUE- The offering of gifts
and other promotional items other than those that are of nominal value
(as determined by the Secretary) to prospective enrollees at promotional
activities.
`(D) COMPENSATION- The use of compensation other than as provided under
guidelines established by the Secretary. Such guidelines shall ensure
that the use of compensation creates incentives for agents and brokers
to enroll individuals in the Medicare Advantage plan that is intended
to best meet their health care needs.
`(E) REQUIRED TRAINING, ANNUAL RETRAINING, AND TESTING OF AGENTS, BROKERS,
AND OTHER THIRD PARTIES- The use by a Medicare Advantage organization
of any individual as an agent, broker, or other third party representing
the organization that has not completed an initial training and testing
program and does not complete an annual retraining and testing program.'.
(2) MEDICARE PRESCRIPTION DRUG PROGRAM- Section 1860D-4(l) of the Social
Security Act, as added by subsection (a)(2), is amended by adding at the
end the following new paragraph:
`(2) The requirement under section 1851(h)(4)(D) to conduct activities described
in section 1851(j)(2) in accordance with the limitations established under
such subsection.'.
(3) EFFECTIVE DATE- The amendments made by this subsection shall take effect
on a date specified by the Secretary (but in no case later than November
15, 2008).
(c) Required Inclusion of Plan Type in Plan Name-
(1) MEDICARE ADVANTAGE PROGRAM- Section 1851(h) of the Social Security Act
(42 U.S.C. 1395w-21(h)) is amended by adding at the end following new paragraph:
`(6) REQUIRED INCLUSION OF PLAN TYPE IN PLAN NAME- For plan years beginning
on or after January 1, 2010, a Medicare Advantage organization must ensure
that the name of each Medicare Advantage plan offered by the Medicare Advantage
organization includes the plan type of the plan (using standard terminology
developed by the Secretary).'.
(2) PRESCRIPTION DRUG PLANS- Section 1860D-4(l) of the Social Security Act,
as added by subsection (a)(2) and amended by subsection (b)(2), is amended
by adding at the end the following new paragraph:
`(3) The inclusion of the plan type in the plan name under section 1851(h)(6).'.
(d) Strengthening the Ability of States To Act in Collaboration With the Secretary
To Address Fraudulent or Inappropriate Marketing Practices-
(1) MEDICARE ADVANTAGE PROGRAM- Section 1851(h) of the Social Security Act
(42 U.S.C. 1395w-21(h), as amended by subsection (c)(1), is amended by adding
at the end the following new paragraph:
`(7) STRENGTHENING THE ABILITY OF STATES TO ACT IN COLLABORATION WITH THE
SECRETARY TO ADDRESS FRAUDULENT OR INAPPROPRIATE MARKETING PRACTICES-
`(A) APPOINTMENT OF AGENTS AND BROKERS- Each Medicare Advantage organization
shall--
`(i) only use agents and brokers who have been licensed under State
law to sell Medicare Advantage plans offered by the Medicare Advantage
organization;
`(ii) in the case where a State has a State appointment law, abide by
such law; and
`(iii) report to the applicable State the termination of any such agent
or broker, including the reasons for such termination (as required under
applicable State law).
`(B) COMPLIANCE WITH STATE INFORMATION REQUESTS- Each Medicare Advantage
organization shall comply in a timely manner with any request by a State
for information regarding the performance of a licensed agent, broker,
or other third party representing the Medicare Advantage organization
as part of an investigation by the State into the conduct of the agent,
broker, or other third party.'.
(2) PRESCRIPTION DRUG PLANS- Section 1860D-4(l) of the Social Security Act,
as amended by subsection (c)(2), is amended by adding at the end the following
new paragraph:
`(4) The requirements regarding the appointment of agents and brokers and
compliance with State information requests under subparagraphs (A) and (B),
respectively, of section 1851(h)(7).'.
(3) EFFECTIVE DATE- The amendments made by this subsection shall apply to
plan years beginning on or after January 1, 2009.
SEC. 104. IMPROVEMENTS TO THE MEDIGAP PROGRAM.
(a) Implementation of NAIC Recommendations-
(1) IN GENERAL- The Secretary of Health and Human Services (in this section
referred to as the `Secretary') shall provide for implementation of the
changes in the NAIC model law and regulations approved by the National Association
of Insurance Commissioners in its Model #651 (`Model Regulation to Implement
the NAIC Medicare Supplement Insurance Minimum Standards Model Act') on
March 11, 2007, as modified to reflect the changes made under this Act and
the Genetic Information Nondiscrimination Act of 2008 (Public Law 110-233).
(2) IMPLEMENTATION DATES-
(A) IN GENERAL- The modifications to Model #651 required under paragraph
(1) shall be completed by the National Association of Insurance Commissioners
not later than October 31, 2008. Except as provided in subparagraph (B),
each State shall have 1 year from the date the National Association of
Insurance Commissioners adopts the revised NAIC model law and regulations
(as changed by Model #651, as so modified) to conform the regulatory program
established by the State to such revised NAIC model law and regulations.
(B) EXTENSION OF EFFECTIVE DATE FOR STATE LAW AMENDMENT- In the case of
a State which the Secretary determines requires State legislation in order
to conform the regulatory program established by the State to such revised
NAIC model law and regulations, the State shall not be regarded as failing
to comply with the requirements of this section solely on the basis of
its failure to meet such requirements before the first day of the first
calendar quarter beginning after the close of the first regular session
of the State legislature that begins after the date of the enactment of
this Act. For purposes of the previous sentence, in the case of a State
that has a 2-year legislative session, each year of the session is considered
to be a separate regular session of the State legislature.
(C) TRANSITION DATES- No carrier may issue a new or revised medicare supplemental
policy or certificate under section 1882 of the Social Security Act (42
U.S.C. 1395ss) that meets the requirements of such revised NAIC model
law and regulations for coverage effective prior to June 1, 2010. A carrier
may continue to offer or issue a medicare supplemental policy under such
section that meets the requirements of the NAIC model law and regulations
and State law (as in effect prior to the adoption of such revised NAIC
model law and regulations) prior to June 1, 2010. Nothing shall preclude
carriers from marketing new or revised medicare supplemental policies
or certificates that meet the requirements of such revised NAIC model
law and regulations on or after the date on which the State conforms the
regulatory program established by the State to such revised NAIC model
law and regulations.
(b) Required Offering of a Range of Policies- Section 1882(o) of the Social
Security Act (42 U.S.C. 1395s(o)) is amended by adding at the end the following
new paragraph:
`(4) In addition to the requirement under paragraph (2), the issuer of the
policy must make available to the individual at least Medicare supplemental
policies with benefit packages classified as `C' or `F'.'.
PART II--LOW-INCOME PROGRAMS
SEC. 111. EXTENSION OF 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 `June 2008' and inserting `December
2009'.
(b) Extending Total Amount Available for Allocation- Section 1933(g) of such
Act (42 U.S.C. 1396u-3(g)) is amended--
(A) by striking `and' at the end of subparagraph (H);
(B) in subparagraph (I)--
(i) by striking `June 30' and inserting `September 30';
(ii) by striking `$200,000,000' and inserting `$300,000,000'; and
(iii) by striking the period at the end and inserting a semicolon; and
(C) by adding at the end the following new subparagraphs:
`(J) for the period that begins on October 1, 2008, and ends on December
31, 2008, the total allocation amount is $100,000,000;
`(K) for the period that begins on January 1, 2009, and ends on September
30, 2009, the total allocation amount is $350,000,000; and
`(L) for the period that begins on October 1, 2009, and ends on December
31, 2009, the total allocation amount is $150,000,000.'; and
(2) in paragraph (3), in the matter preceding subparagraph (A), by striking
`or (H)' and inserting `(H), (J), or (L)'.
SEC. 112. APPLICATION OF FULL LIS SUBSIDY ASSETS TEST UNDER MEDICARE SAVINGS
PROGRAM.
Section 1905(p)(1)(C) of such Act (42 U.S.C. 1396d(p)(1)(C)) is amended by
inserting before the period at the end the following: `or, effective beginning
with January 1, 2010, whose resources (as so determined) do not exceed the
maximum resource level applied for the year under subparagraph (D) of section
1860D-14(a)(3) (determined without regard to the life insurance policy exclusion
provided under subparagraph (G) of such section) applicable to an individual
or to the individual and the individual's spouse (as the case may be)'.
SEC. 113. ELIMINATING BARRIERS TO ENROLLMENT.
(a) SSA Assistance With Medicare Savings Program and Low-Income Subsidy Program
Applications- Section 1144 of such Act (42 U.S.C. 1320b-14) is amended by
adding at the end the following new subsection:
`(c) Assistance With Medicare Savings Program and Low-Income Subsidy Program
Applications-
`(1) DISTRIBUTION OF APPLICATIONS AND INFORMATION TO INDIVIDUALS WHO ARE
POTENTIALLY ELIGIBLE FOR LOW-INCOME SUBSIDY PROGRAM- For each individual
who submits an application for low-income subsidies under section 1860D-14,
requests an application for such subsidies, or is otherwise identified as
an individual who is potentially eligible for such subsidies, the Commissioner
shall do the following:
`(A) Provide information describing the low-income subsidy program under
section 1860D-14 and the Medicare Savings Program (as defined in paragraph
(7)).
`(B) Provide an application for enrollment under such low-income subsidy
program (if not already received by the Commissioner).
`(C) In accordance with paragraph (3), transmit data from such an application
for purposes of initiating an application for benefits under the Medicare
Savings Program.
`(D) Provide information on how the individual may obtain assistance in
completing such application and an application under the Medicare Savings
Program, including information on how the individual may contact the State
health insurance assistance program (SHIP).
`(E) Make the application described in subparagraph (B) and the information
described in subparagraphs (A) and (D) available at local offices of the
Social Security Administration.
`(2) TRAINING PERSONNEL IN EXPLAINING BENEFIT PROGRAMS AND ASSISTING IN
COMPLETING LIS APPLICATION- The Commissioner shall provide training to those
employees of the Social Security Administration who are involved in receiving
applications for benefits described in paragraph (1)(B) in order that they
may promote beneficiary understanding of the low-income subsidy program
and the Medicare Savings Program in order to increase participation in these
programs. Such employees shall provide assistance in completing an application
described in paragraph (1)(B) upon request.
`(3) TRANSMITTAL OF DATA TO STATES- Beginning on January 1, 2010, with the
consent of an individual completing an application for benefits described
in paragraph (1)(B), the Commissioner shall electronically transmit to the
appropriate State Medicaid agency data from such application, as determined
by the Commissioner, which transmittal shall initiate an application of
the individual for benefits under the Medicare Savings Program. In order
to ensure that such data transmittal provides effective assistance for purposes
of State adjudication of applications for benefits under the Medicare Savings
Program, the Commissioner shall consult with the Secretary, after the Secretary
has consulted with the States, regarding the content, form, frequency, and
manner in which data (on a uniform basis for all States) shall be transmitted
under this subparagraph.
`(4) COORDINATION WITH OUTREACH- The Commissioner shall coordinate outreach
activities under this subsection with outreach activities conducted by States
in connection with the low-income subsidy program and the Medicare Savings
Program.
`(5) REIMBURSEMENT OF SOCIAL SECURITY ADMINISTRATION ADMINISTRATIVE COSTS-
`(A) INITIAL MEDICARE SAVINGS PROGRAM COSTS; ADDITIONAL LOW-INCOME SUBSIDY
COSTS-
`(i) INITIAL MEDICARE SAVINGS PROGRAM COSTS- There are hereby appropriated
to the Commissioner to carry out this subsection, out of any funds in
the Treasury not otherwise appropriated, $21,100,000. The amount appropriated
under ths clause shall be available on October 1, 2008, and shall remain
available until expended.
`(ii) ADDITIONAL AMOUNT FOR LOW-INCOME SUBSIDY ACTIVITIES- There are
hereby appropriated to the Commissioner, out of any funds in the Treasury
not otherwise appropriated, $24,800,000 for fiscal year 2009 to carry
out low-income subsidy activities under this Act, to remain available
until expended. Such funds shall be in addition to the Social Security
Administration's Limitation on Administrative Expenditure appropriations
for such fiscal year.
`(B) SUBSEQUENT FUNDING UNDER AGREEMENTS-
`(i) IN GENERAL- Effective for fiscal years beginning on or after October
1, 2010, the Commissioner and the Secretary shall enter into an agreement
which shall provide funding to cover the administrative costs of the
Commissioner's activities under this subsection. Such agreement shall--
`(I) provide funds to the Commissioner for the full cost of the Social
Security Administration's work related to the Medicare Savings Program
required under this section;
`(II) provide such funding quarterly in advance of the applicable
quarter based on estimating methodology agreed to by the Commissioner
and the Secretary; and
`(III) require an annual accounting and reconciliation of the actual
costs incurred and funds provided under this subsection.
`(ii) APPROPRIATION- There are hereby appropriated to the Secretary
solely for the purpose of providing payments to the Commissioner pursuant
to an agreement specified in clause (i) that is in effect, out of any
funds in the Treasury not otherwise appropriated, not more than $3,000,000
for fiscal year 2011 and each fiscal year thereafter.
`(C) LIMITATION- In no case shall funds from the Social Security Administration's
Limitation on Administrative Expenses be used to carry out activities
under this subsection. For fiscal years beginning on or after October
1, 2010, no such activities shall be undertaken by the Social Security
Administration unless the agreement specified in subparagraph (B) is in
effect and full funding has been provided to the Commissioner as specified
in such subparagraph.
`(6) GAO ANALYSIS AND REPORT-
`(A) ANALYSIS- The Comptroller General of the United States shall prepare
an analysis of the impact of this subsection--
`(i) in increasing participation in the Medicare Savings Program, and
`(ii) on States and the Social Security Administration.
`(B) REPORT- Not later than January 1, 2012, the Comptroller General shall
submit to Congress, the Commissioner, and the Secretary a report on the
analysis conducted under subparagraph (A).
`(7) MEDICARE SAVINGS PROGRAM DEFINED- For purposes of this subsection,
the term `Medicare Savings Program' means the program of medical assistance
for payment of the cost of medicare cost-sharing under the Medicaid program
pursuant to sections 1902(a)(10)(E) and 1933.'.
(b) Medicaid Agency Consideration of Data Transmittal- Section 1935(a) of
such Act (42 U.S.C. 1396u-5(a)) is amended by adding at the end the following
new paragraph:
`(4) CONSIDERATION OF DATA TRANSMITTED BY THE SOCIAL SECURITY ADMINISTRATION
FOR PURPOSES OF MEDICARE SAVINGS PROGRAM- The State shall accept data transmitted
under section 1144(c)(3) and act on such data in the same manner and in
accordance with the same deadlines as if the data constituted an initiation
of an application for benefits under the Medicare Savings Program (as defined
for purposes of such section) that had been submitted directly by the applicant.
The date of the individual's application for the low income subsidy program
from which the data have been derived shall constitute the date of filing
of such application for benefits under the Medicare Savings Program.'.
(c) Effective Date- Except as otherwise provided, the amendments made by this
section shall take effect on January 1, 2010.
SEC. 114. ELIMINATION OF MEDICARE PART D LATE ENROLLMENT PENALTIES PAID
BY SUBSIDY ELIGIBLE INDIVIDUALS.
(a) Waiver of Late Enrollment Penalty-
(1) IN GENERAL- Section 1860D-13(b) of the Social Security Act (42 U.S.C.
1395w-113(b)) is amended by adding at the end the following new paragraph:
`(8) WAIVER OF PENALTY FOR SUBSIDY-ELIGIBLE INDIVIDUALS- In no case shall
a part D eligible individual who is determined to be a subsidy eligible
individual (as defined in section 1860D-14(a)(3)) be subject to an increase
in the monthly beneficiary premium established under subsection (a).'.
(2) CONFORMING AMENDMENT- Section 1860D-14(a)(1)(A) of the Social Security
Act (42 U.S.C. 1395w-114(a)(1)(A)) is amended by striking `equal to' and
all that follows through the period and inserting `equal to 100 percent
of the amount described in subsection (b)(1), but not to exceed the premium
amount specified in subsection (b)(2)(B).'.
(b) Effective Date- The amendments made by this section shall apply to subsidies
for months beginning with January 2009.
SEC. 115. ELIMINATING APPLICATION OF ESTATE RECOVERY.
(a) In General- Section 1917(b)(1)(B)(ii) of the Social Security Act (42 U.S.C.
1396p(b)(1)(B)(ii)) is amended by inserting `(but not including medical assistance
for medicare cost-sharing or for benefits described in section 1902(a)(10)(E))'
before the period at the end.
(b) Effective Date- The amendment made by subsection (a) shall take effect
as of January 1, 2010.
SEC. 116. EXEMPTIONS FROM INCOME AND RESOURCES FOR DETERMINATION OF ELIGIBILITY
FOR LOW-INCOME SUBSIDY.
(a) In General- Section 1860D-14(a)(3) of the Social Security Act (42 U.S.C.
1395w-114(a)(3)) is amended--
(1) in subparagraph (C)(i), by inserting `and except that support and maintenance
furnished in kind shall not be counted as income' after `section 1902(r)(2)';
(2) in subparagraph (D), in the matter before clause (i), by inserting `subject
to the life insurance policy exclusion provided under subparagraph (G)'
before `)';
(3) in subparagraph (E)(i), in the matter before subclause (I), by inserting
`subject to the life insurance policy exclusion provided under subparagraph
(G)' before `)'; and
(4) by adding at the end the following new subparagraph:
`(G) LIFE INSURANCE POLICY EXCLUSION- In determining the resources of
an individual (and the eligible spouse of the individual, if any) under
section 1613 for purposes of subparagraphs (D) and (E) no part of the
value of any life insurance policy shall be taken into account.'.
(b) Effective Date- The amendments made by this section shall take effect
on January 1, 2010, and shall apply to determinations of eligibility for months
beginning with January 2010.
SEC. 117. JUDICIAL REVIEW OF DECISIONS OF THE COMMISSIONER OF SOCIAL SECURITY
UNDER THE MEDICARE PART D LOW-INCOME SUBSIDY PROGRAM.
(a) In General- Section 1860D-14(a)(3)(B)(iv) of the Social Security Act (42
U.S.C. 1395w-114(a)(3)(B)(iv)) is amended--
(1) in subclause (I), by striking `and' at the end;
(2) in subclause (II), by striking the period at the end and inserting `;
and'; and
(3) by adding at the end the following new subclause:
`(III) judicial review of the final decision of the Commissioner made
after a hearing shall be available to the same extent, and with the
same limitations, as provided in subsections (g) and (h) of section
205.'.
(b) Effective Date- The amendments made by subsection (a) shall take effect
as if included in the enactment of section 101 of the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003.
SEC. 118. TRANSLATION OF MODEL FORM.
(a) In General- Section 1905(p)(5)(A) of the Social Security Act (42 U.S.C.
1396d(p)(5)(A)) is amended by adding at the end the following: `The Secretary
shall provide for the translation of such application form into at least the
10 languages (other than English) that are most often used by individuals
applying for hospital insurance benefits under section 226 or 226A and shall
make the translated forms available to the States and to the Commissioner
of Social Security.'.
(b) Effective Date- The amendment made by subsection (a) shall take effect
on January 1, 2010.
SEC. 119. MEDICARE ENROLLMENT ASSISTANCE.
(a) Additional Funding for State Health Insurance Assistance Programs-
(A) IN GENERAL- The Secretary of Health and Human Services (in this section
referred to as the `Secretary') shall use amounts made available under
subparagraph (B) to make grants to States for State health insurance assistance
programs receiving assistance under section 4360 of the Omnibus Budget
Reconciliation Act of 1990.
(B) FUNDING- For purposes of making grants under this subsection, 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 Medical Insurance Trust Fund under section
1841 of such Act (42 U.S.C. 1395t), in the same proportion as the Secretary
determines under section 1853(f) of such Act (42 U.S.C. 1395w-23(f)),
of $7,500,000 to the Centers for Medicare & Medicaid Services Program
Management Account for fiscal year 2009, to remain available until expended.
(2) AMOUNT OF GRANTS- The amount of a grant to a State under this subsection
from the total amount made available under paragraph (1) shall be equal
to the sum of the amount allocated to the State under paragraph (3)(A) and
the amount allocated to the State under subparagraph (3)(B).
(3) ALLOCATION TO STATES-
(A) ALLOCATION BASED ON PERCENTAGE OF LOW-INCOME BENEFICIARIES- The amount
allocated to a State under this subparagraph from 2/3 of the total amount
made available under paragraph (1) shall be based on the number of individuals
who meet the requirement under subsection (a)(3)(A)(ii) of section 1860D-14
of the Social Security Act (42 U.S.C. 1395w-114) but who have not enrolled
to receive a subsidy under such section 1860D-14 relative to the total
number of individuals who meet the requirement under such subsection (a)(3)(A)(ii)
in each State, as estimated by the Secretary.
(B) ALLOCATION BASED ON PERCENTAGE OF RURAL BENEFICIARIES- The amount
allocated to a State under this subparagraph from 1/3 of the total amount
made available under paragraph (1) shall be based on the number of part
D eligible individuals (as defined in section 1860D-1(a)(3)(A) of such
Act (42 U.S.C. 1395w-101(a)(3)(A))) residing in a rural area relative
to the total number of such individuals in each State, as estimated by
the Secretary.
(4) PORTION OF GRANT BASED ON PERCENTAGE OF LOW-INCOME BENEFICIARIES TO
BE USED TO PROVIDE OUTREACH TO INDIVIDUALS WHO MAY BE SUBSIDY ELIGIBLE INDIVIDUALS
OR ELIGIBLE FOR THE MEDICARE SAVINGS PROGRAM- Each grant awarded under this
subsection with respect to amounts allocated under paragraph (3)(A) shall
be used to provide outreach to individuals who may be 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)) or eligible for the Medicare Savings Program
(as defined in subsection (e)).
(b) Additional Funding for Area Agencies on Aging-
(A) IN GENERAL- The Secretary, acting through the Assistant Secretary
for Aging, shall make grants to States for area agencies on aging (as
defined in section 102 of the Older Americans Act of 1965 (42 U.S.C. 3002)).
(B) FUNDING- For purposes of making grants under this subsection, 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 Medical Insurance Trust Fund under section
1841 of such Act (42 U.S.C. 1395t), in the same proportion as the Secretary
determines under section 1853(f) of such Act (42 U.S.C. 1395w-23(f)),
of $7,500,000 to the Administration on Aging for fiscal year 2009, to
remain available until expended.
(2) AMOUNT OF GRANT AND ALLOCATION TO STATES BASED ON PERCENTAGE OF LOW-INCOME
AND RURAL BENEFICIARIES- The amount of a grant to a State under this subsection
from the total amount made available under paragraph (1) shall be determined
in the same manner as the amount of a grant to a State under subsection
(a), from the total amount made available under paragraph (1) of such subsection,
is determined under paragraph (2) and subparagraphs (A) and (B) of paragraph
(3) of such subsection.
(3) REQUIRED USE OF FUNDS-
(A) ALL FUNDS- Subject to subparagraph (B), each grant awarded under this
subsection shall be used to provide outreach to eligible Medicare beneficiaries
regarding the benefits available under title XVIII of the Social Security
Act.
(B) OUTREACH TO INDIVIDUALS WHO MAY BE SUBSIDY ELIGIBLE INDIVIDUALS OR
ELIGIBLE FOR THE MEDICARE SAVINGS PROGRAM- Subsection (a)(4) shall apply
to each grant awarded under this subsection in the same manner as it applies
to a grant under subsection (a).
(c) Additional Funding for Aging and Disability Resource Centers-
(A) IN GENERAL- The Secretary shall make grants to Aging and Disability
Resource Centers under the Aging and Disability Resource Center grant
program that are established centers under such program on the date of
the enactment of this Act.
(B) FUNDING- For purposes of making grants under this subsection, 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 Medical Insurance Trust Fund under section
1841 of such Act (42 U.S.C. 1395t), in the same proportion as the Secretary
determines under section 1853(f) of such Act (42 U.S.C. 1395w-23(f)),
of $5,000,000 to the Administration on Aging for fiscal year 2009, to
remain available until expended.
(2) REQUIRED USE OF FUNDS- Each grant awarded under this subsection shall
be used to provide outreach to individuals regarding the benefits available
under the Medicare prescription drug benefit under part D of title XVIII
of the Social Security Act and under the Medicare Savings Program.
(d) Coordination of Efforts To Inform Older Americans About Benefits Available
Under Federal and State Programs-
(1) IN GENERAL- The Secretary, acting through the Assistant Secretary for
Aging, in cooperation with related Federal agency partners, shall make a
grant to, or enter into a contract with, a qualified, experienced entity
under which the entity shall--
(A) maintain and update web-based decision support tools, and integrated,
person-centered systems, designed to inform older individuals (as defined
in section 102 of the Older Americans Act of 1965 (42 U.S.C. 3002)) about
the full range of benefits for which the individuals may be eligible under
Federal and State programs;
(B) utilize cost-effective strategies to find older individuals with the
greatest economic need (as defined in such section 102) and inform the
individuals of the programs;
(C) develop and maintain an information clearinghouse on best practices
and the most cost-effective methods for finding older individuals with
greatest economic need and informing the individuals of the programs;
and
(D) provide, in collaboration with related Federal agency partners administering
the Federal programs, training and technical assistance on the most effective
outreach, screening, and follow-up strategies for the Federal and State
programs.
(2) FUNDING- For purposes of making a grant or entering into a contract
under paragraph (1), 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 Medical Insurance
Trust Fund under section 1841 of such Act (42 U.S.C. 1395t), in the same
proportion as the Secretary determines under section 1853(f) of such Act
(42 U.S.C. 1395w-23(f)), of $5,000,000 to the Administration on Aging for
fiscal year 2009, to remain available until expended.
(e) Medicare Savings Program Defined- For purposes of this section, the term
`Medicare Savings Program' means the program of medical assistance for payment
of the cost of medicare cost-sharing under the Medicaid program pursuant to
sections 1902(a)(10)(E) and 1933 of the Social Security Act (42 U.S.C. 1396a(a)(10)(E),
1396u-3).
Subtitle B--Provisions Relating to Part A
SEC. 121. EXPANSION AND EXTENSION OF THE MEDICARE RURAL HOSPITAL FLEXIBILITY
PROGRAM.
(a) In General- Section 1820(g) of the Social Security Act (42 U.S.C. 1395i-4(g))
is amended by adding at the end the following new paragraph:
`(6) PROVIDING MENTAL HEALTH SERVICES AND OTHER HEALTH SERVICES TO VETERANS
AND OTHER RESIDENTS OF RURAL AREAS-
`(A) GRANTS TO STATES- The Secretary may award grants to States that have
submitted applications in accordance with subparagraph (B) for increasing
the delivery of mental health services or other health care services deemed
necessary to meet the needs of veterans of Operation Iraqi Freedom and
Operation Enduring Freedom living in rural areas (as defined for purposes
of section 1886(d) and including areas that are rural census tracks, as
defined by the Administrator of the Health Resources and Services Administration),
including for the provision of crisis intervention services and the detection
of post-traumatic stress disorder, traumatic brain injury, and other signature
injuries of veterans of Operation Iraqi Freedom and Operation Enduring
Freedom, and for referral of such veterans to medical facilities operated
by the Department of Veterans Affairs, and for the delivery of such services
to other residents of such rural areas.
`(i) IN GENERAL- An application is in accordance with this subparagraph
if the State submits to the Secretary at such time and in such form
as the Secretary may require an application containing the assurances
described in subparagraphs (A)(ii) and (A)(iii) of subsection (b)(1).
`(ii) CONSIDERATION OF REGIONAL APPROACHES, NETWORKS, OR TECHNOLOGY-
The Secretary may, as appropriate in awarding grants to States under
subparagraph (A), consider whether the application submitted by a State
under this subparagraph includes 1 or more proposals that utilize regional
approaches, networks, health information technology, telehealth, or
telemedicine to deliver services described in subparagraph (A) to individuals
described in that subparagraph. For purposes of this clause, a network
may, as the Secretary determines appropriate, include federally qualified
health centers, rural health clinics, home health agencies, community
mental health clinics and other providers of mental health services,
pharmacists, local government, and other providers deemed necessary
to meet the needs of veterans.
`(iii) COORDINATION AT LOCAL LEVEL- The Secretary shall require, as
appropriate, a State to demonstrate consultation with the hospital association
of such State, rural hospitals located in such State, providers of mental
health services, or other appropriate stakeholders for the provision
of services under a grant awarded under this paragraph.
`(iv) SPECIAL CONSIDERATION OF CERTAIN APPLICATIONS- In awarding grants
to States under subparagraph (A), the Secretary shall give special consideration
to applications submitted by States in which veterans make up a high
percentage (as determined by the Secretary) of the total population
of the State. Such consideration shall be given without regard to the
number of veterans of Operation Iraqi Freedom and Operation Enduring
Freedom living in the areas in which mental health services and other
health care services would be delivered under the application.
`(C) COORDINATION WITH VA- The Secretary shall, as appropriate, consult
with the Director of the Office of Rural Health of the Department of Veterans
Affairs in awarding and administering grants to States under subparagraph
(A).
`(D) USE OF FUNDS- A State awarded a grant under this paragraph may, as
appropriate, use the funds to reimburse providers of services described
in subparagraph (A) to individuals described in that subparagraph.
`(E) LIMITATION ON USE OF GRANT FUNDS FOR ADMINISTRATIVE EXPENSES- A State
awarded a grant under this paragraph may not expend more than 15 percent
of the amount of the grant for administrative expenses.
`(F) INDEPENDENT EVALUATION AND FINAL REPORT- The Secretary shall provide
for an independent evaluation of the grants awarded under subparagraph
(A). Not later than 1 year after the date on which the last grant is awarded
to a State under such subparagraph, the Secretary shall submit a report
to Congress on such evaluation. Such report shall include an assessment
of the impact of such grants on increasing the delivery of mental health
services and other health services to veterans of the United States Armed
Forces living in rural areas (as so defined and including such areas that
are rural census tracks), with particular emphasis on the impact of such
grants on the delivery of such services to veterans of Operation Enduring
Freedom and Operation Iraqi Freedom, and to other individuals living in
such rural areas.'.
(b) Use of Funds for Federal Administrative Expenses- Section 1820(g)(5) of
the Social Security Act (42 U.S.C. 1395i-4(g)(5)) is amended--
(1) by striking `beginning with fiscal year 2005' and inserting `for each
of fiscal years 2005 through 2008'; and
(2) by inserting `and, of the total amount appropriated for grants under
paragraphs (1), (2), and (6) for a fiscal year (beginning with fiscal year
2009)' after `2005)'.
(c) Extension of Authorization for FLEX Grants- Section 1820(j) of the Social
Security Act (42 U.S.C. 1395i-4(j)) is amended--
(1) by striking `and for' and inserting `for'; and
(2) by inserting `, for making grants to all States under paragraphs (1)
and (2) of subsection (g), $55,000,000 in each of fiscal years 2009 and
2010, and for making grants to all States under paragraph (6) of subsection
(g), $50,000,000 in each of fiscal years 2009 and 2010, to remain available
until expended' before the period at the end.
(d) Medicare Rural Hospital Flexibility Program- Section 1820(g)(1) of the
Social Security Act (42 U.S.C. 1395i-4(g)(1)) is amended--
(1) in subparagraph (B), by striking `and' at the end;
(2) in subparagraph (C), by striking the period at the end and inserting
`; and'; and
(3) by adding at the end the following new subparagraph:
`(D) providing support for critical access hospitals for quality improvement,
quality reporting, performance improvements, and benchmarking.'.
(e) Assistance to Small Critical Access Hospitals Transitioning to Skilled
Nursing Facilities and Assisted Living Facilities- Section 1820(g) of the
Social Security Act (42 U.S.C. 1395i-4(g)), as amended by subsection (a),
is amended by adding at the end the following new paragraph:
`(7) CRITICAL ACCESS HOSPITALS TRANSITIONING TO SKILLED NURSING FACILITIES
AND ASSISTED LIVING FACILITIES-
`(A) GRANTS- The Secretary may award grants to eligible critical access
hospitals that have submitted applications in accordance with subparagraph
(B) for assisting such hospitals in the transition to skilled nursing
facilities and assisted living facilities.
`(B) APPLICATION- An applicable critical access hospital seeking a grant
under this paragraph shall submit an application to the Secretary on or
before such date and in such form and manner as the Secretary specifies.
`(C) ADDITIONAL REQUIREMENTS- The Secretary may not award a grant under
this paragraph to an eligible critical access hospital unless--
`(i) local organizations or the State in which the hospital is located
provides matching funds; and
`(ii) the hospital provides assurances that it will surrender critical
access hospital status under this title within 180 days of receiving
the grant.
`(D) AMOUNT OF GRANT- A grant to an eligible critical access hospital
under this paragraph may not exceed $1,000,000.
`(E) FUNDING- There are appropriated from the Federal Hospital Insurance
Trust Fund under section 1817 for making grants under this paragraph,
$5,000,000 for fiscal year 2008.
`(F) ELIGIBLE CRITICAL ACCESS HOSPITAL DEFINED- For purposes of this paragraph,
the term `eligible critical access hospital' means a critical access hospital
that has an average daily acute census of less than 0.5 and an average
daily swing bed census of greater than 10.0.'.
SEC. 122. REBASING FOR SOLE COMMUNITY HOSPITALS.
(a) Rebasing Permitted- Section 1886(b)(3) of the Social Security Act (42
U.S.C. 1395ww(b)(3)) is amended by adding at the end the following new subparagraph:
`(L)(i) For cost reporting periods beginning on or after January 1, 2009,
in the case of a sole community hospital there shall be substituted for the
amount otherwise determined under subsection (d)(5)(D)(i) of this section,
if such substitution results in a greater amount of payment under this section
for the hospital, the subparagraph (L) rebased target amount.
`(ii) For purposes of this subparagraph, the term `subparagraph (L) rebased
target amount' has the meaning given the term `target amount' in subparagraph
(C), except that--
`(I) there shall be substituted for the base cost reporting period the 12-month
cost reporting period beginning during fiscal year 2006;
`(II) any reference in subparagraph (C)(i) to the `first cost reporting
period' described in such subparagraph is deemed a reference to the first
cost reporting period beginning on or after January 1, 2009; and
`(III) the applicable percentage increase shall only be applied under subparagraph
(C)(iv) for discharges occurring on or after January 1, 2009.'.
(b) Conforming Amendments- Section 1886(b)(3) of the Social Security Act (42
U.S.C. 1395ww(b)(3)) is amended--
(1) in subparagraph (C), in the matter preceding clause (i), by striking
`subparagraph (I)' and inserting `subparagraphs (I) and (L)'; and
(2) in subparagraph (I)(i), in the matter preceding subclause (I), by striking
`For' and inserting `Subject to subparagraph (L), for'.
SEC. 123. DEMONSTRATION PROJECT ON COMMUNITY HEALTH INTEGRATION MODELS IN
CERTAIN RURAL COUNTIES.
(a) In General- The Secretary shall establish a demonstration project to allow
eligible entities to develop and test new models for the delivery of health
care services in eligible counties for the purpose of improving access to,
and better integrating the delivery of, acute care, extended care, and other
essential health care services to Medicare beneficiaries.
(b) Purpose- The purpose of the demonstration project under this section is
to--
(1) explore ways to increase access to, and improve the adequacy of, payments
for acute care, extended care, and other essential health care services
provided under the Medicare and Medicaid programs in eligible counties;
and
(2) evaluate regulatory challenges facing such providers and the communities
they serve.
(c) Requirements- The following requirements shall apply under the demonstration
project:
(1) Health care providers in eligible counties selected to participate in
the demonstration project under subsection (d)(3) shall (when determined
appropriate by the Secretary), instead of the payment rates otherwise applicable
under the Medicare program, be reimbursed at a rate that covers at least
the reasonable costs of the provider in furnishing acute care, extended
care, and other essential health care services to Medicare beneficiaries.
(2) Methods to coordinate the survey and certification process under the
Medicare program and the Medicaid program across all health service categories
included in the demonstration project shall be tested with the goal of assuring
quality and safety while reducing administrative burdens, as appropriate,
related to completing such survey and certification process.
(3) Health care providers in eligible counties selected to participate in
the demonstration project under subsection (d)(3) and the Secretary shall
work with the State to explore ways to revise reimbursement policies under
the Medicaid program to improve access to the range of health care services
available in such eligible counties.
(4) The Secretary shall identify regulatory requirements that may be revised
appropriately to improve access to care in eligible counties.
(5) Other essential health care services necessary to ensure access to the
range of health care services in eligible counties selected to participate
in the demonstration project under subsection (d)(3) shall be identified.
Ways to ensure adequate funding for such services shall also be explored.
(A) IN GENERAL- Eligibility to participate in the demonstration project
under this section shall be limited to eligible entities.
(B) ELIGIBLE ENTITY DEFINED- In this section, the term `eligible entity'
means an entity that--
(i) is a Rural Hospital Flexibility Program grantee under section 1820(g)
of the Social Security Act (42 U.S.C. 1395i-4(g)); and
(ii) is located in a State in which at least 65 percent of the counties
in the State are counties that have 6 or less residents per square mile.
(A) IN GENERAL- An eligible entity seeking to participate in the demonstration
project under this section shall submit an application to the Secretary
at such time, in such manner, and containing such information as the Secretary
may require.
(B) LIMITATION- The Secretary shall select eligible entities located in
not more than 4 States to participate in the demonstration project under
this section.
(3) SELECTION OF ELIGIBLE COUNTIES- An eligible entity selected by the Secretary
to participate in the demonstration project under this section shall select
not more than 6 eligible counties in the State in which the entity is located
in which to conduct the demonstration project.
(4) ELIGIBLE COUNTY DEFINED- In this section, the term `eligible county'
means a county that meets the following requirements:
(A) The county has 6 or less residents per square mile.
(B) As of the date of the enactment of this Act, a facility designated
as a critical access hospital which meets the following requirements was
located in the county:
(i) As of the date of the enactment of this Act, the critical access
hospital furnished 1 or more of the following:
(I) Home health services.
(III) Rural health clinic services.
(ii) As of the date of the enactment of this Act, the critical access
hospital has an average daily inpatient census of 5 or less.
(C) As of the date of the enactment of this Act, skilled nursing facility
services were available in the county in--
(i) a critical access hospital using swing beds; or
(ii) a local nursing home.
(1) IN GENERAL- The demonstration project under this section shall be administered
jointly by the Administrator of the Office of Rural Health Policy of the
Health Resources and Services Administration and the Administrator of the
Centers for Medicare & Medicaid Services, in accordance with paragraphs
(2) and (3).
(2) HRSA DUTIES- In administering the demonstration project under this section,
the Administrator of the Office of Rural Health Policy of the Health Resources
and Services Administration shall--
(A) award grants to the eligible entities selected to participate in the
demonstration project; and
(B) work with such entities to provide technical assistance related to
the requirements under the project.
(3) CMS DUTIES- In administering the demonstration project under this section,
the Administrator of the Centers for Medicare & Medicaid Services shall
determine which provisions of titles XVIII and XIX of the Social Security
Act (42 U.S.C. 1395 et seq.; 1396 et seq.) the Secretary should waive under
the waiver authority under subsection (i) that are relevant to the development
of alternative reimbursement methodologies, which may include, as appropriate,
covering at least the reasonable costs of the provider in furnishing acute
care, extended care, and other essential health care services to Medicare
beneficiaries and coordinating the survey and certification process under
the Medicare and Medicaid programs, as appropriate, across all service categories
included in the demonstration project.
(1) IN GENERAL- The demonstration project under this section shall be conducted
for a 3-year period beginning on October 1, 2009.
(2) BEGINNING DATE OF DEMONSTRATION PROJECT- The demonstration project under
this section shall be considered to have begun in a State on the date on
which the eligible counties selected to participate in the demonstration
project under subsection (d)(3) begin operations in accordance with the
requirements under the demonstration project.
(A) IN GENERAL- The Secretary shall provide for the transfer, in appropriate
part from the Federal Hospital Insurance Trust Fund established under
section 1817 of the Social Security Act (42 U.S.C. 1395i) and the Federal
Supplementary Medical Insurance Trust Fund established under section 1841
of such Act (42 U.S.C. 1395t), of such sums as are necessary for the costs
to the Centers for Medicare & Medicaid Services of carrying out its
duties under the demonstration project under this section.
(B) BUDGET NEUTRALITY- In conducting the demonstration project under this
section, the Secretary shall ensure that the aggregate payments made by
the Secretary do not exceed the amount which the Secretary estimates would
have been paid if the demonstration project under this section was not
implemented.
(2) HRSA- There are authorized to be appropriated to the Office of Rural
Health Policy of the Health Resources and Services Administration $800,000
for each of fiscal years 2010, 2011, and 2012 for the purpose of carrying
out the duties of such Office under the demonstration project under this
section, to remain available for the duration of the demonstration project.
(1) INTERIM REPORT- Not later than the date that is 2 years after the date
on which the demonstration project under this section is implemented, the
Administrator of the Office of Rural Health Policy of the Health Resources
and Services Administration, in coordination with the Administrator of the
Centers for Medicare & Medicaid Services, shall submit a report to Congress
on the status of the demonstration project that includes initial recommendations
on ways to improve access to, and the availability of, health care services
in eligible counties based on the findings of the demonstration project.
(2) FINAL REPORT- Not later than 1 year after the completion of the demonstration
project, the Administrator of the Office of Rural Health Policy of the Health
Resources and Services Administration, in coordination with the Administrator
of the Centers for Medicare & Medicaid Services, shall submit a report
to Congress on such project, together with recommendations for such legislation
and administrative action as the Secretary determines appropriate.
(i) Waiver Authority- The Secretary may waive such requirements of titles
XVIII and XIX of the Social Security Act (42 U.S.C. 1395 et seq.; 1396 et
seq.) as may be necessary and appropriate for the purpose of carrying out
the demonstration project under this section.
(j) Definitions- In this section:
(1) EXTENDED CARE SERVICES- The term `extended care services' means the
following:
(A) Home health services.
(B) Covered skilled nursing facility services.
(2) COVERED SKILLED NURSING FACILITY SERVICES- The term `covered skilled
nursing facility services' has the meaning given such term in section 1888(e)(2)(A)
of the Social Security Act (42 U.S.C. 1395yy(e)(2)(A)).
(3) CRITICAL ACCESS HOSPITAL- The term `critical access hospital' means
a facility designated as a critical access hospital under section 1820(c)
of such Act (42 U.S.C. 1395i-4(c)).
(4) HOME HEALTH SERVICES- The term `home health services' has the meaning
given such term in section 1861(m) of such Act (42 U.S.C. 1395x(m)).
(5) HOSPICE CARE- The term `hospice care' has the meaning given such term
in section 1861(dd) of such Act (42 U.S.C. 1395x(dd)).
(6) MEDICAID PROGRAM- The term `Medicaid program' means the program under
title XIX of such Act (42 U.S.C. 1396 et seq.).
(7) MEDICARE PROGRAM- The term `Medicare program' means the program under
title XVIII of such Act (42 U.S.C. 1395 et seq.).
(8) OTHER ESSENTIAL HEALTH CARE SERVICES- The term `other essential health
care services' means the following:
(A) Ambulance services (as described in section 1861(s)(7) of the Social
Security Act (42 U.S.C. 1395x(s)(7))).
(B) Rural health clinic services.
(C) Public health services (as defined by the Secretary).
(D) Other health care services determined appropriate by the Secretary.
(9) RURAL HEALTH CLINIC SERVICES- The term `rural health clinic services'
has the meaning given such term in section 1861(aa)(1) of such Act (42 U.S.C.
1395x(aa)(1)).
(10) SECRETARY- The term `Secretary' means the Secretary of Health and Human
Services.
SEC. 124. EXTENSION OF THE RECLASSIFICATION OF CERTAIN HOSPITALS.
(a) In General- Subsection (a) of section 106 of division B of the Tax Relief
and Health Care Act of 2006 (42 U.S.C. 1395 note), as amended by section 117
of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173),
is amended by striking `September 30, 2008' and inserting `September 30, 2009'.
(b) Special Exception Reclassifications- Section 117(a)(2) of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173) is amended
by striking `September 30, 2008' and inserting `September 30, 2009'.
SEC. 125. REVOCATION OF UNIQUE DEEMING AUTHORITY OF THE JOINT COMMISSION.
(a) Revocation- Section 1865 of the Social Security Act (42 U.S.C. 1395bb)
is amended--
(1) by striking subsection (a); and
(2) by redesignating subsections (b), (c), (d), and (e) as subsections (a),
(b), (c), and (d), respectively.
(b) Conforming Amendments- (1) Section 1865 of the Social Security Act (42
U.S.C. 1395bb) is amended--
(A) in subsection (a)(1), as redesignated by subsection (a)(2), by striking
`In addition, if' and inserting `If';
(B) in subsection (b), as so redesignated--
(i) by striking `released to him by the Joint Commission on Accreditation
of Hospitals,' and inserting `released to the Secretary by'; and
(ii) by striking the comma after `Association';
(C) in subsection (c), as so redesignated, by striking `pursuant to subsection
(a) or (b)(1)' and inserting `pursuant to subsection (a)(1)'; and
(D) in subsection (d), as so redesignated, by striking `pursuant to subsection
(a) or (b)(1)' and inserting `pursuant to subsection (a)(1)'.
(2) Section 1861(e) of the Social Security Act (42 U.S.C. 1395x(e)) is amended
in the fourth sentence by striking `and (ii) is accredited by the Joint Commission
on Accreditation of Hospitals, or is accredited by or approved by a program
of the country in which such institution is located if the Secretary finds
the accreditation or comparable approval standards of such program to be essentially
equivalent to those of the Joint Commission on Accreditation of Hospitals'
and inserting `and (ii) is accredited by a national accreditation body recognized
by the Secretary under section 1865(a), or is accredited by or approved by
a program of the country in which such institution is located if the Secretary
finds the accreditation or comparable approval standards of such program to
be essentially equivalent to those of such a national accreditation body.'.
(3) Section 1864(c) of the Social Security Act (42 U.S.C. 1395aa(c)) is amended
by striking `pursuant to subsection (a) or (b)(1) of section 1865' and inserting
`pursuant to section 1865(a)(1)'.
(4) Section 1875(b) of the Social Security Act (42 U.S.C. 1395ll(b)) is amended
by striking `the Joint Commission on Accreditation of Hospitals,' and inserting
`national accreditation bodies under section 1865(a)'.
(5) Section 1834(a)(20)(B) of the Social Security Act (42 U.S.C. 1395m(a)(20)(B))
is amended by striking `section 1865(b)' and inserting `section 1865(a)'.
(6) Section 1852(e)(4)(C) of the Social Security Act (42 U.S.C. 1395w-22(e)(4)(C))
is amended by striking `section 1865(b)(2)' and inserting `section 1865(a)(2)'.
(c) Authority To Recognize the Joint Commission as a National Accreditation
Body- The Secretary of Health and Human Services may recognize the Joint Commission
as a national accreditation body under section 1865 of the Social Security
Act (42 U.S.C. 1395bb), as amended by this section, upon such terms and conditions,
and upon submission of such information, as the Secretary may require.
(d) Effective Date; Transition Rule- (1) Subject to paragraph (2), the amendments
made by this section shall apply with respect to accreditations of hospitals
granted on or after the date that is 24 months after the date of the enactment
of this Act.
(2) For purposes of title XVIII of the Social Security Act (42 U.S.C. 1395
et seq.), the amendments made by this section shall not effect the accreditation
of a hospital by the Joint Commission, or under accreditation or comparable
approval standards found to be essentially equivalent to accreditation or
approval standards of the Joint Commission, for the period of time applicable
under such accreditation.
Subtitle C--Provisions Relating to Part B
PART I--PHYSICIANS' SERVICES
SEC. 131. PHYSICIAN PAYMENT, EFFICIENCY, AND QUALITY IMPROVEMENTS.
(1) INCREASE IN UPDATE FOR THE SECOND HALF OF 2008 AND FOR 2009-
(A) FOR THE SECOND HALF OF 2008- Section 1848(d)(8) of the Social Security
Act (42 U.S.C. 1395w-4(d)(8)), as added by section 101 of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173), is amended--
(i) in the heading, by striking `A PORTION OF';
(ii) in subparagraph (A), by striking `for the period beginning on January
1, 2008, and ending on June 30, 2008,'; and
(iii) in subparagraph (B)--
(I) in the heading, by striking `THE REMAINING PORTION OF 2008 AND';
and
(II) by striking `for the period beginning on July 1, 2008, and ending
on December 31, 2008, and'.
(B) FOR 2009- Section 1848(d) of the Social Security Act (42 U.S.C. 1395w-4(d)),
as amended by section 101 of the Medicare, Medicaid, and SCHIP Extension
Act of 2007 (Public Law 110-173), is amended by adding at the end the
following new paragraph:
`(A) IN GENERAL- Subject to paragraphs (7)(B) and (8)(B), in lieu of the
update to the single conversion factor established in paragraph (1)(C)
that would otherwise apply for 2009, the update to the single conversion
factor shall be 1.1 percent.
`(B) NO EFFECT ON COMPUTATION OF CONVERSION FACTOR FOR 2010 AND SUBSEQUENT
YEARS- The conversion factor under this subsection shall be computed under
paragraph (1)(A) for 2010 and subsequent years as if subparagraph (A)
had never applied.'.
(2) BENEFICIARY PREMIUM PROTECTION- Section 1839(g) of the Social Security
Act (42 U.S.C. 1395r(g)) is amended--
(A) by redesignating paragraphs (1) and (2) as subparagraphs (A) and (B),
respectively, and moving such subparagraphs 2 ems to the right;
(B) in the matter preceding paragraph (1), by striking `shall exclude
an estimate' and inserting `shall exclude--
(C) by adding at the end the following new paragraph:
`(2) with respect to the monthly premium rate under subsection (a)(3) for
2009, $1,200,000,000 of benefits and administrative costs.'.
(3) REVISION OF THE PHYSICIAN ASSISTANCE AND QUALITY INITIATIVE FUND- Section
1848(l)(2) of the Social Security Act (42 U.S.C. 1395w-4(l)(2)), as amended
by section 101(a)(2) of the Medicare, Medicaid, and SCHIP Extension Act
of 2007 (Public Law 110-173), is amended--
(A) in subparagraph (A)--
(i) by striking clause (i)(III); and
(ii) by striking clause (ii)(III); and
(B) in subparagraph (B)--
(i) in clause (i), by adding `and' at the end;
(ii) in clause (ii), by striking `; and' and inserting a period; and
(iii) by striking clause (iii).
(b) Extension and Improvement of the Quality Reporting System-
(1) SYSTEM- Section 1848(k)(2) of the Social Security Act (42 U.S.C. 1395w-4(k)(2)),
as amended by section 101(b)(1) of the Medicare, Medicaid, and SCHIP Extension
Act of 2007 (Public Law 110-173), is amended by adding at the end the following
new subparagraphs:
`(C) FOR 2010 AND SUBSEQUENT YEARS-
`(i) IN GENERAL- Subject to clause (ii), for purposes of reporting data
on quality measures for covered professional services furnished during
2010 and each subsequent year, subject to subsection (m)(3)(C), the
quality measures (including electronic prescribing quality measures)
specified under this paragraph shall be such measures selected by the
Secretary from measures that have been endorsed by the entity with a
contract with the Secretary under section 1890(a).
`(ii) EXCEPTION- In the case of a specified area or medical topic determined
appropriate by the Secretary for which a feasible and practical measure
has not been endorsed by the entity with a contract under section 1890(a),
the Secretary may specify a measure that is not so endorsed as long
as due consideration is given to measures that have been endorsed or
adopted by a consensus organization identified by the Secretary, such
as the AQA alliance.
`(D) OPPORTUNITY TO PROVIDE INPUT ON MEASURES FOR 2009 AND SUBSEQUENT
YEARS- For each quality measure (including an electronic prescribing quality
measure) adopted by the Secretary under subparagraph (B) (with respect
to 2009) or subparagraph (C), the Secretary shall ensure that eligible
professionals have the opportunity to provide input during the development,
endorsement, or selection of measures applicable to services they furnish.'.
(2) REDESIGNATION OF REPORTING SYSTEM- Subsection (c) of section 101 of
division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395w-4
note), as amended by section 101(b)(2) of the Medicare, Medicaid, and SCHIP
Extension Act of 2007 (Public Law 110-173), is redesignated as subsection
(m) of section 1848 of the Social Security Act.
(3) INCENTIVE PAYMENTS UNDER REPORTING SYSTEM- Section 1848(m) of the Social
Security Act, as redesignated by paragraph (2), is amended--
(A) by amending the heading to read as follows: `Incentive Payments for
Quality Reporting';
(B) by striking paragraph (1) and inserting the following:
`(A) IN GENERAL- For 2007 through 2010, with respect to covered professional
services furnished during a reporting period by an eligible professional,
if--
`(i) there are any quality measures that have been established under
the physician reporting system that are applicable to any such services
furnished by such professional for such reporting period; and
`(ii) the eligible professional satisfactorily submits (as determined
under this subsection) to the Secretary data on such quality measures
in accordance with such reporting system for such reporting period,
in addition to the amount otherwise paid under this part, there also shall
be paid to the eligible professional (or to an employer or facility in
the cases described in clause (A) of section 1842(b)(6)) or, in the case
of a group practice under paragraph (3)(C), to the group practice, from
the Federal Supplementary Medical Insurance Trust Fund established under
section 1841 an amount equal to the applicable quality percent of the
Secretary's estimate (based on claims submitted not later than 2 months
after the end of the reporting period) of the allowed charges under this
part for all such covered professional services furnished by the eligible
professional (or, in the case of a group practice under paragraph (3)(C),
by the group practice) during the reporting period.
`(B) APPLICABLE QUALITY PERCENT- For purposes of subparagraph (A), the
term `applicable quality percent' means--
`(i) for 2007 and 2008, 1.5 percent; and
`(ii) for 2009 and 2010, 2.0 percent.';
(C) by striking paragraph (3) and redesignating paragraph (2) as paragraph
(3);
(D) in paragraph (3), as so redesignated--
(i) in the matter preceding subparagraph (A), by striking `For purposes'
and inserting the following:
`(A) IN GENERAL- For purposes';
(ii) by redesignating subparagraphs (A) and (B) as clauses (i) and (ii),
respectively, and moving the indentation of such clauses 2 ems to the
right;
(iii) in subparagraph (A), as added by clause (i), by adding at the
end the following flush sentence:
`For years after 2008, quality measures for purposes of this subparagraph
shall not include electronic prescribing quality measures.'; and
(iv) by adding at the end the following new subparagraphs:
`(C) SATISFACTORY REPORTING MEASURES FOR GROUP PRACTICES-
`(i) IN GENERAL- By January 1, 2010, the Secretary shall establish and
have in place a process under which eligible professionals in a group
practice (as defined by the Secretary) shall be treated as satisfactorily
submitting data on quality measures under subparagraph (A) and as meeting
the requirement described in subparagraph (B)(ii) for covered professional
services for a reporting period (or, for purposes of subsection (a)(5),
for a reporting period for a year) if, in lieu of reporting measures
under subsection (k)(2)(C), the group practice reports measures determined
appropriate by the Secretary, such as measures that target high-cost
chronic conditions and preventive care, in a form and manner, and at
a time, specified by the Secretary.
`(ii) STATISTICAL SAMPLING MODEL- The process under clause (i) shall
provide for the use of a statistical sampling model to submit data on
measures, such as the model used under the Physician Group Practice
demonstration project under section 1866A.
`(iii) NO DOUBLE PAYMENTS- Payments to a group practice under this subsection
by reason of the process under clause (i) shall be in lieu of the payments
that would otherwise be made under this subsection to eligible professionals
in the group practice for satisfactorily submitting data on quality
measures.
`(D) AUTHORITY TO REVISE SATISFACTORILY REPORTING DATA- For years after
2009, the Secretary, in consultation with stakeholders and experts, may
revise the criteria under this subsection for satisfactorily submitting
data on quality measures under subparagraph (A) and the criteria for submitting
data on electronic prescribing quality measures under subparagraph (B)(ii).';
(i) in subparagraph (C), by inserting `for 2007, 2008, and 2009,' after
`provision of law,';
(ii) in subparagraph (D)--
(aa) by inserting `for 2007 and 2008' after `under this subsection';
and
(bb) by striking `paragraph (2)' and inserting `this subsection';
(II) in clause (ii), by striking `shall' and inserting `may establish
procedures to'; and
(aa) by inserting `(or, in the case of a group practice under paragraph
(3)(C), the group practice)' after `an eligible professional';
(bb) by striking `bonus incentive payment' and inserting `incentive
payment under this subsection'; and
(cc) by adding at the end the following new sentence: `If such payments
for such period have already been made, the Secretary shall recoup such payments
from the eligible professional (or the group practice).';
(iii) in subparagraph (E)--
(I) by striking `(I) IN GENERAL- ';
(II) by striking clause (ii);
(III) by redesignating subclauses (I) through (IV) as clauses (i)
through (iv), respectively, and moving the indentation of such clauses
2 ems to the left;
(IV) in clause (ii), as so redesignated, by striking `paragraph (2)'
and inserting `this subsection'; and
(V) in clause (iv), as so redesignated--
(aa) by striking `the bonus' and inserting `any'; and
(bb) by inserting `and the payment adjustment under subsection (a)(5)(A)'
before the period at the end;
(iv) in subparagraph (F)--
(I) by striking `2009, paragraph (3) shall not apply, and' and inserting
`subsequent years,'; and
(II) by striking `paragraph (2)' and inserting `this subsection';
and
(v) by adding at the end the following new subparagraph:
`(G) POSTING ON WEBSITE- The Secretary shall post on the Internet website
of the Centers for Medicare & Medicaid Services, in an easily understandable
format, a list of the names of the following:
`(i) The eligible professionals (or, in the case of reporting under
paragraph (3)(C), the group practices) who satisfactorily submitted
data on quality measures under this subsection.
`(ii) The eligible professionals (or, in the case of reporting under
paragraph (3)(C), the group practices) who are successful electronic
prescribers.'; and
(F) in paragraph (6), by striking subparagraph (C) and inserting the following:
`(i) IN GENERAL- Subject to clauses (ii) and (iii), the term `reporting
period' means--
`(I) for 2007, the period beginning on July 1, 2007, and ending on
December 31, 2007; and
`(II) for 2008, 2009, 2010, and 2011, the entire year.
`(ii) AUTHORITY TO REVISE REPORTING PERIOD- For years after 2009, the
Secretary may revise the reporting period under clause (i) if the Secretary
determines such revision is appropriate, produces valid results on measures
reported, and is consistent with the goals of maximizing scientific
validity and reducing administrative burden. If the Secretary revises
such period pursuant to the preceding sentence, the term `reporting
period' shall mean such revised period.
`(iii) REFERENCE- Any reference in this subsection to a reporting period
with respect to the application of subsection (a)(5) shall be deemed
a reference to the reporting period under subparagraph (D)(iii) of such
subsection.'.
(4) INCLUSION OF QUALIFIED AUDIOLOGISTS AS ELIGIBLE PROFESSIONALS-
(A) IN GENERAL- Section 1848(k)(3)(B) of the Social Security Act (42 U.S.C.
1395w-4(k)(3)(B)), is amended by adding at the end the following new clause:
`(iv) Beginning with 2009, a qualified audiologist (as defined in section
1861(ll)(3)(B)).'.
(B) NO CHANGE IN BILLING- Nothing in the amendment made by subparagraph
(A) shall be construed to change the way in which billing for audiology
services (as defined in section 1861(ll)(2) of the Social Security Act
(42 U.S.C. 1395x(ll)(2))) occurs under title XVIII of such Act as of July
1, 2008.
(5) CONFORMING AMENDMENTS- Section 1848(m) of the Social Security Act, as
added and amended by paragraphs (2) and (3), is amended--
(i) in subparagraph (A)--
(I) by striking `section 1848(k) of the Social Security Act, as added
by subsection (b),' and inserting `subsection (k)'; and
(II) by striking `such section' and inserting `such subsection';
(ii) in subparagraph (B), by striking `of the Social Security Act (42
U.S.C. 1395l)';
(iii) in subparagraph (E), in the matter preceding clause (i), by striking
`1869 or 1878 of the Social Security Act or otherwise' and inserting
`1869, section 1878, or otherwise'; and
(iv) in subparagraph (F)--
(I) by striking `paragraph (2)(B) of section 1848(k) of the Social
Security Act (42 U.S.C. 1395w-4(k))' and inserting `subsection (k)(2)(B)';
and
(II) by striking `paragraph (4) of such section' and inserting `subsection
(k)(4)';
(i) in subparagraph (A), by striking `section 1848(k)(3) of the Social
Security Act, as added by subsection (b)' and inserting `subsection
(k)(3)'; and
(ii) in subparagraph (B), by striking `section 1848(k) of the Social
Security Act, as added by subsection (b)' and inserting `subsection
(k)'; and
(C) by striking paragraph (6)(D).
(6) NO AFFECT ON INCENTIVE PAYMENTS FOR 2007 OR 2008- Nothing in the amendments
made by this subsection or section 132 shall affect the operation of the
provisions of section 1848(m) of the Social Security Act, as redesignated
and amended by such subsection and section, with respect to 2007 or 2008.
(c) Physician Feedback Program To Improve Efficiency and Control Costs-
(1) IN GENERAL- Section 1848 of the Social Security Act (42 U.S.C. 1395w-4),
as amended by subsection (b), is amended by adding at the end the following
new subsection:
`(n) Physician Feedback Program-
`(A) IN GENERAL- The Secretary shall establish a Physician Feedback Program
(in this subsection referred to as the `Program') under which the Secretary
shall use claims data under this title (and may use other data) to provide
confidential reports to physicians (and, as determined appropriate by
the Secretary, to groups of physicians) that measure the resources involved
in furnishing care to individuals under this title. If determined appropriate
by the Secretary, the Secretary may include information on the quality
of care furnished to individuals under this title by the physician (or
group of physicians) in such reports.
`(B) RESOURCE USE- The resources described in subparagraph (A) may be
measured--
`(i) on an episode basis;
`(ii) on a per capita basis; or
`(iii) on both an episode and a per capita basis.
`(2) IMPLEMENTATION- The Secretary shall implement the Program by not later
than January 1, 2009.
`(3) DATA FOR REPORTS- To the extent practicable, reports under the Program
shall be based on the most recent data available.
`(4) AUTHORITY TO FOCUS APPLICATION- The Secretary may focus the application
of the Program as appropriate, such as focusing the Program on--
`(A) physician specialties that account for a certain percentage of all
spending for physicians' services under this title;
`(B) physicians who treat conditions that have a high cost or a high volume,
or both, under this title;
`(C) physicians who use a high amount of resources compared to other physicians;
`(D) physicians practicing in certain geographic areas; or
`(E) physicians who treat a minimum number of individuals under this title.
`(5) AUTHORITY TO EXCLUDE CERTAIN INFORMATION IF INSUFFICIENT INFORMATION-
The Secretary may exclude certain information regarding a service from a
report under the Program with respect to a physician (or group of physicians)
if the Secretary determines that there is insufficient information relating
to that service to provide a valid report on that service.
`(6) ADJUSTMENT OF DATA- To the extent practicable, the Secretary shall
make appropriate adjustments to the data used in preparing reports under
the Program, such as adjustments to take into account variations in health
status and other patient characteristics.
`(7) EDUCATION AND OUTREACH- The Secretary shall provide for education and
outreach activities to physicians on the operation of, and methodologies
employed under, the Program.
`(8) DISCLOSURE EXEMPTION- Reports under the Program shall be exempt from
disclosure under section 552 of title 5, United States Code.'.
(2) GAO STUDY AND REPORT ON THE PHYSICIAN FEEDBACK PROGRAM-
(A) STUDY- The Comptroller General of the United States shall conduct
a study of the Physician Feedback Program conducted under section 1848(n)
of the Social Security Act, as added by paragraph (1), including the implementation
of the Program.
(B) REPORT- Not later than March 1, 2011, the Comptroller General of the
United States shall submit a report to Congress containing the results
of the study conducted under subparagraph (A), together with recommendations
for such legislation and administrative action as the Comptroller General
determines appropriate.
(d) Plan for Transition to Value-Based Purchasing Program for Physicians and
Other Practitioners-
(1) IN GENERAL- The Secretary of Health and Human Services shall develop
a plan to transition to a value-based purchasing program for payment under
the Medicare program for covered professional services (as defined in section
1848(k)(3)(A) of the Social Security Act (42 U.S.C. 1395w-4(k)(3)(A))).
The Secretary shall consult with the Medicare Payment Advisory Commission
in the development of such plan.
(2) REPORT- Not later than May 1, 2010, the Secretary of Health and Human
Services shall submit a report to Congress containing the plan developed
under paragraph (1), together with recommendations for such legislation
and administrative action as the Secretary determines appropriate.
SEC. 132. INCENTIVES FOR ELECTRONIC PRESCRIBING.
(a) Incentive Payments- Section 1848(m) of the Social Security Act, as added
and amended by section 131(b), is amended--
(1) by inserting after paragraph (1), the following new paragraph:
`(2) INCENTIVE PAYMENTS FOR ELECTRONIC PRESCRIBING-
`(A) IN GENERAL- For 2009 through 2013, with respect to covered professional
services furnished during a reporting period by an eligible professional,
if the eligible professional is a successful electronic prescriber for
such reporting period, in addition to the amount otherwise paid under
this part, there also shall be paid to the eligible professional (or to
an employer or facility in the cases described in clause (A) of section
1842(b)(6)) or, in the case of a group practice under paragraph (3)(C),
to the group practice, from the Federal Supplementary Medical Insurance
Trust Fund established under section 1841 an amount equal to the applicable
electronic prescribing percent of the Secretary's estimate (based on claims
submitted not later than 2 months after the end of the reporting period)
of the allowed charges under this part for all such covered professional
services furnished by the eligible professional (or, in the case of a
group practice under paragraph (3)(C), by the group practice) during the
reporting period.
`(B) LIMITATION WITH RESPECT TO ELECTRONIC PRESCRIBING QUALITY MEASURES-
The provisions of this paragraph and subsection (a)(5) shall not apply
to an eligible professional (or, in the case of a group practice under
paragraph (3)(C), to the group practice) if, for the reporting period
(or, for purposes of subsection (a)(5), for the reporting period for a
year)--
`(i) the allowed charges under this part for all covered professional
services furnished by the eligible professional (or group, as applicable)
for the codes to which the electronic prescribing quality measure applies
(as identified by the Secretary and published on the Internet website
of the Centers for Medicare & Medicaid Services as of January 1,
2008, and as subsequently modified by the Secretary) are less than 10
percent of the total of the allowed charges under this part for all
such covered professional services furnished by the eligible professional
(or the group, as applicable); or
`(ii) if determined appropriate by the Secretary, the eligible professional
does not submit (including both electronically and nonelectronically)
a sufficient number (as determined by the Secretary) of prescriptions
under part D.
If the Secretary makes the determination to apply clause (ii) for a period,
then clause (i) shall not apply for such period.
`(C) APPLICABLE ELECTRONIC PRESCRIBING PERCENT- For purposes of subparagraph
(A), the term `applicable electronic prescribing percent' means--
`(i) for 2009 and 2010, 2.0 percent;
`(ii) for 2011 and 2012, 1.0 percent; and
`(iii) for 2013, 0.5 percent.';
(2) in paragraph (3), as redesignated by section 131(b)--
(A) in the heading, by inserting `AND SUCCESSFUL ELECTRONIC PRESCRIBER'
after `REPORTING'; and
(B) by inserting after subparagraph (A) the following new subparagraph:
`(B) SUCCESSFUL ELECTRONIC PRESCRIBER-
`(i) IN GENERAL- For purposes of paragraph (2) and subsection (a)(5),
an eligible professional shall be treated as a successful electronic
prescriber for a reporting period (or, for purposes of subsection (a)(5),
for the reporting period for a year) if the eligible professional meets
the requirement described in clause (ii), or, if the Secretary determines
appropriate, the requirement described in clause (iii). If the Secretary
makes the determination under the preceding sentence to apply the requirement
described in clause (iii) for a period, then the requirement described
in clause (ii) shall not apply for such period.
`(ii) REQUIREMENT FOR SUBMITTING DATA ON ELECTRONIC PRESCRIBING QUALITY
MEASURES- The requirement described in this clause is that, with respect
to covered professional services furnished by an eligible professional
during a reporting period (or, for purposes of subsection (a)(5), for
the reporting period for a year), if there are any electronic prescribing
quality measures that have been established under the physician reporting
system and are applicable to any such services furnished by such professional
for the period, such professional reported each such measure under such
system in at least 50 percent of the cases in which such measure is
reportable by such professional under such system.
`(iii) REQUIREMENT FOR ELECTRONICALLY PRESCRIBING UNDER PART D- The
requirement described in this clause is that the eligible professional
electronically submitted a sufficient number (as determined by the Secretary)
of prescriptions under part D during the reporting period (or, for purposes
of subsection (a)(5), for the reporting period for a year).
`(iv) USE OF PART D DATA- Notwithstanding sections 1860D-15(d)(2)(B)
and 1860D-15(f)(2), the Secretary may use data regarding drug claims
submitted for purposes of section 1860D-15 that are necessary for purposes
of clause (iii), paragraph (2)(B)(ii), and paragraph (5)(G).
`(v) STANDARDS FOR ELECTRONIC PRESCRIBING- To the extent practicable,
in determining whether eligible professionals meet the requirements
under clauses (ii) and (iii) for purposes of clause (i), the Secretary
shall ensure that eligible professionals utilize electronic prescribing
systems in compliance with standards established for such systems pursuant
to the Part D Electronic Prescribing Program under section 1860D-4(e).';
and
(3) in paragraph (5)(E), by striking clause (iii) and inserting the following
new clause:
`(iii) the determination of a successful electronic prescriber under
paragraph (3), the limitation under paragraph (2)(B), and the exception
under subsection (a)(5)(B); and'.
(b) Incentive Payment Adjustment- Section 1848(a) of the Social Security Act
(42 U.S.C. 1395w-4(a)) is amended by adding at the end the following new paragraph:
`(5) INCENTIVES FOR ELECTRONIC PRESCRIBING-
`(i) IN GENERAL- Subject to subparagraph (B) and subsection (m)(2)(B),
with respect to covered professional services furnished by an eligible
professional during 2012 or any subsequent year, if the eligible professional
is not a successful electronic prescriber for the reporting period for
the year (as determined under subsection (m)(3)(B)), the fee schedule
amount for such services furnished by such professional during the year
(including the fee schedule amount for purposes of determining a payment
based on such amount) shall be equal to the applicable percent of the
fee schedule amount that would otherwise apply to such services under
this subsection (determined after application of paragraph (3) but without
regard to this paragraph).
`(ii) APPLICABLE PERCENT- For purposes of clause (i), the term `applicable
percent' means--
`(I) for 2012, 99 percent;
`(II) for 2012, 98.5 percent; and
`(III) for 2014 and each subsequent year, 98 percent.
`(B) SIGNIFICANT HARDSHIP EXCEPTION- The Secretary may, on a case-by-case
basis, exempt an eligible professional from the application of the payment
adjustment under subparagraph (A) if the Secretary determines, subject
to annual renewal, that compliance with the requirement for being a successful
electronic prescriber would result in a significant hardship, such as
in the case of an eligible professional who practices in a rural area
without sufficient Internet access.
`(i) PHYSICIAN REPORTING SYSTEM RULES- Paragraphs (5), (6), and (8)
of subsection (k) shall apply for purposes of this paragraph in the
same manner as they apply for purposes of such subsection.
`(ii) INCENTIVE PAYMENT VALIDATION RULES- Clauses (ii) and (iii) of
subsection (m)(5)(D) shall apply for purposes of this paragraph in a
similar manner as they apply for purposes of such subsection.
`(D) DEFINITIONS- For purposes of this paragraph:
`(i) ELIGIBLE PROFESSIONAL; COVERED PROFESSIONAL SERVICES- The terms
`eligible professional' and `covered professional services' have the
meanings given such terms in subsection (k)(3).
`(ii) PHYSICIAN REPORTING SYSTEM- The term `physician reporting system'
means the system established under subsection (k).
`(iii) REPORTING PERIOD- The term `reporting period' means, with respect
to a year, a period specified by the Secretary.'.
(c) GAO Report on Electronic Prescribing- Not later than September 1, 2012,
the Comptroller General of the United States shall submit to Congress a report
on the implementation of the incentives for electronic prescribing established
under the provisions of, and amendments made by, this section. Such report
shall include information regarding the following:
(1) The percentage of eligible professionals (as defined in section 1848(k)(3)
of the Social Security Act (42 U.S.C. 1395w-4(k)(3)) that are using electronic
prescribing systems, including a determination of whether less than 50 percent
of eligible professionals are using electronic prescribing systems.
(2) If less than 50 percent of eligible professionals are using electronic
prescribing systems, recommendations for increasing the use of electronic
prescribing systems by eligible professionals, such as changes to the incentive
payment adjustments established under section 1848(a)(5) of such Act, as
added by subsection (b).
(3) The estimated savings to the Medicare program under title XVIII of such
Act resulting from the use of electronic prescribing systems.
(4) Reductions in avoidable medical errors resulting from the use of electronic
prescribing systems.
(5) The extent to which the privacy and security of the personal health
information of Medicare beneficiaries is protected when such beneficiaries'
prescription drug data and usage information is used for purposes other
than their direct clinical care, including--
(A) whether information identifying the beneficiary is, and remains, removed
from data regarding the beneficiary's prescription drug utilization; and
(B) the extent to which current law requires sufficient and appropriate
oversight and audit capabilities to monitor the practice of prescription
drug data mining.
(6) Such other recommendations and administrative action as the Comptroller
General determines to be appropriate.
SEC. 133. EXPANDING ACCESS TO PRIMARY CARE SERVICES.
(a) Incentive Payment Program for Primary Care Services Furnished in Physician
Scarcity Areas-
(1) IN GENERAL- Section 1833 of the Social Security Act (42 U.S.C. 1395l)
is amended by adding at the end the following new subsection:
`(v) Incentive Payments for Primary Care Services Furnished in Physician Scarcity
Areas-
`(1) IN GENERAL- In the case of primary care services furnished on or after
January 1, 2011, by a primary care physician in a primary care scarcity
county, in addition to the amount of payment that would otherwise be made
for such services under this part, there also shall be paid (on a monthly
or quarterly basis) an amount equal to 5 percent of the payment amount for
the service under this part.
`(2) DEFINITIONS- In this subsection:
`(A) PRIMARY CARE PHYSICIAN- The term `primary care physician' means a
physician (as described in section 1861(r)(1)) for whom primary care services
accounted for at least a specified percent (as determined by the Secretary)
of the allowed charges under this part for such physician in a prior period
as determined appropriate by the Secretary.
`(B) PRIMARY CARE SCARCITY COUNTY- The term `primary care scarcity county'
means the primary care scarcity counties that the Secretary was using
under subsection (u) with respect to physicians' services furnished on
December 31, 2007.
`(C) PRIMARY CARE SERVICES- The term `primary care services' means procedure
codes for services in the category of the Healthcare Common Procedure
Coding System, as established by the Secretary under section 1848(c)(5)
(as of December 31, 2008 and as subsequently modified by the Secretary)
consisting of evaluation and management services, but limited to such
procedure codes in the category of office or other outpatient services,
and consisting of subcategories of such procedure codes for services for
both new and established patients.
`(3) JUDICIAL REVIEW- There shall be no administrative or judicial review
under section 1869, 1878, or otherwise, respecting the identification of
primary care physicians, primary care specialty areas, or primary care services
under this subsection.'.
(2) CONFORMING AMENDMENT- Section 1834(g)(2)(B) of the Social Security Act
(42 U.S.C. 1395m(g)(2)(B)) is amended by adding at the end the following
sentence: `Section 1833(v) shall not be taken into account in determining
the amounts that would otherwise be paid pursuant to the preceding sentence.'.
(b) Revisions to the Medicare Medical Home Demonstration Project-
(1) AUTHORITY TO EXPAND- Section 204(b) of division B of the Tax Relief
and Health Care Act of 2006 (42 U.S.C. 1395b-1 note) is amended--
(A) in paragraph (1), by striking `The project' and inserting `Subject
to paragraph (3), the project'; and
(B) by adding at the end the following new paragraph:
`(3) EXPANSION- The Secretary may expand the duration and the scope of the
project under paragraph (1), to an extent determined appropriate by the
Secretary, if the Secretary determines that such expansion will result in
any of the following conditions being met:
`(A) The expansion of the project is expected to improve the quality of
patient care without increasing spending under the Medicare program (not
taking into account amounts available under subsection (g)).
`(B) The expansion of the project is expected to reduce spending under
the Medicare program (not taking into account amounts available under
subsection (g)) without reducing the quality of patient care.'.
(2) FUNDING AND APPLICATION- Section 204 of division B of the Tax Relief
and Health Care Act of 2006 (42 U.S.C. 1395b-1 note) is amended by adding
at the end the following new subsections:
`(g) Funding From SMI Trust Fund- There shall be available, from the Federal
Supplementary Medical Insurance Trust Fund (under section 1841 of the Social
Security Act (42 U.S.C. 1395t)), the amount of $100,000,000 to carry out the
project.
`(h) Application- Chapter 35 of title 44, United States Code, shall not apply
to the conduct of the project.'.
(c) Application of Budget-Neutrality Adjustor to Conversion Factor- Section
1848(c)(2)(B) of the Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)) is amended
by inserting at the end the following new clause:
`(iv) ALTERNATIVE APPLICATION OF BUDGET-NEUTRALITY ADJUSTMENT- Notwithstanding
subsection (d)(9)(A), effective for fee schedules established beginning
with 2009, with respect to the 5-year review of work relative value
units used in fee schedules for 2007 and 2008, in lieu of continuing
to apply budget-neutrality adjustments required under clause (ii) for
2007 and 2008 to work relative value units, the Secretary shall apply
such budget-neutrality adjustments to the conversion factor otherwise
determined for years beginning with 2009.'.
SEC. 134. EXTENSION OF FLOOR ON MEDICARE WORK GEOGRAPHIC ADJUSTMENT UNDER
THE MEDICARE PHYSICIAN FEE SCHEDULE.
(a) In General- Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C.
1395w-4(e)(1)(E)), as amended by section 103 of the Medicare, Medicaid, and
SCHIP Extension Act of 2007 (Public Law 110-173), is amended by striking `before
July 1, 2008' and inserting `before January 1, 2010'.
(b) Treatment of Physicians' Services Furnished in Certain Areas- Section
1848(e)(1)(G) of the Social Security Act (42 U.S.C. 1395w-4(e)(1)(G)) is amended
by adding at the end the following new sentence: `For purposes of payment
for services furnished in the State described in the preceding sentence on
or after January 1, 2009, after calculating the work geographic index in subparagraph
(A)(iii), the Secretary shall increase the work geographic index to 1.5 if
such index would otherwise be less than 1.5'.
(c) Technical Correction- Section 602(1) of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (Public Law 108-173; 117 Stat.
2301) is amended to read as follows:
`(1) in subparagraph (A), by striking `subparagraphs (B), (C), and (E)'
and inserting `subparagraphs (B), (C), (E), and (G)'; and'.
SEC. 135. IMAGING PROVISIONS.
(a) Accreditation Requirement-
(1) ACCREDITATION REQUIREMENT- Section 1834 of the Social Security Act (42
U.S.C. 1395m) is amended by inserting after subsection (d) the following
new subsection:
`(e) Accreditation Requirement for Advanced Diagnostic Imaging Services-
`(A) IN GENERAL- Beginning with January 1, 2012, with respect to the technical
component of advanced diagnostic imaging services for which payment is
made under the fee schedule established under section 1848(b) and that
are furnished by a supplier, payment may only be made if such supplier
is accredited by an accreditation organization designated by the Secretary
under paragraph (2)(B)(i).
`(B) ADVANCED DIAGNOSTIC IMAGING SERVICES DEFINED- In this subsection,
the term `advanced diagnostic imaging services' includes--
`(i) diagnostic magnetic resonance imaging, computed tomography, and
nuclear medicine (including positron emission tomography); and
`(ii) such other diagnostic imaging services, including services described
in section 1848(b)(4)(B) (excluding X-ray, ultrasound, and fluoroscopy),
as specified by the Secretary in consultation with physician specialty
organizations and other stakeholders.
`(C) SUPPLIER DEFINED- In this subsection, the term `supplier' has the
meaning given such term in section 1861(d).
`(2) ACCREDITATION ORGANIZATIONS-
`(A) FACTORS FOR DESIGNATION OF ACCREDITATION ORGANIZATIONS- The Secretary
shall consider the following factors in designating accreditation organizations
under subparagraph (B)(i) and in reviewing and modifying the list of accreditation
organizations designated pursuant to subparagraph (C):
`(i) The ability of the organization to conduct timely reviews of accreditation
applications.
`(ii) Whether the organization has established a process for the timely
integration of new advanced diagnostic imaging services into the organization's
accreditation program.
`(iii) Whether the organization uses random site visits, site audits,
or other strategies for ensuring accredited suppliers maintain adherence
to the criteria described in paragraph (3).
`(iv) The ability of the organization to take into account the capacities
of suppliers located in a rural area (as defined in section 1886(d)(2)(D)).
`(v) Whether the organization has established reasonable fees to be
charged to suppliers applying for accreditation.
`(vi) Such other factors as the Secretary determines appropriate.
`(B) DESIGNATION- Not later than January 1, 2010, the Secretary shall
designate organizations to accredit suppliers furnishing the technical
component of advanced diagnostic imaging services. The list of accreditation
organizations so designated may be modified pursuant to subparagraph (C).
`(C) REVIEW AND MODIFICATION OF LIST OF ACCREDITATION ORGANIZATIONS-
`(i) IN GENERAL- The Secretary shall review the list of accreditation
organizations designated under subparagraph (B) taking into account
the factors under subparagraph (A). Taking into account the results
of such review, the Secretary may, by regulation, modify the list of
accreditation organizations designated under subparagraph (B).
`(ii) SPECIAL RULE FOR ACCREDITATIONS DONE PRIOR TO REMOVAL FROM LIST
OF DESIGNATED ACCREDITATION ORGANIZATIONS- In the case where the Secretary
removes an organization from the list of accreditation organizations
designated under subparagraph (B), any supplier that is accredited by
the organization during the period beginning on the date on which the
organization is designated as an accreditation organization under subparagraph
(B) and ending on the date on which the organization is removed from
such list shall be considered to have been accredited by an organization
designated by the Secretary under subparagraph (B) for the remaining
period such accreditation is in effect.
`(3) CRITERIA FOR ACCREDITATION- The Secretary shall establish procedures
to ensure that the criteria used by an accreditation organization designated
under paragraph (2)(B) to evaluate a supplier that furnishes the technical
component of advanced diagnostic imaging services for the purpose of accreditation
of such supplier is specific to each imaging modality. Such criteria shall
include--
`(A) standards for qualifications of medical personnel who are not physicians
and who furnish the technical component of advanced diagnostic imaging
services;
`(B) standards for qualifications and responsibilities of medical directors
and supervising physicians, including standards that recognize the considerations
described in paragraph (4);
`(C) procedures to ensure that equipment used in furnishing the technical
component of advanced diagnostic imaging services meets performance specifications;
`(D) standards that require the supplier have procedures in place to ensure
the safety of persons who furnish the technical component of advanced
diagnostic imaging services and individuals to whom such services are
furnished;
`(E) standards that require the establishment and maintenance of a quality
assurance and quality control program by the supplier that is adequate
and appropriate to ensure the reliability, clarity, and accuracy of the
technical quality of diagnostic images produced by such supplier; and
`(F) any other standards or procedures the Secretary determines appropriate.
`(4) RECOGNITION IN STANDARDS FOR THE EVALUATION OF MEDICAL DIRECTORS AND
SUPERVISING PHYSICIANS- The standards described in paragraph (3)(B) shall
recognize whether a medical director or supervising physician--
`(A) in a particular specialty receives training in advanced diagnostic
imaging services in a residency program;
`(B) has attained, through experience, the necessary expertise to be a
medical director or a supervising physician;
`(C) has completed any continuing medical education courses relating to
such services; or
`(D) has met such other standards as the Secretary determines appropriate.
`(5) RULE FOR ACCREDITATIONS MADE PRIOR TO DESIGNATION- In the case of a
supplier that is accredited before January 1, 2010, by an accreditation
organization designated by the Secretary under paragraph (2)(B) as of January
1, 2010, such supplier shall be considered to have been accredited by an
organization designated by the Secretary under such paragraph as of January
1, 2012, for the remaining period such accreditation is in effect.'.
(2) CONFORMING AMENDMENTS-
(A) IN GENERAL- Section 1862(a) of the Social Security Act (42 U.S.C.
1395y(a)) is amended--
(i) in paragraph (21), by striking `or' at the end;
(ii) in paragraph (22), by striking the period at the end and inserting
`; or'; and
(iii) by inserting after paragraph (22) the following new paragraph:
`(23) which are the technical component of advanced diagnostic imaging services
described in section 1834(e)(1)(B) for which payment is made under the fee
schedule established under section 1848(b) and that are furnished by a supplier
(as defined in section 1861(d)), if such supplier is not accredited by an
accreditation organization designated by the Secretary under section 1834(e)(2)(B).'.
(B) EFFECTIVE DATE- The amendments made by this paragraph shall apply
to advanced diagnostic imaging services furnished on or after January
1, 2012.
(b) Demonstration Project To Assess the Appropriate Use of Imaging Services-
(1) CONDUCT OF DEMONSTRATION PROJECT-
(A) IN GENERAL- The Secretary of Health and Human Services (in this section
referred to as the `Secretary') shall conduct a demonstration project
using the models described in paragraph (2)(E) to collect data regarding
physician compliance with appropriateness criteria selected under paragraph
(2)(D) in order to determine the appropriateness of advanced diagnostic
imaging services furnished to Medicare beneficiaries.
(B) ADVANCED DIAGNOSTIC IMAGING SERVICES- In this subsection, the term
`advanced diagnostic imaging services' has the meaning given such term
in section 1834(e)(1)(B) of the Social Security Act, as added by subsection
(a).
(C) AUTHORITY TO FOCUS DEMONSTRATION PROJECT- The Secretary may focus
the demonstration project with respect to certain advanced diagnostic
imaging services, such as services that account for a large amount of
expenditures under the Medicare program, services that have recently experienced
a high rate of growth, or services for which appropriateness criteria
exists.
(2) IMPLEMENTATION AND DESIGN OF DEMONSTRATION PROJECT-
(A) IMPLEMENTATION AND DURATION-
(i) IMPLEMENTATION- The Secretary shall implement the demonstration
project under this subsection not later than January 1, 2010.
(ii) DURATION- The Secretary shall conduct the demonstration project
under this subsection for a 2-year period.
(B) APPLICATION AND SELECTION OF PARTICIPATING PHYSICIANS-
(i) APPLICATION- Each physician that desires to participate in the demonstration
project under this subsection shall submit an application to the Secretary
at such time, in such manner, and containing such information as the
Secretary may require.
(ii) SELECTION- The Secretary shall select physicians to participate
in the demonstration project under this subsection from among physicians
submitting applications under clause (i). The Secretary shall ensure
that the physicians selected--
(I) represent a wide range of geographic areas, demographic characteristics
(such as urban, rural, and suburban), and practice settings (such
as private and academic practices); and
(II) have the capability to submit data to the Secretary (or an entity
under a subcontract with the Secretary) in an electronic format in
accordance with standards established by the Secretary.
(C) ADMINISTRATIVE COSTS AND INCENTIVES- The Secretary shall--
(i) reimburse physicians for reasonable administrative costs incurred
in participating in the demonstration project under this subsection;
and
(ii) provide reasonable incentives to physicians to encourage participation
in the demonstration project under this subsection.
(D) USE OF APPROPRIATENESS CRITERIA-
(i) IN GENERAL- The Secretary, in consultation with medical specialty
societies and other stakeholders, shall select criteria with respect
to the clinical appropriateness of advanced diagnostic imaging services
for use in the demonstration project under this subsection.
(ii) CRITERIA SELECTED- Any criteria selected under clause (i) shall--
(I) be developed or endorsed by a medical specialty society; and
(II) be developed in adherence to appropriateness principles developed
by a consensus organization, such as the AQA alliance.
(E) MODELS FOR COLLECTING DATA REGARDING PHYSICIAN COMPLIANCE WITH SELECTED
CRITERIA- Subject to subparagraph (H), in carrying out the demonstration
project under this subsection, the Secretary shall use each of the following
models for collecting data regarding physician compliance with appropriateness
criteria selected under subparagraph (D):
(i) A model described in subparagraph (F).
(ii) A model described in subparagraph (G).
(iii) Any other model that the Secretary determines to be useful in
evaluating the use of appropriateness criteria for advanced diagnostic
imaging services.
(F) POINT OF SERVICE MODEL DESCRIBED- A model described in this subparagraph
is a model that--
(i) uses an electronic or paper intake form that--
(I) contains a certification by the physician furnishing the imaging
service that the data on the intake form was confirmed with the Medicare
beneficiary before the service was furnished;
(II) contains standardized data elements for diagnosis, service ordered,
service furnished, and such other information determined by the Secretary,
in consultation with medical specialty societies and other stakeholders,
to be germane to evaluating the effectiveness of the use of appropriateness
criteria selected under subparagraph (D); and
(III) is accessible to physicians participating in the demonstration
project under this subsection in a format that allows for the electronic
submission of such form; and
(ii) provides for feedback reports in accordance with paragraph (3)(B).
(G) POINT OF ORDER MODEL DESCRIBED- A model described in this subparagraph
is a model that--
(i) uses a computerized order-entry system that requires the transmittal
of relevant supporting information at the time of referral for advanced
diagnostic imaging services and provides automated decision-support
feedback to the referring physician regarding the appropriateness of
furnishing such imaging services; and
(ii) provides for feedback reports in accordance with paragraph (3)(B).
(H) LIMITATION- In no case may the Secretary use prior authorization--
(i) as a model for collecting data regarding physician compliance with
appropriateness criteria selected under subparagraph (D) under the demonstration
project under this subsection; or
(ii) under any model used for collecting such data under the demonstration
project.
(I) REQUIRED CONTRACTS AND PERFORMANCE STANDARDS FOR CERTAIN ENTITIES-
(i) IN GENERAL- The Secretary shall enter into contracts with entities
to carry out the model described in subparagraph (G).
(ii) PERFORMANCE STANDARDS- The Secretary shall establish and enforce
performance standards for such entities under the contracts entered
into under clause (i), including performance standards with respect
to--
(I) the satisfaction of Medicare beneficiaries who are furnished advanced
diagnostic imaging services by a physician participating in the demonstration
project;
(II) the satisfaction of physicians participating in the demonstration
project;
(III) if applicable, timelines for the provision of feedback reports
under paragraph (3)(B); and
(IV) any other areas determined appropriate by the Secretary.
(3) COMPARISON OF UTILIZATION OF ADVANCED DIAGNOSTIC IMAGING SERVICES AND
FEEDBACK REPORTS-
(A) COMPARISON OF UTILIZATION OF ADVANCED DIAGNOSTIC IMAGING SERVICES-
The Secretary shall consult with medical specialty societies and other
stakeholders to develop mechanisms for comparing the utilization of advanced
diagnostic imaging services by physicians participating in the demonstration
project under this subsection against--
(i) the appropriateness criteria selected under paragraph (2)(D); and
(ii) to the extent feasible, the utilization of such services by physicians
not participating in the demonstration project.
(B) FEEDBACK REPORTS- The Secretary shall, in consultation with medical
specialty societies and other stakeholders, develop mechanisms to provide
feedback reports to physicians participating in the demonstration project
under this subsection. Such feedback reports shall include--
(i) a profile of the rate of compliance by the physician with appropriateness
criteria selected under paragraph (2)(D), including a comparison of--
(I) the rate of compliance by the physician with such criteria; and
(II) the rate of compliance by the physician's peers (as defined by
the Secretary) with such criteria; and
(ii) to the extent feasible, a comparison of--
(I) the rate of utilization of advanced diagnostic imaging services
by the physician; and
(II) the rate of utilization of such services by the physician's peers
(as defined by the Secretary) who are not participating in the demonstration
project.
(4) CONDUCT OF DEMONSTRATION PROJECT AND WAIVER-
(A) CONDUCT OF DEMONSTRATION PROJECT- Chapter 35 of title 44, United States
Code, shall not apply to the conduct of the demonstration project under
this subsection.
(B) WAIVER- The Secretary may waive such provisions of titles XI and XVIII
of the Social Security Act (42 U.S.C. 1301 et seq.; 1395 et seq.) as may
be necessary to carry out the demonstration project under this subsection.
(5) EVALUATION AND REPORT-
(A) EVALUATION- The Secretary shall evaluate the demonstration project
under this subsection to--
(i) assess the timeliness and efficacy of the demonstration project;
(ii) assess the performance of entities under a contract entered into
under paragraph (2)(I)(i);
(I) on the rates of appropriate, uncertain, and inappropriate advanced
diagnostic imaging services furnished by physicians participating
in the demonstration project;
(II) on patterns and trends in the appropriateness and inappropriateness
of such services furnished by such physicians;
(III) on patterns and trends in national and regional variations of
care with respect to the furnishing of such services; and
(IV) on the correlation between the appropriateness of the services
furnished and image results; and
(I) the thresholds used under the demonstration project to identify
acceptable and outlier levels of performance with respect to the appropriateness
of advanced diagnostic imaging services furnished;
(II) whether prospective use of appropriateness criteria could have
an effect on the volume of such services furnished;
(III) whether expansion of the use of appropriateness criteria with
respect to such services to a broader population of Medicare beneficiaries
would be advisable;
(IV) whether, under such an expansion, physicians who demonstrate
consistent compliance with such appropriateness criteria should be
exempted from certain requirements;
(V) the use of incident-specific versus practice-specific outlier
information in formulating future recommendations with respect to
the use of appropriateness criteria for such services under the Medicare
program; and
(VI) the potential for using methods (including financial incentives),
in addition to those used under the models under the demonstration
project, to ensure compliance with such criteria.
(B) REPORT- Not later than 1 year after the completion of the demonstration
project under this subsection, the Secretary shall submit to Congress
a report containing the results of the evaluation of the demonstration
project conducted under subparagraph (A), together with recommendations
for such legislation and administrative action as the Secretary determines
appropriate.
(6) FUNDING- The Secretary 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) of $10,000,000, for carrying
out the demonstration project under this subsection (including costs associated
with administering the demonstration project, reimbursing physicians for
administrative costs and providing incentives to encourage participation
under paragraph (2)(C), entering into contracts under paragraph (2)(I),
and evaluating the demonstration project under paragraph (5)).
(c) GAO Studies and Reports-
(1) STUDY ON ACCREDITATION REQUIREMENT FOR ADVANCED DIAGNOSTIC IMAGING SERVICES-
(i) IN GENERAL- The Comptroller General of the United States (in this
subsection referred to as the `Comptroller General') shall conduct a
study, by imaging modality, on--
(I) the effect of the accreditation requirement under section 1834(e)
of the Social Security Act, as added by subsection (a); and
(II) any other relevant questions involving access to, and the value
of, advanced diagnostic imaging services for Medicare beneficiaries.
(ii) ISSUES- The study conducted under clause (i) shall examine the
following:
(I) The impact of such accreditation requirement on the number, type,
and quality of imaging services furnished to Medicare beneficiaries.
(II) The cost of such accreditation requirement, including costs to
facilities of compliance with such requirement and costs to the Secretary
of administering such requirement.
(III) Access to imaging services by Medicare beneficiaries, especially
in rural areas, before and after implementation of such accreditation
requirement.
(IV) Such other issues as the Secretary determines appropriate.
(i) PRELIMINARY REPORT- Not later than March 1, 2013, the Comptroller
General shall submit a preliminary report to Congress on the study conducted
under subparagraph (A).
(ii) FINAL REPORT- Not later than March 1, 2014, the Comptroller General
shall submit a final report to Congress on the study conducted under
subparagraph (A), together with recommendations for such legislation
and administrative action as the Comptroller General determines appropriate.
(2) STUDY ON INTEREST RATE AND EQUIPMENT UTILIZATION ASSUMPTIONS USED IN
DETERMINING PRACTICE EXPENSE-
(i) IN GENERAL- The Comptroller General shall conduct a study on the
assumptions used for interest rate and equipment utilization in the
methodology for determination of practice expense relative value units
under section 1848(c)(2)(C)(ii) of the Social Security Act (42 U.S.C.
1395w-4(c)(2)(C)(ii)) with respect to imaging services.
(ii) COLLECTION OF DATA- In conducting the study under clause (i), the
Comptroller General shall collect data on imaging equipment utilization
for different modalities of imaging equipment used in--
(I) different types of practices; and
(II) different geographic areas.
(B) REPORT- Not later than June 1, 2010, the Comptroller General shall
submit to Congress a report containing the results of the study conducted
under subparagraph (A), including the data collected under clause (ii)
of such subparagraph, together with recommendations for such legislation
and administrative action as the Comptroller General determines appropriate.
SEC. 136. EXTENSION OF TREATMENT OF CERTAIN PHYSICIAN PATHOLOGY SERVICES
UNDER MEDICARE.
Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000 (as enacted into law by section 1(a)(6) of Public Law
106-554), as amended by section 732 of the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 (42 U.S.C. 1395w-4 note), section 104 of division
B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395w-4 note),
and section 104 of the Medicare, Medicaid, and SCHIP Extension Act of 2007
(Public Law 110-173), is amended by striking `2007, and the first 6 months
of 2008' and inserting `2007, 2008, and 2009'.
SEC. 137. ACCOMMODATION OF PHYSICIANS ORDERED TO ACTIVE DUTY IN THE ARMED
SERVICES.
Section 1842(b)(6)(D)(iii) of the Social Security Act (42 U.S.C. 1395u(b)(6)(D)(iii)),
as amended by section 116 of the Medicare, Medicaid, and SCHIP Extension Act
of 2007 (Public Law 110-173), is amended by striking `(before July 1, 2008)'.
SEC. 138. ADJUSTMENT FOR MEDICARE MENTAL HEALTH SERVICES.
(1) IN GENERAL- For purposes of payment for services furnished under the
physician fee schedule under section 1848 of the Social Security Act (42
U.S.C. 1395w-4) during the period beginning on July 1, 2008, and ending
on December 31, 2009, the Secretary of Health and Human Services shall increase
the fee schedule otherwise applicable for specified services by 5 percent.
(2) NONAPPLICATION OF BUDGET-NEUTRALITY- The budget-neutrality provision
of section 1848(c)(2)(B)(ii) of the Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)(ii))
shall not apply to the adjustments described in paragraph (1).
(b) Definition of Specified Services- In this section, the term `specified
services' means procedure codes for services in the categories of the Health
Care Common Procedure Coding System, established by the Secretary of Health
and Human Services under section 1848(c)(5) of the Social Security Act (42
U.S.C. 1395w-4(c)(5)), as of July 1, 2007, and as subsequently modified by
the Secretary, consisting of psychiatric therapeutic procedures furnished
in office or other outpatient facility settings or in inpatient hospital,
partial hospital, or residential care facility settings, but only with respect
to such services in such categories that are in the subcategories of services
which are--
(1) insight oriented, behavior modifying, or supportive psychotherapy; or
(2) interactive psychotherapy.
(c) Implementation- Notwithstanding any other provision of law, the Secretary
may implement this section by program instruction or otherwise.
SEC. 139. IMPROVEMENTS FOR MEDICARE ANESTHESIA TEACHING PROGRAMS.
(a) Special Payment Rule for Teaching Anesthesiologists- Section 1848(a) of
the Social Security Act (42 U.S.C. 1395w-4(a)), as amended by section 132(b),
is amended--
(1) in paragraph (4)(A), by inserting `except as provided in paragraph (5),'
after `anesthesia cases,'; and
(2) by adding at the end the following new paragraph:
`(6) SPECIAL RULE FOR TEACHING ANESTHESIOLOGISTS- With respect to physicians'
services furnished on or after January 1, 2010, in the case of teaching
anesthesiologists involved in the training of physician residents in a single
anesthesia case or two concurrent anesthesia cases, the fee schedule amount
to be applied shall be 100 percent of the fee schedule amount otherwise
applicable under this section if the anesthesia services were personally
performed by the teaching anesthesiologist alone and paragraph (4) shall
not apply if--
`(A) the teaching anesthesiologist is present during all critical or key
portions of the anesthesia service or procedure involved; and
`(B) the teaching anesthesiologist (or another anesthesiologist with whom
the teaching anesthesiologist has entered into an arrangement) is immediately
available to furnish anesthesia services during the entire procedure.'.
(b) Treatment of Certified Registered Nurse Anesthetists- With respect to
items and services furnished on or after January 1, 2010, the Secretary of
Health and Human Services shall make appropriate adjustments to payments under
the Medicare program under title XVIII of the Social Security Act for teaching
certified registered nurse anesthetists to implement a policy with respect
to teaching certified registered nurse anesthetists that--
(1) is consistent with the adjustments made by the special rule for teaching
anesthesiologists under section 1848(a)(6) of the Social Security Act, as
added by subsection (a); and
(2) maintains the existing payment differences between teaching anesthesiologists
and teaching certified registered nurse anesthetists.
PART II--OTHER PAYMENT AND COVERAGE IMPROVEMENTS
SEC. 141. EXTENSION OF EXCEPTIONS PROCESS FOR MEDICARE THERAPY CAPS.
Section 1833(g)(5) of the Social Security Act (42 U.S.C. 1395l(g)(5)), as
amended by section 105 of the Medicare, Medicaid, and SCHIP Extension Act
of 2007 (Public Law 110-173), is amended by striking `June 30, 2008' and inserting
`December 31, 2009'.
SEC. 142. EXTENSION OF PAYMENT RULE FOR BRACHYTHERAPY AND THERAPEUTIC RADIOPHARMACEUTICALS.
Section 1833(t)(16)(C) of the Social Security Act (42 U.S.C. 1395l(t)(16)(C)),
as amended by section 106 of the Medicare, Medicaid, and SCHIP Extension Act
of 2007 (Public Law 110-173), is amended by striking `July 1, 2008' each place
it appears and inserting `January 1, 2010'.
SEC. 143. SPEECH-LANGUAGE PATHOLOGY SERVICES.
(a) In General- Section 1861(ll) of the Social Security Act (42 U.S.C. 1395x(ll))
is amended--
(1) by redesignating paragraphs (2) and (3) as paragraphs (3) and (4), respectively;
and
(2) by inserting after paragraph (1) the following new paragraph:
`(2) The term `outpatient speech-language pathology services' has the meaning
given the term `outpatient physical therapy services' in subsection (p), except
that in applying such subsection--
`(A) `speech-language pathology' shall be substituted for `physical therapy'
each place it appears; and
`(B) `speech-language pathologist' shall be substituted for `physical therapist'
each place it appears.'.
(b) Conforming Amendments-
(1) Section 1832(a)(2)(C) of the Social Security Act (42 U.S.C. 1395k(a)(2)(C))
is amended--
(A) by striking `and outpatient' and inserting `, outpatient'; and
(B) by inserting before the semicolon at the end the following: `, and
outpatient speech-language pathology services (other than services to
which the second sentence of section 1861(p) applies through the application
of section 1861(ll)(2))'.
(2) Subparagraphs (A) and (B) of section 1833(a)(8) of the Social Security
Act (42 U.S.C. 1395l(a)(8)) are each amended by striking `(which includes
outpatient speech-language pathology services)' and inserting `, outpatient
speech-language pathology services,'.
(3) Section 1833(g)(1) of the Social Security Act (42 U.S.C. 1395l(g)(1))
is amended--
(A) by inserting `and speech-language pathology services of the type described
in such section through the application of section 1861(ll)(2)' after
`1861(p)'; and
(B) by inserting `and speech-language pathology services' after `and physical
therapy services'.
(4) The second sentence of section 1835(a) of the Social Security Act (42
U.S.C. 1395n(a)) is amended--
(A) by striking `section 1861(g)' and inserting `subsection (g) or (ll)(2)
of section 1861' each place it appears; and
(B) by inserting `or outpatient speech-language pathology services, respectively'
after `occupational therapy services'.
(5) Section 1861(p) of the Social Security Act (42 U.S.C. 1395x(p)) is amended
by striking the fourth sentence.
(6) Section 1861(s)(2)(D) of the Social Security Act (42 U.S.C. 1395x(s)(2)(D))
is amended by inserting `, outpatient speech-language pathology services,'
after `physical therapy services'.
(7) Section 1862(a)(20) of the Social Security Act (42 U.S.C. 1395y(a)(20))
is amended--
(A) by striking `outpatient occupational therapy services or outpatient
physical therapy services' and inserting `outpatient physical therapy
services, outpatient speech-language pathology services, or outpatient
occupational therapy services'; and
(B) by striking `section 1861(g)' and inserting `subsection (g) or (ll)(2)
of section 1861'.
(8) Section 1866(e)(1) of the Social Security Act (42 U.S.C. 1395cc(e)(1))
is amended--
(A) by striking `section 1861(g)' and inserting `subsection (g) or (ll)(2)
of section 1861' the first two places it appears;
(B) by striking `defined) or' and inserting `defined),'; and
(C) by inserting before the semicolon at the end the following: `, or
(through the operation of section 1861(ll)(2)) with respect to the furnishing
of outpatient speech-language pathology'.
(9) Section 1877(h)(6) of the Social Security Act (42 U.S.C. 1395nn(h)(6))
is amended by adding at the end the following new subparagraph:
`(L) Outpatient speech-language pathology services.'.
(c) Effective Date- The amendments made by this section shall apply to services
furnished on or after July 1, 2009.
(d) Construction- Nothing in this section shall be construed to affect existing
regulations and policies of the Centers for Medicare & Medicaid Services
that require physician oversight of care as a condition of payment for speech-language
pathology services under part B of the Medicare program.
SEC. 144. PAYMENT AND COVERAGE IMPROVEMENTS FOR PATIENTS WITH CHRONIC OBSTRUCTIVE
PULMONARY DISEASE AND OTHER CONDITIONS.
(a) Coverage of Pulmonary and Cardiac Rehabilitation-
(1) IN GENERAL- Section 1861 of the Social Security Act (42 U.S.C. 1395x),
as amended by section 101(a), is amended--
(A) in subsection (s)(2)--
(i) in subparagraph (AA), by striking `and' at the end;
(ii) in subparagraph (BB), by adding `and' after the semicolon at the
end; and
(iii) by adding at the end the following new subparagraph:
`(CC) items and services furnished under a cardiac rehabilitation program
(as defined in subsection (eee)(1)) or under a pulmonary rehabilitation
program (as defined in subsection (fff)(1));'; and
(B) by adding at the end the following new subsections:
`Cardiac Rehabilitation Program
`(eee)(1) The term `cardiac rehabilitation program' means a physician-supervised
program (as described in paragraph (2)) that furnishes the items and services
described in paragraph (3).
`(2) A program described in this paragraph is a program under which--
`(A) items and services under the program are delivered--
`(i) in a physician's office;
`(ii) in a hospital on an outpatient basis; or
`(iii) in other settings determined appropriate by the Secretary.
`(B) a physician is immediately available and accessible for medical consultation
and medical emergencies at all times items and services are being furnished
under the program, except that, in the case of items and services furnished
under such a program in a hospital, such availability shall be presumed;
and
`(C) individualized treatment is furnished under a written plan established,
reviewed, and signed by a physician every 30 days that describes--
`(i) the individual's diagnosis;
`(ii) the type, amount, frequency, and duration of the items and services
furnished under the plan; and
`(iii) the goals set for the individual under the plan.
`(3) The items and services described in this paragraph are--
`(A) physician-prescribed exercise;
`(B) cardiac risk factor modification, including education, counseling,
and behavioral intervention (to the extent such education, counseling, and
behavioral intervention is closely related to the individual's care and
treatment and is tailored to the individual's needs);
`(C) psychosocial assessment;
`(D) outcomes assessment; and
`(E) such other items and services as the Secretary may determine, but only
if such items and services are--
`(i) reasonable and necessary for the diagnosis or active treatment of
the individual's condition;
`(ii) reasonably expected to improve or maintain the individual's condition
and functional level; and
`(iii) furnished under such guidelines relating to the frequency and duration
of such items and services as the Secretary shall establish, taking into
account accepted norms of medical practice and the reasonable expectation
of improvement of the individual.
`(4) The Secretary shall establish standards to ensure that a physician with
expertise in the management of individuals with cardiac pathophysiology who
is licensed to practice medicine in the State in which a cardiac rehabilitation
program (or the intensive cardiac rehabilitation program, as the case may
be) is offered--
`(A) is responsible for such program; and
`(B) in consultation with appropriate staff, is involved substantially in
directing the progress of individual in the program.
`Pulmonary Rehabilitation Program
`(fff)(1) The term `pulmonary rehabilitation program' means a physician-supervised
program (as described in subsection (eee)(2) with respect to a program under
this subsection) that furnishes the items and services described in paragraph
(2).
`(2) The items and services described in this paragraph are--
`(A) physician-prescribed exercise;
`(B) education or training (to the extent the education or training is closely
and clearly related to the individual's care and treatment and is tailored
to such individual's needs);
`(C) psychosocial assessment;
`(D) outcomes assessment; and
`(E) such other items and services as the Secretary may determine, but only
if such items and services are--
`(i) reasonable and necessary for the diagnosis or active treatment of
the individual's condition;
`(ii) reasonably expected to improve or maintain the individual's condition
and functional level; and
`(iii) furnished under such guidelines relating to the frequency and duration
of such items and services as the Secretary shall establish, taking into
account accepted norms of medical practice and the reasonable expectation
of improvement of the individual.
`(3) The Secretary shall establish standards to ensure that a physician with
expertise in the management of individuals with respiratory pathophysiology
who is licensed to practice medicine in the State in which a pulmonary rehabilitation
program is offered--
`(A) is responsible for such program; and
`(B) in consultation with appropriate staff, is involved substantially in
directing the progress of individual in the program.'.
(2) EFFECTIVE DATE- The amendments made by this subsection shall apply to
items and services furnished on or after January 1, 2010.
(b) Repeal of Transfer of Ownership of Oxygen Equipment-
(1) IN GENERAL- Section 1834(a)(5)(F) of the Social Security Act (42 U.S.C.
1395m(a)(5)(F)) is amended--
(A) in the heading, by striking `OWNERSHIP OF EQUIPMENT' and inserting
`RENTAL CAP'; and
(B) by striking clause (ii) and inserting the following:
`(ii) PAYMENTS AND RULES AFTER RENTAL CAP- After the 36th continuous
month during which payment is made for the equipment under this paragraph--
`(I) the supplier furnishing such equipment under this subsection
shall continue to furnish the equipment during any period of medical
need for the remainder of the reasonable useful lifetime of the equipment,
as determined by the Secretary;
`(II) payments for oxygen shall continue to be made in the amount
recognized for oxygen under paragraph (9) for the period of medical
need; and
`(III) maintenance and servicing payments shall, if the Secretary
determines such payments are reasonable and necessary, be made (for
parts and labor not covered by the supplier's or manufacturer's warranty,
as determined by the Secretary to be appropriate for the equipment),
and such payments shall be in an amount determined to be appropriate
by the Secretary.'.
(2) EFFECTIVE DATE- The amendments made by paragraph (1) shall take effect
on January 1, 2009.
(c) Revision of Payment for Oxygen and Oxygen Equipment, Portable Oxygen Equipment,
and Oxygen for Stationary Equipment-
(1) SEPARATE PAYMENT FOR OXYGEN EQUIPMENT AND OXYGEN FOR STATIONARY EQUIPMENT-
Section 1834(a) of the Social Security Act (42 U.S.C. 1395m(a)) is amended
by adding at the end the following new paragraph:
`(22) ADDITIONAL SPECIAL PAYMENT RULE BEGINNING IN 2009-
`(A) IN GENERAL- Notwithstanding the preceding provisions of this subsection,
for oxygen equipment (other than portable oxygen and oxygen equipment)
furnished during 2009, the payment amount otherwise determined under this
subsection for such equipment shall be equal to--
`(i) the amount of the monthly payment amount otherwise established
by the Secretary under this subsection for oxygen and oxygen equipment
(other than portable oxygen equipment) furnished in 2009; minus
`(ii) 71 percent of the amount of the monthly payment amount established
by the Secretary under this subsection for oxygen for stationary equipment
furnished in such year.
`(B) APPLICATION OF UPDATE TO SPECIAL PAYMENT AMOUNT- The covered item
update under paragraph (14) for oxygen equipment for 2010 and each subsequent
year shall be applied to the payment amount under subparagraph (A) unless
payment is made for such items and supplies under section 1847.'.
(2) ADD-ON PAYMENT FOR OXYGEN FOR STATIONARY OXYGEN EQUIPMENT- Section 1834(a)(5)
of the Social Security Act (42 U.S.C. 1395m(a)(5)) is amended by adding
at the end the following new subparagraph:
`(G) ADD-ON FOR OXYGEN FOR STATIONARY OXYGEN EQUIPMENT- In the case of
oxygen furnished on or after January 1, 2009, when oxygen is used with
stationary oxygen equipment, the payment amount recognized under subparagraph
(A) shall be increased by the amount established by the Secretary for
such oxygen (or 71 percent of such amount during the rental period for
such equipment).'.
(3) EQUALIZING ADD-ON PAYMENT FOR OXYGEN FOR PORTABLE OXYGEN AND OXYGEN
EQUIPMENT DURING MONTHLY RENTAL PERIOD AND PAYMENT FOR SUCH OXYGEN AND OXYGEN
EQUIPMENT AFTER SUCH RENTAL PERIOD- Section 1834(a)(9) of the Social Security
Act (42 U.S.C. 1395m(a)(9)) is amended by adding at the end the following
new subparagraph:
`(E) SPECIAL RULE FOR ADD-ON PAYMENT FOR PORTABLE OXYGEN AND OXYGEN EQUIPMENT-
In the case of oxygen and oxygen equipment furnished on or after January
1, 2009, for purposes of paragraph (5)(B), the monthly amount recognized
under this paragraph for portable oxygen and oxygen equipment in a year
shall be equal to the monthly payment amount for portable oxygen and oxygen
equipment applicable for the year under this subsection after the end
of the 36-month period under paragraph (5)(F).'.
(4) SPECIAL RULE FOR ADD-ON PAYMENTS FOR OXYGEN GENERATING PORTABLE EQUIPMENT-
Section 1834(a)(9) of the Social Security Act (42 U.S.C. 1395m(a)(9)), as
amended by paragraph (3), is amended by adding at the end the following
new subparagraph:
`(F) SPECIAL RULE FOR ADD-ON PAYMENT FOR OXYGEN GENERATING PORTABLE EQUIPMENT-
In the case of oxygen generating portable equipment, as defined by the
Secretary, furnished on or after January 1, 2009, the Secretary shall
make the following monthly add-on payments during the 36-month rental
period under paragraph (5)(F):
`(i) An amount equal to the monthly payment amount specified in subparagraph
(E) for the month.
`(ii) An amount equal to the monthly payment amount otherwise established
by the Secretary under this subsection for such equipment for the month
that recognizes that such equipment substitutes for the delivery of
portable oxygen and oxygen contents during the remaining useful life
of the equipment that occurs after the end of such 36-month rental period.'.
(5) CAP ON TOTAL MONTHLY PAYMENT FOR LIQUID OR GASEOUS STATIONARY AND PORTABLE
SYSTEMS- Section 1834(a)(5) of the Social Security Act (42 U.S.C. 1395m(a)(5)),
as amended by paragraph (2), is amended by adding at the end the following
new subparagraph:
`(H) CAP ON TOTAL PAYMENTS FOR LIQUID OR GASEOUS STATIONARY AND PORTABLE
SYSTEMS- In the case of a liquid or gaseous stationary and portable system
furnished on or after January 1, 2009, the total monthly amount recognized
under this part for such system for a month (including any add-on payments
under this subsection) may not exceed the total monthly amount that would
have otherwise been recognized under this part for such system for the
month (including any add-on payments under this subsection) if the amendments
made by section 144(c) of the Medicare Efficiency and Development of Improvement
of Care and Services Act (MEDICS Act) of 2008 had not been enacted.'.
(6) CONFORMING AMENDMENTS- (A) Section 1834(a)(5)(A) of the Social Security
Act (42 U.S.C. 1395m(a)(5)(A)) is amended--
(i) by inserting `and, in the case of items and services furnished on
or after January 1, 2009, other than oxygen for stationary equipment'
after `portable oxygen equipment'; and
(ii) by striking `subparagraphs (B), (C), (E), and (F)' and inserting
`the succeeding provisions of this paragraph'.
(B) Section 1834(a)(9) of the Social Security Act (42 U.S.C. 1395m(a)(9))
is amended--
(i) in the first sentence of the matter preceding subparagraph (A), by
striking `For purposes' and inserting `Subject to paragraphs (21) and
(22), for purposes'; and
(ii) in the second sentence of the matter preceding subparagraph (A)--
(I) by inserting `and, in the case of items and services furnished on
or after January 1, 2009, other than oxygen for stationary equipment'
after `portable oxygen equipment';
(II) by striking `and' before `(ii)' and inserting a comma; and
(III) by inserting `, and (iii) in the case of items and services furnished
on or after January 1, 2009, for oxygen for stationary equipment' before
`(each such group'.
(d) Application to Competitive Bidding- The amendments made by subsections
(b) and (c) shall not apply to contracts entered into under section 1847 of
the Social Security Act (42 U.S.C. 1395w-3) prior to September 1, 2008, pursuant
to the implementation of subsection (a)(1)(B)(i)(I) of such section 1847.
(e) Institute of Medicine Study and Report on Payments for Different Classes
of Oxygen Equipment-
(1) STUDY- Not later than 3 months after the date of the enactment of this
Act, the Secretary of Health and Human Services shall enter into a contract
with the Institute of Medicine of the National Academies (in this section
referred to as the `Institute') under which the Institute shall conduct
a study on the furnishing of, and payments for, oxygen and oxygen equipment
under the Medicare program. Such study shall include an analysis of the
following:
(A) The costs and activities associated with furnishing different modalities
of oxygen equipment (covering gaseous and liquid portable equipment and
oxygen generating portable equipment), including--
(i) the acquisition cost of the oxygen equipment;
(ii) the delivery and refilling of oxygen contents for stationary and
portable systems, including the frequency of delivery;
(iii) the delivery of the equipment and the provision of supplies and
accessories;
(iv) training and education, intake of patient information and related
documentation, and responding to beneficiary inquiries;
(v) servicing of different types of oxygen and oxygen equipment, including--
(I) the type and frequency of routine and nonroutine servicing furnished,
and variation across suppliers in furnishing such servicing; and
(II) the extent to which emergency or after hours servicing is needed
and furnished; and
(vi) other items or activities involved with furnishing oxygen and oxygen
equipment not described in clauses (i) though (v).
(B) Whether the various items and activities described in subparagraph
(A) are medically necessary and affect patient outcomes.
(C)(i) The adequacy of Medicare payment rates for oxygen equipment and
necessary servicing and items and activities furnished in connection with
the provision of oxygen and oxygen equipment; and
(ii) how such payment rates compare to competitively bid rates.
(D) Whether payment rates for oxygen and oxygen equipment under the Medicare
program should vary depending on the modality of oxygen equipment used
or should be the same for all modalities.
(E) The adequacy of add-on payments under the Medicare program for--
(i) contents for stationary equipment;
(ii) contents for portable equipment; and
(iii) oxygen-generating portable equipment.
(F)(i) Whether, during the rental period for oxygen equipment under the
Medicare program, payment for such equipment and servicing should be bundled
together or whether separate payments are appropriate; and
(ii) if separate payments are appropriate, how the payment should be allocated
between equipment and servicing.
(G) Options that could be considered for suppliers to document or report
under the Medicare program detailed information on activities related
to furnishing oxygen and oxygen equipment to Medicare beneficiaries.
(2) SURVEY- In conducting the study under paragraph (1), the Institute shall
conduct a survey of suppliers of oxygen and oxygen equipment to obtain data
on items described in paragraph (1)(A).
(3) REPORT- Not later than 18 months after the date of the enactment of
this Act, the Institute shall submit to the Secretary of Health and Human
Services a report containing the results of the study conducted under paragraph
(1), together with such recommendations as the Institute determines appropriate.
(4) FUNDING- For the purpose of carrying out this section, 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), of $5,000,000 to the Centers
for Medicare & Medicaid Services Program Management Account.
SEC. 145. REVISION OF PAYMENT FOR POWER-DRIVEN WHEELCHAIRS.
(a) In General- Section 1834(a)(7)(A) of the Social Security Act (42 U.S.C.
1395m(a)(7)(A)) is amended--
(A) in subclause (II), by inserting `subclause (III) and' after `Subject
to'; and
(B) by adding at the end the following new subclause:
`(III) SPECIAL RULE FOR POWER-DRIVEN WHEELCHAIRS- For purposes of
payment for power-driven wheelchairs, subclause (II) shall be applied
by substituting `15 percent' and `6 percent' for `10 percent' and
`7.5 percent', respectively.'; and
(A) in the heading, by inserting `COMPLEX, REHABILITATIVE' before `POWER-DRIVEN';
and
(B) by inserting `complex, rehabilitative' before `power-driven'.
(b) Technical Amendment- Section 1834(a)(7)(C)(ii)(II) of the Social Security
Act (42 U.S.C. 1395m(a)(7)(C)(ii)(II)) is amended by striking `(A)(ii) or'.
(1) IN GENERAL- Subject to paragraph (2), the amendments made by subsection
(a) shall take effect on January 1, 2009, and shall apply to power-driven
wheelchairs furnished on or after such date.
(2) APPLICATION TO COMPETITIVE BIDDING- The amendments made by subsection
(a) shall not apply to contracts entered into under section 1847 of the
Social Security Act (42 U.S.C. 1395w-3) prior to January 1, 2009, pursuant
to the implementation of subsection (a)(1)(B)(i)(I) of such section 1847.
SEC. 146. CLINICAL LABORATORY TESTS.
(a) Repeal of Medicare Competitive Bidding Demonstration Project for Clinical
Laboratory Services-
(1) IN GENERAL- Section 1847 of the Social Security Act (42 U.S.C. 1395w-3)
is amended by striking subsection (e).
(2) CONFORMING AMENDMENTS- Section 1833(a)(1)(D) of the Social Security
Act (42 U.S.C. 1395l(a)(1)(D)) is amended--
(A) by inserting `or' before `(ii)'; and
(B) by striking `or (iii) on the basis' and all that follows before the
comma at the end.
(3) EFFECTIVE DATE- The amendments made by this subsection shall take effect
on the date of the enactment of this Act.
(b) Clinical Laboratory Test Fee Schedule Update Adjustment- Section 1833(h)(2)(A)(i)
of the Social Security Act (42 U.S.C. 1395l(h)(2)(A)(ii)) is amended by inserting
`minus, for each of the years 2009 through 2013, 0.5 percentage points' after
`city average)'.
SEC. 147. IMPROVED ACCESS TO AMBULANCE SERVICES.
(a) Extension of Increased Medicare Payments for Ground Ambulance Services-
Section 1834(l)(13) of the Social Security Act (42 U.S.C. 1395m(l)(13)) is
amended--
(1) in subparagraph (A)--
(A) in the matter preceding clause (i), by inserting `and for such services
furnished on or after July 1, 2008, and before January 1, 2010' after
`2007,';
(B) in clause (i), by inserting `(or 3 percent if such service is furnished
on or after July 1, 2008, and before January 1, 2010)' after `2 percent';
and
(C) in clause (ii), by inserting `(or 2 percent if such service is furnished
on or after July 1, 2008, and before January 1, 2010)' after `1 percent';
and
(2) in subparagraph (B)--
(A) in the heading, by striking `2006' and inserting `APPLICABLE PERIOD';
and
(B) by inserting `applicable' before `period'.
(b) Air Ambulance Payment Improvements-
(1) TREATMENT OF CERTAIN AREAS FOR PAYMENT FOR AIR AMBULANCE SERVICES UNDER
THE AMBULANCE FEE SCHEDULE- Notwithstanding any other provision of law,
for purposes of making payments under section 1834(l) of the Social Security
Act (42 U.S.C. 1395m(l)) for air ambulance services furnished during the
period beginning on July 1, 2008, and ending on December 31, 2009, any area
that was designated as a rural area for purposes of making payments under
such section for air ambulance services furnished on December 31, 2006,
shall be treated as a rural area for purposes of making payments under such
section for air ambulance services furnished during such period.
(2) CLARIFICATION REGARDING SATISFACTION OF REQUIREMENT OF MEDICALLY NECESSARY-
(A) IN GENERAL- Section 1834(l)(14)(B)(i) of the Social Security Act (42
U.S.C. 1395m(l)(14)(B)(i)) is amended by striking `reasonably determines
or certifies' and inserting `certifies or reasonably determines'.
(B) EFFECTIVE DATE- The amendment made by subparagraph (A) shall apply
to services furnished on or after the date of the enactment of this Act.
SEC. 148. EXTENSION AND EXPANSION OF THE MEDICARE HOLD HARMLESS PROVISION
UNDER THE PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT DEPARTMENT (HOPD)
SERVICES FOR CERTAIN HOSPITALS.
Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C. 1395l(t)(7)(D)(i))
is amended--
(A) in the first sentence, by striking `2009' and inserting `2010'; and
(B) by striking the second sentence and inserting the following new sentence:
`For purposes of the preceding sentence, the applicable percentage shall
be 95 percent with respect to covered OPD services furnished in 2006,
90 percent with respect to such services furnished in 2007, and 85 percent
with respect to such services furnished in 2008 or 2009.'; and
(2) by adding at the end the following new subclause:
`(III) In the case of a sole community hospital (as defined in section
1886(d)(5)(D)(iii)) that has not more than 100 beds, for covered OPD
services furnished on or after January 1, 2009, and before January 1,
2010, for which the PPS amount is less than the pre-BBA amount, the
amount of payment under this subsection shall be increased by 85 percent
of the amount of such difference.'.
SEC. 149. CLARIFICATION OF PAYMENT FOR CLINICAL LABORATORY TESTS FURNISHED
BY CRITICAL ACCESS HOSPITALS.
(a) In General- Section 1834(g)(4) of the Social Security Act (42 U.S.C. 1395m(g)(4))
is amended--
(1) in the heading, by striking `NO BENEFICIARY COST-SHARING FOR' and inserting
`TREATMENT OF'; and
(2) by adding at the end the following new sentence: `For purposes of the
preceding sentence and section 1861(mm)(3), clinical diagnostic laboratory
services furnished by a critical access hospital shall be treated as being
furnished as part of outpatient critical access services without regard
to whether the individual with respect to whom such services are furnished
is physically present in the critical access hospital, or in a skilled nursing
facility or a clinic (including a rural health clinic) that is operated
by a critical access hospital, at the time the specimen is collected.'.
(b) Effective Date- The amendments made by subsection (a) shall apply to services
furnished on or after July 1, 2009.
SEC. 150. ADDING CERTAIN ENTITIES AS ORIGINATING SITES FOR PAYMENT OF TELEHEALTH
SERVICES.
(a) In General- Section 1834(m)(4)(C)(ii) of the Social Security Act (42 U.S.C.
1395m(m)(4)(C)(ii)) is amended by adding at the end the following new subclauses:
`(VI) A hospital-based or critical access hospital-based renal dialysis
center (including satellites).
`(VII) A skilled nursing facility (as defined in section 1819(a)).
`(VIII) A community mental health center (as defined in section 1861(ff)(3)(B)).'.
(b) Conforming Amendment- Section 1888(e)(2)(A)(ii) of the Social Security
Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting `telehealth services
furnished under section 1834(m)(4)(C)(ii)(VII),' after `section 1861(s)(2),'.
(c) Effective Date- The amendments made by this section shall apply to services
furnished on or after January 1, 2009.
SEC. 151. MEDPAC STUDY AND REPORT ON IMPROVING CHRONIC CARE DEMONSTRATION
PROGRAMS.
(a) Study- The Medicare Payment Advisory Commission shall conduct a study
on the feasability and advisability of establishing a Medicare Chronic Care
Practice Research Network that would serve as a standing network of providers
testing new models of care coordination and other care approaches for chronically
ill beneficiaries, including the initiation, operation, evaluation, and, if
appropriate, expansion of such models to the broader Medicare patient population.
(b) Report- Not later than June 15, 2009, the Medicare Payment Advisory Commission
shall submit to Congress a report containing the results of the study conducted
under subsection (a).
SEC. 152. INCREASE OF FQHC PAYMENT LIMITS.
(a) In General- Section 1833 of the Social Security Act (42 U.S.C. 1395l),
as amended by section 133(a), is amended by adding at the end the following
new subsection:
`(w) Increase of FQHC Payment Limits- In the case of services furnished by
federally qualified health centers (as defined in section 1861(aa)(4)), the
Secretary shall establish payment limits with respect to such services under
this part for services furnished--
`(1) in 2010, at the limits otherwise established under this part for such
year increased by $5; and
`(2) in a subsequent year, at the limits established under this subsection
for the previous year increased by the percentage increase in the MEI (as
defined in section 1842(i)(3)) for such subsequent year.'.
(b) Study and Report on the Effects and Adequacy of the Medicare Federally
Qualified Health Center Payment Structure-
(1) STUDY- The Comptroller General of the United States shall conduct a
study to determine whether the structure for payments for services furnished
by federally qualified health centers (as defined in section 1861(aa)(4)
of the Social Security Act (42 U.S.C. 1395x(aa)(4)) under part B of title
XVIII of the Social Security Act (42 U.S.C. 1395j et seq.) adequately reimburses
federally qualified health centers for the care furnished to Medicare beneficiaries.
In conducting such study, the Comptroller General shall--
(A) use the most current cost report data available;
(B) examine the effects of the payment limits established with respect
to such services under such part B on the ability of federally qualified
health centers to furnish care to Medicare beneficiaries; and
(C) examine the cost of furnishing services covered under the Medicare
program as of the date of the enactment of this Act that were not covered
under such program as of the date on which the Secretary determined the
payment rate for federally qualified health centers in 1991.
(2) REPORT- Not later than 15 months after the date of the enactment of
this Act, the Comptroller General of the United States shall submit to Congress
a report on the study conducted under paragraph (1), together with recommendations
for such legislation and administrative action the Comptroller General determines
appropriate, taking into consideration the structure and adequacy of the
prospective payment methodology used to make payments to federally qualified
health centers under the Medicaid program under title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.).
SEC. 153. KIDNEY DISEASE EDUCATION AND AWARENESS PROVISIONS.
(a) Chronic Kidney Disease Initiatives- Part P of title III of the Public
Health Service Act (42 U.S.C. 280g et seq.) is amended by adding at the end
the following new section:
`SEC. 399R. CHRONIC KIDNEY DISEASE INITIATIVES.
`(a) In General- The Secretary shall establish pilot projects to--
`(1) increase public and medical community awareness (particularly of those
who treat patients with diabetes and hypertension) regarding chronic kidney
disease, focusing on prevention;
`(2) increase screening for chronic kidney disease, focusing on Medicare
beneficiaries at risk of chronic kidney disease; and
`(3) enhance surveillance systems to better assess the prevalence and incidence
of chronic kidney disease.
`(1) SCOPE- The Secretary shall select at least 3 States in which to conduct
pilot projects under this section.
`(2) DURATION- The pilot projects under this section shall be conducted
for a period that is not longer than 5 years and shall begin on January
1, 2009.
`(c) Evaluation and Report- The Comptroller General of the United States shall
conduct an evaluation of the pilot projects conducted under this section.
Not later than 12 months after the date on which the pilot projects are completed,
the Comptroller General shall submit to Congress a report on the evaluation.
`(d) Authorization of Appropriations- There are authorized to be appropriated
such sums as may be necessary for the purpose of carrying out this section.'.
(b) Medicare Coverage of Kidney Disease Patient Education Services-
(1) COVERAGE OF KIDNEY DISEASE EDUCATION SERVICES-
(A) COVERAGE- Section 1861(s)(2) of the Social Security Act (42 U.S.C.
1395x(s)(2)), as amended by section 144(a), is amended--
(i) in subparagraph (BB), by striking `and' after the semicolon at the
end;
(ii) in subparagraph (CC), by adding `and' after the semicolon at the
end; and
(iii) by adding at the end the following new subparagraph:
`(DD) kidney disease education services (as defined in subsection (ggg));'.
(B) SERVICES DESCRIBED- Section 1861 of the Social Security Act (42 U.S.C.
1395x), as amended by section 144(a), is amended by adding at the end
the following new subsection:
`Kidney Disease Education Services
`(ggg)(1) The term `kidney disease education services' means educational services
that are--
`(A) furnished to an individual with stage IV chronic kidney disease who,
according to accepted clinical guidelines identified by the Secretary, will
require dialysis or a kidney transplant;
`(B) furnished, upon the referral of the physician managing the individual's
kidney condition, by a qualified person (as defined in paragraph (2)); and
`(i) to provide comprehensive information (consistent with the standards
set under paragraph (3)) regarding--
`(I) the management of comorbidities, including for purposes of delaying
the need for dialysis;
`(II) the prevention of uremic complications; and
`(III) each option for renal replacement therapy (including hemodialysis
and peritoneal dialysis at home and in-center as well as vascular access
options and transplantation);
`(ii) to ensure that the individual has the opportunity to actively participate
in the choice of therapy; and
`(iii) to be tailored to meet the needs of the individual involved.
`(2)(A) The term `qualified person' means--
`(i) a physician (as defined in section 1861(r)(1)) or a physician assistant,
nurse practitioner, or clinical nurse specialist (as defined in section
1861(aa)(5)), who furnishes services for which payment may be made under
the fee schedule established under section 1848; and
`(ii) a provider of services located in a rural area (as defined in section
1886(d)(2)(D)).
`(B) Such term does not include a provider of services (other than a provider
of services described in subparagraph (A)(ii)) or a renal dialysis facility.
`(3) The Secretary shall set standards for the content of such information
to be provided under paragraph (1)(C)(i) after consulting with physicians,
other health professionals, health educators, professional organizations,
accrediting organizations, kidney patient organizations, dialysis facilities,
transplant centers, network organizations described in section 1881(c)(2),
and other knowledgeable persons. To the extent possible the Secretary shall
consult with persons or entities described in the previous sentence, other
than a dialysis facility, that has not received industry funding from a drug
or biological manufacturer or dialysis facility.
`(4) No individual shall be furnished more than 6 sessions of kidney disease
education services under this title.'.
(C) PAYMENT UNDER THE PHYSICIAN FEE SCHEDULE- Section 1848(j)(3) of the
Social Security Act (42 U.S.C. 1395w-4(j)(3)), is amended by inserting
`(2)(DD),' after `(2)(AA),'.
(D) LIMITATION ON NUMBER OF SESSIONS- Section 1862(a)(1) of the Social
Security Act (42 U.S.C. 1395y(a)(1)) is amended--
(i) in subparagraph (M), by striking `and' at the end;
(ii) in subparagraph (N), by striking the semicolon at the end and inserting
`, and'; and
(iii) by adding at the end the following new subparagraph:
`(O) in the case of kidney disease education services (as defined in paragraph
(1) of section 1861(ggg)), which are furnished in excess of the number of
sessions covered under paragraph (4) of such section;'.
(2) EFFECTIVE DATE- The amendments made by this subsection shall apply to
services furnished on or after January 1, 2010.
SEC. 154. RENAL DIALYSIS PROVISIONS.
(1) UPDATE- Section 1881(b)(12)(G) of the Social Security Act (42 U.S.C.
1395rr(b)(12)(G)) is amended--
(A) in clause (i), by striking `and' at the end;
(i) by inserting `and before January 1, 2009,' after `April 1, 2007,';
and
(ii) by striking the period at the end and inserting a semicolon; and
(C) by adding at the end the following new clauses:
`(iii) furnished on or after January 1, 2009, and before January 1, 2010,
by 1.0 percent above the amount of such composite rate component for such
services furnished on December 31, 2008; and
`(iv) furnished on or after January 1, 2010, by 1.0 percent above the amount
of such composite rate component for such services furnished on December
31, 2009.'.
(2) SITE NEUTRAL COMPOSITE RATE- Section 1881(b)(12)(A) of the Social Security
Act (42 U.S.C. 1395rr(b)(12)(A)) is amended by adding at the end the following
new sentence: `Under such system, the payment rate for dialysis services
furnished on or after January 1, 2009, by providers of services shall be
the same as the payment rate (computed without regard to this sentence)
for such services furnished by renal dialysis facilities, and in applying
the geographic index under subparagraph (D) to providers of services, the
labor share shall be based on the labor share otherwise applied for renal
dialysis facilities.'.
(b) Development of ESRD Bundled Payment System-
(1) IN GENERAL- 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:
`(14)(A)(i) Subject to subparagraph (E), for services furnished on or after
January 1, 2011, the Secretary shall implement a payment system under which
a single payment is made under this title to a provider of services or a renal
dialysis facility for renal dialysis services (as defined in subparagraph
(B)) in lieu of any other payment (including a payment adjustment under paragraph
(12)(B)(ii)) and for such services and items furnished pursuant to paragraph
(4).
`(ii) In implementing the system under this paragraph the Secretary shall
ensure that the estimated total amount of payments under this title for 2011
for renal dialysis services shall equal 98 percent of the estimated total
amount of payments for renal dialysis services, including payments under paragraph
(12)(B)(ii), that would have been made under this title with respect to services
furnished in 2011 if such system had not been implemented. In making the estimation
under subclause (I), the Secretary shall use per patient utilization data
from 2007, 2008, or 2009, whichever has the lowest per patient utilization.
`(B) For purposes of this paragraph, the term `renal dialysis services' includes--
`(i) items and services included in the composite rate for renal dialysis
services as of December 31, 2010;
`(ii) erythropoiesis stimulating agents and any oral form of such agents
that are furnished to individuals for the treatment of end stage renal disease;
`(iii) other drugs and biologicals that are furnished to individuals for
the treatment of end stage renal disease and for which payment was (before
the application of this paragraph) made separately under this title, and
any oral equivalent form of such drug or biological; and
`(iv) diagnostic laboratory tests and other items and services not described
in clause (i) that are furnished to individuals for the treatment of end
stage renal disease.
Such term does not include vaccines.
`(C) The system under this paragraph may provide for payment on the basis
of services furnished during a week or month or such other appropriate unit
of payment as the Secretary specifies.
`(i) shall include a payment adjustment based on case mix that may take
into account patient weight, body mass index, comorbidities, length of time
on dialysis, age, race, ethnicity, and other appropriate factors;
`(ii) shall include a payment adjustment for high cost outliers due to unusual
variations in the type or amount of medically necessary care, including
variations in the amount of erythropoiesis stimulating agents necessary
for anemia management;
`(iii) shall include a payment adjustment that reflects the extent to which
costs incurred by low-volume facilities (as defined by the Secretary) in
furnishing renal dialysis services exceed the costs incurred by other facilities
in furnishing such services, and for payment for renal dialysis services
furnished on or after January 1, 2011, and before January 1, 2014, such
payment adjustment shall not be less than 10 percent; and
`(iv) may include such other payment adjustments as the Secretary determines
appropriate, such as a payment adjustment--
`(I) for pediatric providers of services and renal dialysis facilities;
`(II) by a geographic index, such as the index referred to in paragraph
(12)(D), as the Secretary determines to be appropriate; and
`(III) for providers of services or renal dialysis facilities located
in rural areas.
The Secretary shall take into consideration the unique treatment needs of
children and young adults in establishing such system.
`(E)(i) The Secretary shall provide for a four-year phase-in (in equal increments)
of the payment amount under the payment system under this paragraph, with
such payment amount being fully implemented for renal dialysis services furnished
on or after January 1, 2014.
`(ii) A provider of services or renal dialysis facility may make a one-time
election to be excluded from the phase-in under clause (i) and be paid entirely
based on the payment amount under the payment system under this paragraph.
Such an election shall be made prior to January 1, 2011, in a form and manner
specified by the Secretary, and is final and may not be rescinded.
`(iii) The Secretary shall make an adjustment to the payments under this paragraph
for years during which the phase-in under clause (i) is applicable so that
the estimated total amount of payments under this paragraph, including payments
under this subparagraph, shall equal the estimated total amount of payments
that would otherwise occur under this paragraph without such phase-in.
`(F)(i) Subject to clause (ii), beginning in 2012, the Secretary shall annually
increase payment amounts established under this paragraph by an ESRD market
basket percentage increase factor for a bundled payment system for renal dialysis
services that reflects changes over time in the prices of an appropriate mix
of goods and services included in renal dialysis services minus 1.0 percentage
point.
`(ii) For years during which a phase-in of the payment system pursuant to
subparagraph (E) is applicable, the following rules shall apply to the portion
of the payment under the system that is based on the payment of the composite
rate that would otherwise apply if the system under this paragraph had not
been enacted:
`(I) The update under clause (i) shall not apply.
`(II) The Secretary shall annually increase such composite rate by the ESRD
market basket percentage increase factor described in clause (i) minus 1.0
percentage point.
`(G) There shall be no administrative or judicial review under section 1869,
section 1878, or otherwise of the determination of payment amounts under subparagraph
(A), the establishment of an appropriate unit of payment under subparagraph
(C), the identification of renal dialysis services included in the bundled
payment, the adjustments under subparagraph (D), the application of the phase-in
under subparagraph (E), and the establishment of the market basket percentage
increase factors under subparagraph (F).
`(H) Erythropoiesis stimulating agents and other drugs and biologicals shall
be treated as prescribed and dispensed or administered and available only
under part B if they are--
`(i) furnished to an individual for the treatment of end stage renal disease;
and
`(ii) included in subparagraph (B) for purposes of payment under this paragraph.'.
(2) PROHIBITION OF UNBUNDLING- Section 1862(a) of the Social Security Act
(42 U.S.C. 1395y(a)), as amended by section 135(a)(2), is amended--
(A) in paragraph (22), by striking `or' at the end;
(B) in paragraph (23), by striking the period at the end and inserting
`; or'; and
(C) by inserting after paragraph (23) the following new paragraph:
`(24) where such expenses are for renal dialysis services (as defined in
subparagraph (B) of section 1881(b)(14)) for which payment is made under
such section unless such payment is made under such section to a provider
of services or a renal dialysis facility for such services.'.
(3) CONFORMING AMENDMENTS- (A) Section 1881(b) of the Social Security Act
(42 U.S.C. 1395rr(b)) is amended--
(i) in paragraph (12)(A), by striking `In lieu of payment' and inserting
`Subject to paragraph (14), in lieu of payment';
(ii) in the second sentence of paragraph (12)(F)--
(I) by inserting `or paragraph (14)' after `this paragraph'; and
(II) by inserting `or under the system under paragraph (14)' after `subparagraph
(B)'; and
(iii) in paragraph (13)--
(I) in subparagraph (A), in the matter preceding clause (i), by striking
`The payment amounts' and inserting `Subject to paragraph (14), the
payment amounts'; and
(II) in subparagraph (B)--
(aa) in clause (i), by striking `(i)' after `(B)' and by inserting
`, subject to paragraph (14)' before the period at the end; and
(bb) by striking clause (ii).
(B) Section 1861(s)(2)(F) of the Social Security Act (42 U.S.C. 1395x(s)(2)(F))
is amended by inserting `, and, for items and services furnished on or after
January 1, 2011, renal dialysis services (as defined in section 1881(b)(14)(B))'
before the semicolon at the end.
(C) Section 623(e) of the Medicare Prescription Drug, Improvement, and Modernization
Act of 2003 (42 U.S.C. 1395rr note) is repealed.
(4) RULE OF CONSTRUCTION- Nothing in this subsection or the amendments made
by this subsection shall be construed as authorizing or requiring the Secretary
of Health and Human Services to make payments under the payment system implemented
under paragraph (14)(A)(i) of section 1881(b) of the Social Security Act
(42 U.S.C. 1395rr(b)), as added by paragraph (1), for any unrecovered amount
for any bad debt attributable to deductible and coinsurance on items and
services not included in the basic case-mix adjusted composite rate under
paragraph (12) of such section as in effect before the date of the enactment
of this Act.
(c) Quality Incentives in the End-Stage Renal Disease Program- Section 1881
of the Social Security Act (42 U.S.C. 1395rr) is amended by adding at the
end the following new subsection:
`(h) Quality Incentives in the End-Stage Renal Disease Program-
`(A) IN GENERAL- With respect to renal dialysis services (as defined in
subsection (b)(14)(B)) furnished on or after January 1, 2012, in the case
of a provider of services or a renal dialysis facility that does not meet
the requirement described in subparagraph (B) with respect to the year,
payments otherwise made to such provider or facility under the system
under subsection (b)(14) for such services shall be reduced by up to 2.0
percent, as determined appropriate by the Secretary.
`(B) REQUIREMENT- The requirement described in this subparagraph is that
the provider or facility meets (or exceeds) the total performance score
under paragraph (3) with respect to performance standards established
by the Secretary with respect to measures specified in paragraph (2).
`(C) NO EFFECT IN SUBSEQUENT YEARS- The reduction under subparagraph (A)
shall apply only with respect to the year involved, and the Secretary
shall not take into account such reduction in computing the single payment
amount under the system under paragraph (14) in a subsequent year.
`(A) IN GENERAL- The measures specified under this paragraph with respect
to the year involved shall include--
`(i) measures on anemia management that reflect the labeling approved
by the Food and Drug Administration for such management and measures
on dialysis adequacy;
`(ii) to the extent feasible, such measure (or measures) of patient
satisfaction as the Secretary shall specify; and
`(iii) such other measures as the Secretary specifies, including, to
the extent feasible, measures on--
`(II) bone mineral metabolism; and
`(III) vascular access, including for maximizing the placement of
arterial venous fistula.
`(B) USE OF ENDORSED MEASURES-
`(i) IN GENERAL- Subject to clause (ii), any measure specified by the
Secretary under subparagraph (A)(iii) must have been endorsed by the
entity with a contract under section 1890(a).
`(ii) EXCEPTION- In the case of a specified area or medical topic determined
appropriate by the Secretary for which a feasible and practical measure
has not been endorsed by the entity with a contract under section 1890(a),
the Secretary may specify a measure that is not so endorsed as long
as due consideration is given to measures that have been endorsed or
adopted by a consensus organization identified by the Secretary.
`(C) UPDATING MEASURES- The Secretary shall establish a process for updating
the measures specified under subparagraph (A) in consultation with interested
parties.
`(D) CONSIDERATION- In specifying measures under subparagraph (A), the
Secretary shall consider the availability of measures that address the
unique treatment needs of children and young adults with kidney failure.
`(A) TOTAL PERFORMANCE SCORE-
`(i) IN GENERAL- Subject to clause (ii), the Secretary shall develop
a methodology for assessing the total performance of each provider of
services and renal dialysis facility based on performance standards
with respect to the measures selected under paragraph (2) for a performance
period established under paragraph (4)(D) (in this subsection referred
to as the `total performance score').
`(ii) APPLICATION- For providers of services and renal dialysis facilities
that do not meet (or exceed) the total performance score established
by the Secretary, the Secretary shall ensure that the application of
the methodology developed under clause (i) results in an appropriate
distribution of reductions in payment under paragraph (1) among providers
and facilities achieving different levels of total performance scores,
with providers and facilities achieving the lowest total performance
scores receiving the largest reduction in payment under paragraph (1)(A).
`(iii) WEIGHTING OF MEASURES- In calculating the total performance score,
the Secretary shall weight the scores with respect to individual measures
calculated under subparagraph (B) to reflect priorities for quality
improvement, such as weighting scores to ensure that providers of services
and renal dialysis facilities have strong incentives to meet or exceed
anemia management and dialysis adequacy performance standards, as determined
appropriate by the Secretary.
`(B) PERFORMANCE SCORE WITH RESPECT TO INDIVIDUAL MEASURES- The Secretary
shall also calculate separate performance scores for each measure, including
for dialysis adequacy and anemia management.
`(4) PERFORMANCE STANDARDS-
`(A) ESTABLISHMENT- Subject to subparagraph (E), the Secretary shall establish
performance standards with respect to measures selected under paragraph
(2) for a performance period with respect to a year (as established under
subparagraph (D)).
`(B) ACHIEVEMENT AND IMPROVEMENT- The performance standards established
under subparagraph (A) shall include levels of achievement and improvement,
as determined appropriate by the Secretary.
`(C) TIMING- The Secretary shall establish the performance standards under
subparagraph (A) prior to the beginning of the performance period for
the year involved.
`(D) PERFORMANCE PERIOD- The Secretary shall establish the performance
period with respect to a year. Such performance period shall occur prior
to the beginning of such year.
`(E) SPECIAL RULE- The Secretary shall initially use as the performance
standard for the measures specified under paragraph (2)(A)(i) for a provider
of services or a renal dialysis facility the lesser of--
`(i) the performance of such provider or facility for such measures
in the year selected by the Secretary under the second sentence of subsection
(b)(14)(A)(ii); or
`(ii) a performance standard based on the national performance rates
for such measures in a period determined by the Secretary.
`(5) LIMITATION ON REVIEW- There shall be no administrative or judicial
review under section 1869, section 1878, or otherwise of the following:
`(A) The determination of the amount of the payment reduction under paragraph
(1).
`(B) The establishment of the performance standards and the performance
period under paragraph (4).
`(C) The specification of measures under paragraph (2).
`(D) The methodology developed under paragraph (3) that is used to calculate
total performance scores and performance scores for individual measures.
`(A) IN GENERAL- The Secretary shall establish procedures for making information
regarding performance under this subsection available to the public, including--
`(i) the total performance score achieved by the provider of services
or renal dialysis facility under paragraph (3) and appropriate comparisons
of providers of services and renal dialysis facilities to the national
average with respect to such scores; and
`(ii) the performance score achieved by the provider or facility with
respect to individual measures.
`(B) OPPORTUNITY TO REVIEW- The procedures established under subparagraph
(A) shall ensure that a provider of services and a renal dialysis facility
has the opportunity to review the information that is to be made public
with respect to the provider or facility prior to such data being made
public.
`(i) IN GENERAL- The Secretary shall provide certificates to providers
of services and renal dialysis facilities who furnish renal dialysis
services under this section to display in patient areas. The certificate
shall indicate the total performance score achieved by the provider
or facility under paragraph (3).
`(ii) DISPLAY- Each facility or provider receiving a certificate under
clause (i) shall prominently display the certificate at the provider
or facility.
`(D) WEB-BASED LIST- The Secretary shall establish a list of providers
of services and renal dialysis facilities who furnish renal dialysis services
under this section that indicates the total performance score and the
performance score for individual measures achieved by the provider and
facility under paragraph (3). Such information shall be posted on the
Internet website of the Centers for Medicare & Medicaid Services in
an easily understandable format.'.
(d) GAO Report on ESRD Bundling System and Quality Initiative- Not later than
March 1, 2013, the Comptroller General of the United States shall submit to
Congress a report on the implementation of the payment system under subsection
(b)(14) of section 1881 of the Social Security Act (as added by subsection
(b)) for renal dialysis services and related services (defined in subparagraph
(B) of such subsection (b)(14)) and the quality initiative under subsection
(h) of such section 1881 (as added by subsection (b)). Such report shall include
the following information:
(1) The changes in utilization rates for erythropoiesis stimulating agents.
(2) The mode of administering such agents, including information on the
proportion of individuals receiving such agents intravenously as compared
to subcutaneously.
(3) An analysis of the payment adjustment under subparagraph (D)(iii) of
such subsection (b)(14), including an examination of the extent to which
costs incurred by rural, low-volume providers and facilities (as defined
by the Secretary) in furnishing renal dialysis services exceed the costs
incurred by other providers and facilities in furnishing such services,
and a recommendation regarding the appropriateness of such adjustment.
(4) The changes, if any, in utilization rates of drugs and biologicals that
the Secretary identifies under subparagraph (B)(iii) of such subsection
(b)(14), and any oral equivalent or oral substitutable forms of such drugs
and biologicals or of drugs and biologicals described in clause (ii), that
have occurred after implementation of the payment system under such subsection
(b)(14).
(5) Any other information or recommendations for legislative and administrative
actions determined appropriate by the Comptroller General.
Subtitle D--Provisions Relating to Part C
SEC. 161. PHASE-OUT OF INDIRECT MEDICAL EDUCATION (IME).
(a) In General- Section 1853(k) of the Social Security Act (42 U.S.C. 1395w-23(k))
is amended--
(1) in paragraph (1), in the matter preceding subparagraph (A), by striking
`paragraph (2)' and inserting `paragraphs (2) and (4)'; and
(2) by adding at the end the following new paragraph:
`(4) PHASE-OUT OF THE INDIRECT COSTS OF MEDICAL EDUCATION FROM CAPITATION
RATES-
`(A) IN GENERAL- After determining the applicable amount for an area for
a year under paragraph (1) (beginning with 2010), the Secretary shall
adjust such applicable amount to exclude from such applicable amount the
phase-in percentage (as defined in subparagraph (B)(i)) for the year of
the Secretary's estimate of the standardized costs for payments under
section 1886(d)(5)(B) in the area for the year. Any adjustment under the
preceding sentence shall be made prior to the application of paragraph
(2).
`(B) PERCENTAGES DEFINED- For purposes of this paragraph:
`(i) PHASE-IN PERCENTAGE- The term `phase-in percentage' means, for
an area for a year, the ratio (expressed as a percentage, but in no
case greater than 100 percent) of--
`(I) the maximum cumulative adjustment percentage for the year (as
defined in clause (ii)); to
`(II) the standardized IME cost percentage (as defined in clause (iii))
for the area and year.
`(ii) MAXIMUM CUMULATIVE ADJUSTMENT PERCENTAGE- The term `maximum cumulative
adjustment percentage' means, for--
`(I) 2010, 0.60 percent; and
`(II) a subsequent year, the maximum cumulative adjustment percentage
for the previous year increased by 0.60 percentage points.
`(iii) STANDARDIZED IME COST PERCENTAGE- The term `standardized IME
cost percentage' means, for an area for a year, the per capita costs
for payments under section 1886(d)(5)(B) (expressed as a percentage
of the fee-for-service amount specified in subparagraph (C)) for the
area and the year.
`(C) FEE-FOR-SERVICE AMOUNT- The fee-for-service amount specified in this
subparagraph for an area for a year is the amount specified under subsection
(c)(1)(D) for the area and the year.'.
(b) Excluding Adjustment From the Update- Section 1853(k)(1)(B)(i) of the
Social Security Act (42 U.S.C. 1395w-23(k)(1)(B)(i)) is amended by striking
`paragraph (2)' and inserting `paragraphs (2) and (4)'.
(c) Hold Harmless for PACE Program Payments- Section 1894(d) of the Social
Security Act (42 U.S.C. 1395eee(d)) is amended by adding at the end the following
new paragraph:
`(3) CAPITATION RATES DETERMINED WITHOUT REGARD TO THE PHASE-OUT OF THE
INDIRECT COSTS OF MEDICAL EDUCATION FROM THE ANNUAL MEDICARE ADVANTAGE CAPITATION
RATE- Capitation amounts under this subsection shall be determined without
regard to the application of section 1853(k)(4).'.
SEC. 162. REVISIONS TO REQUIREMENTS FOR MEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE
PLANS.
(a) Requirements To Assure Access to Network Coverage-
(1) INDIVIDUAL MARKET- Section 1852(d) of the Social Security Act (42 U.S.C.
1395w-22(d)) is amended--
(A) in paragraph (4), in the second sentence, by striking `The Secretary'
and inserting `Subject to paragraph (5), the Secretary'; and
(B) by adding at the end the following new paragraph:
`(5) REQUIREMENT OF CERTAIN NONEMPLOYER MEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE
PLANS TO USE CONTRACTS WITH PROVIDERS-
`(A) IN GENERAL- For plan year 2011 and subsequent plan years, in the
case of a Medicare Advantage private fee-for-service plan not described
in paragraph (1) or (2) of section 1857(i) operating in a network area
(as defined in subparagraph (B)), the plan shall meet the access standards
under paragraph (4) in that area only through entering into written contracts
as provided for under subparagraph (B) of such paragraph and not, in whole
or in part, through the establishment of payment rates meeting the requirements
under subparagraph (A) of such paragraph.
`(B) NETWORK AREA DEFINED- For purposes of subparagraph (A), the term
`network area' means, for a plan year, an area which the Secretary identifies
(in the Secretary's announcement of the proposed payment rates for the
previous plan year under section 1853(b)(1)(B)) as having at least 2 network-based
plans (as defined in subparagraph (C)) with enrollment under this part
as of the first day of the year in which such announcement is made.
`(C) NETWORK-BASED PLAN DEFINED-
`(i) IN GENERAL- For purposes of subparagraph (B), the term `network-based
plan' means--
`(I) except as provided in clause (ii), a Medicare Advantage plan
that is a coordinated care plan described in section 1851(a)(2)(A)(i);
`(II) a network-based MSA plan; and
`(III) a reasonable cost reimbursement plan under section 1876.
`(ii) EXCLUSION OF NON-NETWORK REGIONAL PPOS- The term `network-based
plan' shall not include an MA regional plan that, with respect to the
area, meets access adequacy standards under this part substantially
through the authority of section 422.112(a)(1)(ii) of title 42, Code
of Federal Regulations, rather than through written contracts.'.
(2) EMPLOYER PLANS- Section 1852(d) of the Social Security Act (42 U.S.C.
1395w-22(d)), as amended by paragraph (1), is amended--
(A) in paragraph (4), in the second sentence, by striking `paragraph (5)'
and inserting `paragraphs (5) and (6)'; and
(B) by adding at the end the following new paragraph:
`(6) REQUIREMENT OF ALL EMPLOYER MEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE
PLANS TO USE CONTRACTS WITH PROVIDERS- For plan year 2011 and subsequent
plan years, in the case of a Medicare Advantage private fee-for-service
plan that is described in paragraph (1) or (2) of section 1857(i), the plan
shall meet the access standards under paragraph (4) only through entering
into written contracts as provided for under subparagraph (B) of such paragraph
and not, in whole or in part, through the establishment of payment rates
meeting the requirements under subparagraph (A) of such paragraph.'.
(A) IN GENERAL- Section 1852(d)(4)(B) of the Social Security Act (42 U.S.C.
1395w-22(d)(4)(B)) is amended by striking `a sufficient number' through
`terms of the plan' and inserting `a sufficient number and range of providers
within such category to meet the access standards in subparagraphs (A)
through (E) of paragraph (1)'.
(B) EFFECTIVE DATE- The amendment made by subparagraph (A) shall apply
to plan year 2010 and subsequent plan years.
(b) Clarification Regarding Utilization- Section 1859(b)(2) of the Social
Security Act (42 U.S.C. 1395w-28(b)(2)) is amended by adding at the end the
following flush sentence:
`Nothing in subparagraph (B) shall be construed to preclude a plan from
varying rates for such a provider based on the specialty of the provider,
the location of the provider, or other factors related to such provider
that are not related to utilization, or to preclude a plan from increasing
rates for such a provider based on increased utilization of specified preventive
or screening services.'.
SEC. 163. REVISIONS TO QUALITY IMPROVEMENT PROGRAMS.
(a) Requirement for MA Private Fee-for-Service and MSA Plans To Have a Quality
Improvement Program-
(1) IN GENERAL- Section 1852(e)(1) of the Social Security Act (42 U.S.C.
1395w-112(e)(1)) is amended by striking `(other than an MA private fee-for-service
plan or an MSA plan)'.
(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply to plan
years beginning on or after January 1, 2010.
(b) Data Collection Requirements for MA Regional Plans, MA Private Fee-for-Service
Plans, and MSA Plans-
(1) IN GENERAL- Section 1852(e)(3)(A) of the Social Security Act (42 U.S.C.
1395w-22(e)(3)(A)) is amended--
(A) in clause (i), by adding at the end the following new sentence: `With
respect to MA private fee-for-service plans and MSA plans, such requirements
may not exceed the requirements under this subparagraph with respect to
MA local plans that are preferred provider organization plans, except
that the limitation under clause (iii) shall not apply and such requirements
shall apply regardless of whether or not the services are furnished by
providers of services, physicians, or other health care practitioners
and suppliers that have contracts with the organization offering the MA
private fee-for-service plan or the MSA plan.'
(B) by striking clause (ii)--
(I) by inserting `LOCAL' after `TO'; and
(II) by inserting `AND MA REGIONAL PLANS' after `ORGANIZATIONS'; and
(ii) by inserting `and to MA regional plans' after `organization plans'.
(2) EFFECTIVE DATE- The amendments made by paragraph (1) shall apply to
plan years beginning on or after January 1, 2010.
SEC. 164. REVISIONS RELATING TO SPECIALIZED MEDICARE ADVANTAGE PLANS FOR
SPECIAL NEEDS INDIVIDUALS.
(a) Extension of Authority To Restrict Enrollment- Section 1859(f) of the
Social Security Act (42 U.S.C. 1395w-28(f)), as amended by section 108(a)
of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173)
is amended by striking `2010' and inserting `2011'.
(b) Moratorium on Authority To Designate Other Plans as Specialized MA Plans-
During the period beginning on January 1, 2010, and ending on December 31,
2010, the Secretary of Health and Human Services may not exercise the authority
provided under section 231(d) of the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 (42 U.S.C. 1395w-21 note) to designate other
plans as specialized MA plans for special needs individuals.
(c) Requirements for Enrollment-
(1) IN GENERAL- Section 1859 of the Social Security Act (42 U.S.C. 1395w-28)
is amended--
(A) in subsection (b)(6)(A), by inserting `and that, as of January 1,
2010, meets the applicable requirements of paragraph (2), (3), or (4)
of subsection (f), as the case may be' before the period at the end; and
(i) by amending the heading to read as follows: `Requirements Regarding
Enrollment in Specialized MA Plans for Special Needs Individuals';
(ii) by designating the sentence beginning `In the case of' as paragraph
(1) with the heading `REQUIREMENTS FOR ENROLLMENT- ' and with appropriate
indentation; and
(iii) by adding at the end the following new paragraphs:
`(2) ADDITIONAL REQUIREMENTS FOR INSTITUTIONAL SNPS- In the case of a specialized
MA plan for special needs individuals described in subsection (b)(6)(B)(i),
the applicable requirements described in this paragraph are as follows:
`(A) Each individual that enrolls in the plan on or after January 1, 2010,
is a special needs individuals described in subsection (b)(6)(B)(i). In
the case of an individual who is living in the community but requires
an institutional level of care, such individual shall not be considered
a special needs individual described in subsection (b)(6)(B)(i) unless
the determination that the individual requires an institutional level
of care was made--
`(i) using a State assessment tool of the State in which the individual
resides; and
`(ii) by an entity other than the organization offering the plan.
`(B) The plan meets the requirements described in paragraph (5).
`(3) ADDITIONAL REQUIREMENTS FOR DUAL SNPS- In the case of a specialized
MA plan for special needs individuals described in subsection (b)(6)(B)(ii),
the applicable requirements described in this paragraph are as follows:
`(A) Each individual that enrolls in the plan on or after January 1, 2010,
is a special needs individuals described in subsection (b)(6)(B)(ii).
`(B) The plan meets the requirements described in paragraph (5).
`(C) The plan provides each prospective enrollee, prior to enrollment,
with a comprehensive written statement (using standardized content and
format established by the Secretary) that describes--
`(i) the benefits and cost-sharing protections that the individual is
entitled to under the State Medicaid program under title XIX; and
`(ii) which of such benefits and cost-sharing protections are covered
under the plan.
Such statement shall be included with any description of benefits offered
by the plan.
`(D) The plan has a contract with the State Medicaid agency to provide
benefits, or arrange for benefits to be provided, for which such individual
is entitled to receive as medical assistance under title XIX. Such benefits
may include long-term care services consistent with State policy.
`(4) ADDITIONAL REQUIREMENTS FOR SEVERE OR DISABLING CHRONIC CONDITION SNPS-
In the case of a specialized MA plan for special needs individuals described
in subsection (b)(6)(B)(iii), the applicable requirements described in this
paragraph are as follows:
`(A) Each individual that enrolls in the plan on or after January 1, 2010,
is a special needs individual described in subsection (b)(6)(B)(iii).
`(B) The plan meets the requirements described in paragraph (5).'.
(2) AUTHORITY TO OPERATE BUT NO SERVICE AREA EXPANSION FOR DUAL SNPS THAT
DO NOT MEET CERTAIN REQUIREMENTS- Notwithstanding subsection (f) of section
1859 of the Social Security Act (42 U.S.C. 1395w-28), during the period
beginning on January 1, 2010, and ending on December 31, 2010, in the case
of a specialized Medicare Advantage plan for special needs individuals described
in subsection (b)(6)(B)(ii) of such section, as amended by this section,
that does not meet the requirement described in subsection (f)(3)(D) of
such section, the Secretary of Health and Human Services--
(A) shall permit such plan to be offered under part C of title XVIII of
such Act; and
(B) shall not permit an expansion of the service area of the plan under
such part C.
(3) RESOURCES FOR STATE MEDICAID AGENCIES- The Secretary of Health and Human
Services shall provide for the designation of appropriate staff and resources
that can address State inquiries with respect to the coordination of State
and Federal policies for specialized MA plans for special needs individuals
described in section 1859(b)(6)(B)(ii) of the Social Security Act (42 U.S.C.
1395w-28(b)(6)(B)(ii)), as amended by this section.
(4) NO REQUIREMENT FOR CONTRACT- Nothing in the provisions of, or amendments
made by, this subsection shall require a State to enter into a contract
with a Medicare Advantage organization with respect to a specialized MA
plan for special needs individuals described in section 1859(b)(6)(B)(ii)
of the Social Security Act (42 U.S.C. 1395w-28(b)(6)(B)(ii)), as amended
by this section.
(d) Care Management Requirements for All SNPs-
(1) REQUIREMENTS- Section 1859(f) of the Social Security Act (42 U.S.C.
1395w-28(f)), as amended by subsection (c)(1), is amended by adding at the
end the following new paragraph:
`(5) CARE MANAGEMENT REQUIREMENTS FOR ALL SNPS- The requirements described
in this paragraph are that the organization offering a specialized MA plan
for special needs individuals described in subsection (b)(6)(B)(i)--
`(A) have in place an evidenced-based model of care with appropriate networks
of providers and specialists; and
`(B) with respect to each individual enrolled in the plan--
`(i) conduct an initial assessment and an annual reassessment of the
individual's physical, psychosocial, and functional needs;
`(ii) develop a plan, in consultation with the individual as feasible,
that identifies goals and objectives, including measurable outcomes
as well as specific services and benefits to be provided; and
`(iii) use an interdisciplinary team in the management of care.'.
(2) REVIEW TO ENSURE COMPLIANCE WITH CARE MANAGEMENT REQUIREMENTS- Section
1857(d) of the Social Security Act (42 U.S.C. 1395w-27(d)) is amended by
adding at the end the following new paragraph:
`(6) REVIEW TO ENSURE COMPLIANCE WITH CARE MANAGEMENT REQUIREMENTS FOR SPECIALIZED
MEDICARE ADVANTAGE PLANS FOR SPECIAL NEEDS INDIVIDUALS- In conjunction with
the periodic audit of a specialized Medicare Advantage plan for special
needs individuals under paragraph (1), the Secretary shall conduct a review
to ensure that such organization offering the plan meets the requirements
described in section 1859(f)(5).'.
(e) Clarification of the Definition of a Severe or Disabling Chronic Conditions
Specialized Needs Individual-
(1) IN GENERAL- Section 1859(b)(6)(B)(iii) of the Social Security Act (42
U.S.C. 1395w-28(b)(6)(B)(iii)) is amended by inserting `who have one or
more comorbid and medically complex chronic conditions that are substantially
disabling or life threatening, have a high risk of hospitalization or other
significant adverse health outcomes, and require specialized delivery systems
across domains of care' before the period at the end.
(2) PANEL- The Secretary of Health and Human Services shall convene a panel
of clinical advisors to determine the conditions that meet the definition
of severe and disabling chronic conditions under section 1859(b)(6)(B)(iii)
of the Social Security Act (42 U.S.C. 1395w-28(b)(6)(B)(iii)), as amended
by paragraph (1). The panel shall include the Director of the Agency for
Healthcare Research and Quality (or the Director's designee).
(f) Special Requirements Regarding Quality Reporting for Specialized MA Plans
for Special Needs Individuals-
(1) IN GENERAL- Section 1852(e)(3)(A) of the Social Security Act (42 U.S.C.
1395w-22(e)(3)(A)), as amended by section 163, is amended by inserting after
clause (i) the following new clause:
`(ii) SPECIAL REQUIREMENTS FOR SPECIALIZED MA PLANS FOR SPECIAL NEEDS
INDIVIDUALS- In addition to the data required to be collected, analyzed,
and reported under clause (i) and notwithstanding the limitations under
subparagraph (B), as part of the quality improvement program under paragraph
(1), each MA organization offering a specialized Medicare Advantage
plan for special needs individuals shall provide for the collection,
analysis, and reporting of data that permits the measurement of health
outcomes and other indices of quality with respect to the requirements
described in paragraphs (2) through (5) of subsection (f). Such data
may be based on claims data and shall be at the plan level.'.
(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall take effect
on a date specified by the Secretary of Health and Human Services (but in
no case later than January 1, 2010), and shall apply to all specialized
Medicare Advantage plans for special needs individuals regardless of when
the plan first entered the Medicare Advantage program under part C of title
XVIII of the Social Security Act.
(g) Effective Date and Application- The amendments made by subsections (c)(1),
(d), and (e)(1) shall apply to plan years beginning on or after January 1,
2010, and shall apply to all specialized Medicare Advantage plans for special
needs individuals regardless of when the plan first entered the Medicare Advantage
program under part C of title XVIII of the Social Security Act.
(h) No Affect on Medicaid Benefits for Duals- Nothing in the provisions of,
or amendments made by, this section shall affect the benefits available under
the Medicaid program under title XIX of the Social Security Act for special
needs individuals described in section 1859(b)(6)(B)(ii) of such Act (42 U.S.C.
1395w-28(b)(6)(B)(ii)).
SEC. 165. LIMITATION ON OUT-OF-POCKET COSTS FOR DUAL ELIGIBLES AND QUALIFIED
MEDICARE BENEFICIARIES ENROLLED IN A SPECIALIZED MEDICARE ADVANTAGE PLAN FOR
SPECIAL NEEDS INDIVIDUALS.
(a) In General- Section 1852(a) of the Social Security Act (42 U.S.C. 1395w-22(a))
is amended by adding at the end the following new paragraph:
`(7) LIMITATION ON COST-SHARING FOR DUAL ELIGIBLES AND QUALIFIED MEDICARE
BENEFICIARIES- In the case of an individual who is a full-benefit dual eligible
individual (as defined in section 1935(c)(6)) or a qualified medicare beneficiary
(as defined in section 1905(p)(1)) and who is enrolled in a specialized
Medicare Advantage plan for special needs individuals described in section
1859(b)(6)(B)(ii), the plan may not impose cost-sharing that exceeds the
amount of cost-sharing that would be permitted with respect to the individual
under title XIX if the individual were not enrolled in such plan.'.
(b) Effective Date- The amendment made by subsection (a) shall apply to plan
years beginning on or after January 1, 2010.
SEC. 166. ADJUSTMENT TO THE MEDICARE ADVANTAGE STABILIZATION FUND.
Section 1858(e)(2)(A)(i) of the Social Security Act (42 U.S.C. 1395w-27a(e)(2)(A)(i)),
as amended by section 110 of the Medicare, Medicaid, and SCHIP Extension Act
of 2007 (Public Law 110-173), is amended--
(1) by striking `2013' and inserting `2014'; and
(2) by striking `$1,790,000,000' and inserting `$1'.
SEC. 167. ACCESS TO MEDICARE REASONABLE COST CONTRACT PLANS.
(a) Extension of Reasonable Cost Contracts- Section 1876(h)(5)(C)(ii) of the
Social Security Act (42 U.S.C. 1395mm(h)(5)(C)(ii)), as amended by section
109 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law
110-173), is amended by striking `January 1, 2009' and inserting `January
1, 2010' in the matter preceding subclause (I).
(b) Requirement for at Least Two Medicare Advantage Organizations To Be Offering
a Plan in an Area for the Prohibition To Be Applicable- Subclauses (I) and
(II) of section 1876(h)(5)(C)(ii) of the Social Security Act (42 U.S.C. 1395mm(h)(5)(C)(ii))
are each amended by inserting `, provided that all such plans are not offered
by the same Medicare Advantage organization' after `clause (iii)'.
(c) Revision of Requirements for a Plan That Are Used To Determine if Prohibition
Is Applicable-
(1) IN GENERAL- Section 1876(h)(5)(C)(iii)(I) of the Social Security Act
(42 U.S.C. 1395mm(h)(5)(C)(iii)(I)) is amended by inserting `that are not
in another Metropolitan Statistical Area with a population of more than
250,000' after `such Metropolitan Statistical Area'.
(2) CLARIFICATION- Section 1876(h)(5)(C)(iii)(I) of the Social Security
Act (42 U.S.C. 1395mm(h)(5)(C)(iii)(I)) is amended by adding at the end
the following new sentence: `If the service area includes a portion in more
than 1 Metropolitan Statistical Area with a population of more than 250,000,
the minimum enrollment determination under the preceding sentence shall
be made with respect to each such Metropolitan Statistical Area (and such
applicable contiguous counties to such Metropolitan Statistical Area).'.
(d) GAO Study and Report-
(1) STUDY- The Comptroller General of the United States shall conduct a
study of the reasons (if any) why reasonable cost contracts under section
1876(h) of the Social Security Act (42 U.S.C. 1395mm(h)) are unable to become
Medicare Advantage plans under part C of title XVIII of such Act.
(2) REPORT- Not later than December 31, 2009, the Comptroller General of
the United States shall submit to Congress a report containing the results
of the study conducted under paragraph (1), together with recommendations
for such legislation and administrative action as the Comptroller General
determines appropriate.
SEC. 168. MEDPAC STUDY AND REPORT ON QUALITY MEASURES.
(a) Study- The Medicare Payment Advisory Commission shall conduct a study
on how comparable measures of performance and patient experience can be collected
and reported by 2011 for the Medicare Advantage program under part C of title
XVIII of the Social Security Act and the original Medicare fee-for-service
program under parts A and B of such title. Such study shall address technical
issues, such as data requirements, in addition to issues relating to appropriate
quality benchmarks that--
(1) compare the quality of care Medicare beneficiaries receive across Medicare
Advantage plans; and
(2) compare the quality of care Medicare beneficiaries receive under Medicare
Advantage plans and under the original Medicare fee-for-service program.
(b) Report- Not later than March 31, 2010, the Medicare Payment Advisory Commission
shall submit to Congress a report containing the results of the study conducted
under subsection (a), together with recommendations for such legislation and
administrative action as the Medicare Payment Advisory Commission determines
appropriate.
SEC. 169. MEDPAC STUDY AND REPORT ON MEDICARE ADVANTAGE PAYMENTS.
(a) Study- The Medicare Payment Advisory Commission (in this section referred
to as the `Commission') shall conduct a study of the following:
(1) The correlation between--
(A) the costs that Medicare Advantage organizations with respect to Medicare
Advantage plans incur in providing coverage under the plan for items and
services covered under the original Medicare fee-for-service program under
parts A and B of title XVIII of the Social Security Act, as reflected
in plan bids; and
(B) county-level spending under such original Medicare fee-for-service
program on a per capita basis, as calculated by the Chief Actuary of the
Centers for Medicare & Medicaid Services.
The study with respect to the issue described in the preceding sentence
shall include differences in correlation statistics by plan type and geographic
area.
(2) Based on these results of the study with respect to the issue described
in paragraph (1), and other data the Commission determines appropriate--
(A) alternate approaches to payment with respect to a Medicare beneficiary
enrolled in a Medicare Advantage plan other than through county-level
payment area equivalents.
(B) the accuracy and completeness of county-level estimates of per capita
spending under such original Medicare fee-for-service program (including
counties in Puerto Rico), as used to determine the annual Medicare Advantage
capitation rate under section 1853 of the Social Security Act (42 U.S.C.
1395w-23), and whether such estimates include--
(i) expenditures with respect to Medicare beneficiaries at facilities
of the Department of Veterans Affairs; and
(ii) all appropriate administrative expenses, including claims processing.
(3) Ways to improve the accuracy and completeness of county-level estimates
of per capita spending described in paragraph (2)(B).
(b) Report- Not later than March 31, 2010, the Commission shall submit to
Congress a report containing the results of the study conducted under subsection
(a), together with recommendations for such legislation and administrative
action as the Commission determines appropriate.
Subtitle E--Provisions Relating to Part D
PART I--IMPROVING PHARMACY ACCESS
SEC. 171. PROMPT PAYMENT BY PRESCRIPTION DRUG PLANS AND MA-PD PLANS UNDER
PART D.
(a) Prompt Payment by Prescription Drug Plans- Section 1860D-12(b) of the
Social Security Act (42 U.S.C. 1395w-112(b)) is amended by adding at the end
the following new paragraph:
`(4) PROMPT PAYMENT OF CLEAN CLAIMS-
`(i) IN GENERAL- Each contract entered into with a PDP sponsor under
this part with respect to a prescription drug plan offered by such sponsor
shall provide that payment shall be issued, mailed, or otherwise transmitted
with respect to all clean claims submitted by pharmacies (other than
pharmacies that dispense drugs by mail order only or are located in,
or contract with, a long-term care facility) under this part within
the applicable number of calendar days after the date on which the claim
is received.
`(ii) CLEAN CLAIM DEFINED- In this paragraph, the term `clean claim'
means a claim that has no defect or impropriety (including any lack
of any required substantiating documentation) or particular circumstance
requiring special treatment that prevents timely payment from being
made on the claim under this part.
`(iii) DATE OF RECEIPT OF CLAIM- In this paragraph, a claim is considered
to have been received--
`(I) with respect to claims submitted electronically, on the date
on which the claim is transferred; and
`(II) with respect to claims submitted otherwise, on the 5th day after
the postmark date of the claim or the date specified in the time stamp
of the transmission.
`(B) APPLICABLE NUMBER OF CALENDAR DAYS DEFINED- In this paragraph, the
term `applicable number of calendar days' means--
`(i) with respect to claims submitted electronically, 14 days; and
`(ii) with respect to claims submitted otherwise, 30 days.
`(i) IN GENERAL- Subject to clause (ii), if payment is not issued, mailed,
or otherwise transmitted within the applicable number of calendar days
(as defined in subparagraph (B)) after a clean claim is received, the
PDP sponsor shall pay interest to the pharmacy that submitted the claim
at a rate equal to the weighted average of interest on 3-month marketable
Treasury securities determined for such period, increased by 0.1 percentage
point for the period beginning on the day after the required payment
date and ending on the date on which payment is made (as determined
under subparagraph (D)(iv)). Interest amounts paid under this subparagraph
shall not be counted against the administrative costs of a prescription
drug plan or treated as allowable risk corridor costs under section
1860D-15(e).
`(ii) AUTHORITY NOT TO CHARGE INTEREST- The Secretary may provide that
a PDP sponsor is not charged interest under clause (i) in the case where
there are exigent circumstances, including natural disasters and other
unique and unexpected events, that prevent the timely processing of
claims.
`(D) PROCEDURES INVOLVING CLAIMS-
`(i) CLAIM DEEMED TO BE CLEAN- A claim is deemed to be a clean claim
if the PDP sponsor involved does not provide notice to the claimant
of any deficiency in the claim--
`(I) with respect to claims submitted electronically, within 10 days
after the date on which the claim is received; and
`(II) with respect to claims submitted otherwise, within 15 days after
the date on which the claim is received.
`(ii) CLAIM DETERMINED TO NOT BE A CLEAN CLAIM-
`(I) IN GENERAL- If a PDP sponsor determines that a submitted claim
is not a clean claim, the PDP sponsor shall, not later than the end
of the period described in clause (i), notify the claimant of such
determination. Such notification shall specify all defects or improprieties
in the claim and shall list all additional information or documents
necessary for the proper processing and payment of the claim.
`(II) DETERMINATION AFTER SUBMISSION OF ADDITIONAL INFORMATION- A
claim is deemed to be a clean claim under this paragraph if the PDP
sponsor involved does not provide notice to the claimant of any defect
or impropriety in the claim within 10 days of the date on which additional
information is received under subclause (I).
`(iii) OBLIGATION TO PAY- A claim submitted to a PDP sponsor that is
not paid or contested by the sponsor within the applicable number of
days (as defined in subparagraph (B)) after the date on which the claim
is received shall be deemed to be a clean claim and shall be paid by
the PDP sponsor in accordance with subparagraph (A).
`(iv) DATE OF PAYMENT OF CLAIM- Payment of a clean claim under such
subparagraph is considered to have been made on the date on which--
`(I) with respect to claims paid electronically, the payment is transferred;
and
`(II) with respect to claims paid otherwise, the payment is submitted
to the United States Postal Service or common carrier for delivery.
`(E) ELECTRONIC TRANSFER OF FUNDS- A PDP sponsor shall pay all clean claims
submitted electronically by electronic transfer of funds if the pharmacy
so requests or has so requested previously. In the case where such payment
is made electronically, remittance may be made by the PDP sponsor electronically
as well.
`(F) PROTECTING THE RIGHTS OF CLAIMANTS-
`(i) IN GENERAL- Nothing in this paragraph shall be construed to prohibit
or limit a claim or action not covered by the subject matter of this
section that any individual or organization has against a provider or
a PDP sponsor.
`(ii) ANTI-RETALIATION- Consistent with applicable Federal or State
law, a PDP sponsor shall not retaliate against an individual or provider
for exercising a right of action under this subparagraph.
`(G) RULE OF CONSTRUCTION- A determination under this paragraph that a
claim submitted by a pharmacy is a clean claim shall not be construed
as a positive determination regarding eligibility for payment under this
title, nor is it an indication of government approval of, or acquiescence
regarding, the claim submitted. The determination shall not relieve any
party of civil or criminal liability with respect to the claim, nor does
it offer a defense to any administrative, civil, or criminal action with
respect to the claim.'.
(b) Prompt Payment by MA-PD Plans- Section 1857(f) of the Social Security
Act (42 U.S.C. 1395w-27) is amended by adding at the end the following new
paragraph:
`(3) INCORPORATION OF CERTAIN PRESCRIPTION DRUG PLAN CONTRACT REQUIREMENTS-
The following provisions shall apply to contracts with a Medicare Advantage
organization offering an MA-PD plan in the same manner as they apply to
contracts with a PDP sponsor offering a prescription drug plan under part
D:
`(A) PROMPT PAYMENT- Section 1860D-12(b)(4).'.
(c) Effective Date- The amendments made by this section shall apply to plan
years beginning on or after January 1, 2010.
SEC. 172. SUBMISSION OF CLAIMS BY PHARMACIES LOCATED IN OR CONTRACTING WITH
LONG-TERM CARE FACILITIES.
(a) Submission of Claims by Pharmacies Located in or Contracting With Long-Term
Care Facilities-
(1) SUBMISSION OF CLAIMS TO PRESCRIPTION DRUG PLANS- Section 1860D-12(b)
of the Social Security Act (42 U.S.C. 1395w-112(b)), as amended by section
171(a), is amended by adding at the end the following new paragraph:
`(5) SUBMISSION OF CLAIMS BY PHARMACIES LOCATED IN OR CONTRACTING WITH LONG-TERM
CARE FACILITIES- Each contract entered into with a PDP sponsor under this
part with respect to a prescription drug plan offered by such sponsor shall
provide that a pharmacy located in, or having a contract with, a long-term
care facility shall have not less than 30 days (but not more than 90 days)
to submit claims to the sponsor for reimbursement under the plan.'.
(2) SUBMISSION OF CLAIMS TO MA-PD PLANS- Section 1857(f)(3) of the Social
Security Act, as added by section 171(b), is amended by adding at the end
the following new subparagraph:
`(B) SUBMISSION OF CLAIMS BY PHARMACIES LOCATED IN OR CONTRACTING WITH
LONG-TERM CARE FACILITIES- Section 1860D-12(b)(5).'.
(b) Effective Date- The amendments made by this section shall apply to plan
years beginning on or after January 1, 2010.
SEC. 173. REGULAR UPDATE OF PRESCRIPTION DRUG PRICING STANDARD.
(a) Requirement for Prescription Drug Plans- Section 1860D-12(b) of the Social
Security Act (42 U.S.C. 1395w-112(b)), as amended by section 172(a)(1), is
amended by adding at the end the following new paragraph:
`(6) REGULAR UPDATE OF PRESCRIPTION DRUG PRICING STANDARD- If the PDP sponsor
of a prescription drug plan uses a standard for reimbursement of pharmacies
based on the cost of a drug, each contract entered into with such sponsor
under this part with respect to the plan shall provide that the sponsor
shall update such standard not less frequently than once every 7 days, beginning
with an initial update on January 1 of each year, to accurately reflect
the market price of acquiring the drug.'.
(b) Requirement for MA-PD Plans- Section 1857(f)(3) of the Social Security
Act, as amended by section 172(a)(2), is amended by adding at the end the
following new subparagraph:
`(C) REGULAR UPDATE OF PRESCRIPTION DRUG PRICING STANDARD- Section 1860D-12(b)(6).'.
(c) Effective Date- The amendments made by this section shall apply to plan
years beginning on or after January 1, 2009.
PART II--OTHER PROVISIONS
SEC. 175. INCLUSION OF BARBITURATES AND BENZODIAZEPINES AS COVERED PART
D DRUGS.
(a) In General- Section 1860D-2(e)(2)(A) of the Social Security Act (42 U.S.C.
1395w-102(e)(2)(A)) is amended by inserting after `agents),' the following
`other than subparagraph (I) of such section (relating to barbiturates) if
the barbiturate is used in the treatment of epilepsy, cancer, or a chronic
mental health disorder, and other than subparagraph (J) of such section (relating
to benzodiazepines),'.
(b) Effective Date- The amendments made by subsection (a) shall apply to prescriptions
dispensed on or after January 1, 2012.
SEC. 176. FORMULARY REQUIREMENTS WITH RESPECT TO CERTAIN CATEGORIES OR CLASSES
OF DRUGS.
Section 1860D-4(b)(3) of the Social Security Act (42 U.S.C. 1395w-104(b)(3))
is amended--
(1) in subparagraph (C)(i), by striking `The formulary' and inserting `Subject
to subparagraph (G), the formulary'; and
(2) by inserting after subparagraph (F) the following new subparagraph:
`(G) REQUIRED INCLUSION OF DRUGS IN CERTAIN CATEGORIES AND CLASSES-
`(i) IDENTIFICATION OF DRUGS IN CERTAIN CATEGORIES AND CLASSES- Beginning
with plan year 2010, the Secretary shall identify, as appropriate, categories
and classes of drugs for which both of the following criteria are met:
`(I) Restricted access to drugs in the category or class would have
major or life threatening clinical consequences for individuals who
have a disease or disorder treated by the drugs in such category or
class.
`(II) There is significant clinical need for such individuals to have
access to multiple drugs within a category or class due to unique
chemical actions and pharmacological effects of the drugs within the
category or class, such as drugs used in the treatment of cancer.
`(ii) FORMULARY REQUIREMENTS- Subject to clause (iii), PDP sponsors
offering prescription drug plans shall be required to include all covered
part D drugs in the categories and classes identified by the Secretary
under clause (i).
`(iii) EXCEPTIONS- The Secretary may establish exceptions that permits
a PDP sponsor of a prescription drug plan to exclude from its formulary
a particular covered part D drug in a category or class that is otherwise
required to be included in the formulary under clause (ii) (or to otherwise
limit access to such a drug). Any exceptions established under the preceding
sentence shall be provided under a process that--
`(I) ensures that any exception to such requirement is based upon
scientific evidence and medical standards of practice; and
`(II) includes a public notice and comment period.'.
Subtitle F--Other Provisions
SEC. 181. USE OF PART D DATA.
Section 1860D-12(b)(3)(D) of the Social Security Act (42 U.S.C. 1395w-112(b)(3)(D))
is amended by adding at the end the following sentence: `Notwithstanding any
other provision of law, information provided to the Secretary under the application
of section 1857(e)(1) to contracts under this section under the preceding
sentence may be used for the purposes of carrying out this part, improving
public health through research on the utilization, safety, effectiveness,
quality, and efficiency of health care services (as the Secretary determines
appropriate), and conducting Congressional oversight, monitoring, and analysis
of the program under this title.'.
SEC. 182. REVISION OF DEFINITION OF MEDICALLY ACCEPTED INDICATION FOR DRUGS.
(a) Revision of Definition for Part D Drugs-
(1) IN GENERAL- Section 1860D-2(e)(1) of the Social Security Act (42 U.S.C.
1395w-102(e)(1)) is amended, in the matter following subparagraph (B)--
(A) by striking `(as defined in section 1927(k)(6))' and inserting `(as
defined in paragraph (4))'; and
(B) by adding at the end the following new paragraph:
`(4) MEDICALLY ACCEPTED INDICATION DEFINED-
`(A) IN GENERAL- For purposes of paragraph (1), the term `medically accepted
indication' has the meaning given that term--
`(i) in the case of a covered part D drug used in an anticancer chemotherapeutic
regimen, in section 1861(t)(2)(B), except that in applying such section--
`(I) `prescription drug plan or MA-PD plan' shall be substituted for
`carrier' each place it appears; and
`(II) subject to subparagraph (B), the compendia described in section
1927(g)(1)(B)(i)(III) shall be included in the list of compendia described
in clause (ii)(I) section 1861(t)(2)(B); and
`(ii) in the case of any other covered part D drug, in section 1927(k)(6).
`(B) CONFLICT OF INTEREST- On and after January 1, 2010, subparagraph
(A)(i)(II) shall not apply unless the compendia described in section 1927(g)(1)(B)(i)(III)
meets the requirement in the third sentence of section 1861(t)(2)(B).
`(C) UPDATE- For purposes of applying subparagraph (A)(ii), the Secretary
shall revise the list of compendia described in section 1927(g)(1)(B)(i)
as is appropriate for identifying medically accepted indications for drugs.
Any such revision shall be done in a manner consistent with the process
for revising compendia under section 1861(t)(2)(B).'.
(2) EFFECTIVE DATE- The amendments made by this subsection shall apply to
plan years beginning on or after January 1, 2009.
(b) Conflicts of Interest- Section 1861(t)(2)(B) of the Social Security Act
(42 U.S.C. 1395x(t)(2)(B)) is amended by adding at the end the following new
sentence: `On and after January 1, 2010, no compendia may be included on the
list of compendia under this subparagraph unless the compendia has a publicly
transparent process for evaluating therapies and for identifying potential
conflicts of interests.'.
SEC. 183. CONTRACT WITH A CONSENSUS-BASED ENTITY REGARDING PERFORMANCE MEASUREMENT.
(1) IN GENERAL- Part E of title XVIII of the Social Security Act (42 U.S.C.
1395x et seq.) is amended by inserting after section 1889 the following
new section:
`CONTRACT WITH A CONSENSUS-BASED ENTITY REGARDING PERFORMANCE MEASUREMENT
`Sec. 1890. (a) Contract-
`(1) IN GENERAL- For purposes of activities conducted under this Act, the
Secretary shall identify and have in effect a contract with a consensus-based
entity, such as the National Quality Forum, that meets the requirements
described in subsection (c). Such contract shall provide that the entity
will perform the duties described in subsection (b).
`(2) TIMING FOR FIRST CONTRACT- As soon as practicable after the date of
the enactment of this subsection, the Secretary shall enter into the first
contract under paragraph (1).
`(3) PERIOD OF CONTRACT- A contract under paragraph (1) shall be for a period
of 4 years (except as may be renewed after a subsequent bidding process).
`(4) COMPETITIVE PROCEDURES- Competitive procedures (as defined in section
4(5) of the Office of Federal Procurement Policy Act (41 U.S.C. 403(5)))
shall be used to enter into a contract under paragraph (1).
`(b) Duties- The duties described in this subsection are the following:
`(1) PRIORITY SETTING PROCESS- The entity shall synthesize evidence and
convene key stakeholders to make recommendations, with respect to activities
conducted under this Act, on an integrated national strategy and priorities
for health care performance measurement in all applicable settings. In making
such recommendations, the entity shall--
`(A) ensure that priority is given to measures--
`(i) that address the health care provided to patients with prevalent,
high-cost chronic diseases;
`(ii) with the greatest potential for improving the quality, efficiency,
and patient-centeredness of health care; and
`(iii) that may be implemented rapidly due to existing evidence, standards
of care, or other reasons; and
`(B) take into account measures that--
`(i) may assist consumers and patients in making informed health care
decisions;
`(ii) address health disparities across groups and areas; and
`(iii) address the continuum of care a patient receives, including services
furnished by multiple health care providers or practitioners and across
multiple settings.
`(2) ENDORSEMENT OF MEASURES- The entity shall provide for the endorsement
of standardized health care performance measures. The endorsement process
under the preceding sentence shall consider whether a measure--
`(A) is evidence-based, reliable, valid, verifiable, relevant to enhanced
health outcomes, actionable at the caregiver level, feasible to collect
and report, and responsive to variations in patient characteristics, such
as health status, language capabilities, race or ethnicity, and income
level; and
`(B) is consistent across types of health care providers, including hospitals
and physicians.
`(3) MAINTENANCE OF MEASURES- The entity shall establish and implement a
process to ensure that measures endorsed under paragraph (2) are updated
(or retired if obsolete) as new evidence is developed.
`(4) PROMOTION OF THE DEVELOPMENT OF ELECTRONIC HEALTH RECORDS- The entity
shall promote the development and use of electronic health records that
contain the functionality for automated collection, aggregation, and transmission
of performance measurement information.
`(5) ANNUAL REPORT TO CONGRESS AND THE SECRETARY; SECRETARIAL PUBLICATION
AND COMMENT-
`(A) ANNUAL REPORT- By not later than March 1 of each year (beginning
with 2009), the entity shall submit to Congress and the Secretary a report
containing a description of--
`(i) the implementation of quality measurement initiatives under this
Act and the coordination of such initiatives with quality initiatives
implemented by other payers;
`(ii) the recommendations made under paragraph (1); and
`(iii) the performance by the entity of the duties required under the
contract entered into with the Secretary under subsection (a).
`(B) SECRETARIAL REVIEW AND PUBLICATION OF ANNUAL REPORT- Not later than
6 months after receiving a report under subparagraph (A) for a year, the
Secretary shall--
`(i) review such report; and
`(ii) publish such report in the Federal Register, together with any
comments of the Secretary on such report.
`(c) Requirements Described- The requirements described in this subsection
are the following:
`(1) PRIVATE NONPROFIT- The entity is a private nonprofit entity governed
by a board.
`(2) BOARD MEMBERSHIP- The members of the board of the entity include--
`(A) representatives of health plans and health care providers and practitioners
or representatives of groups representing such health plans and health
care providers and practitioners;
`(B) health care consumers or representatives of groups representing health
care consumers; and
`(C) representatives of purchasers and employers or representatives of
groups representing purchasers or employers.
`(3) ENTITY MEMBERSHIP- The membership of the entity includes persons who
have experience with--
`(A) urban health care issues;
`(B) safety net health care issues;
`(C) rural and frontier health care issues; and
`(D) health care quality and safety issues.
`(4) OPEN AND TRANSPARENT- With respect to matters related to the contract
with the Secretary under subsection (a), the entity conducts its business
in an open and transparent manner and provides the opportunity for public
comment on its activities.
`(5) VOLUNTARY CONSENSUS STANDARDS SETTING ORGANIZATION- The entity operates
as a voluntary consensus standards setting organization as defined for purposes
of section 12(d) of the National Technology Transfer and Advancement Act
of 1995 (Public Law 104-113) and Office of Management and Budget Revised
Circular A-119 (published in the Federal Register on February 10, 1998).
`(6) EXPERIENCE- The entity has at least 4 years of experience in establishing
national consensus standards.
`(7) MEMBERSHIP FEES- If the entity requires a membership fee for participation
in the functions of the entity, such fees shall be reasonable and adjusted
based on the capacity of the potential member to pay the fee. In no case
shall membership fees pose a barrier to the participation of individuals
or groups with low or nominal resources to participate in the functions
of the entity.
`(d) Funding- For purposes of carrying out this section, 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),
of $10,000,000 to the Centers for Medicare & Medicaid Services Program
Management Account for each of fiscal years 2009 through 2012.'.
(2) SENSE OF THE SENATE- It is the Sense of the Senate that the selection
by the Secretary of Health and Human Services of an entity to contract with
under section 1890(a) of the Social Security Act, as added by paragraph
(1), should not be construed as diminishing the significant contributions
of the Boards of Medicine, the quality alliances, and other clinical and
technical experts to efforts to measure and improve the quality of health
care services.
(b) GAO Study and Reports on the Performance and Costs of the Consensus-Based
Entity Under the Contract-
(1) IN GENERAL- The Comptroller General of the United States shall conduct
a study on--
(A) the performance of the entity with a contract with the Secretary of
Health and Human Services under section 1890(a) of the Social Security
Act, as added by subsection (a), of its duties under such contract; and
(B) the costs incurred by such entity in performing such duties.
(2) REPORTS- Not later than 18 months and 36 months after the effective
date of the first contract entered into under such section 1890(a), the
Comptroller General of the United States shall submit to Congress a report
containing the results of the study conducted under paragraph (1), together
with recommendations for such legislation and administrative action as the
Comptroller General determines appropriate.
SEC. 184. COST-SHARING FOR CLINICAL TRIALS.
Section 1833 of the Social Security Act (42 U.S.C. 1395l), as amended by section
152(a), is amended by adding at the end the following new subsection:
`(x) Methods of Payment- The Secretary may develop alternative methods of
payment for items and services provided under clinical trials and comparative
effectiveness studies sponsored or supported by an agency of the Department
of Health and Human Services, as determined by the Secretary, to those that
would otherwise apply under this section, to the extent such alternative methods
are necessary to preserve the scientific validity of such trials or studies,
such as in the case where masking the identity of interventions from patients
and investigators is necessary to comply with the particular trial or study
design.'.
SEC. 185. ADDRESSING HEALTH CARE DISPARITIES.
Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is amended
by inserting after section 1808 the following new section:
`ADDRESSING HEALTH CARE DISPARITIES
`Sec. 1809. (a) Evaluating Data Collection Approaches- The Secretary shall
evaluate approaches for the collection of data under this title, to be performed
in conjunction with existing quality reporting requirements and programs under
this title, that allow for the ongoing, accurate, and timely collection and
evaluation of data on disparities in health care services and performance
on the basis of race, ethnicity, and gender. In conducting such evaluation,
the Secretary shall consider the following objectives:
`(1) Protecting patient privacy.
`(2) Minimizing the administrative burdens of data collection and reporting
on providers and health plans participating under this title.
`(3) Improving Medicare program data on race, ethnicity, and gender.
`(b) Reports to Congress-
`(1) REPORT ON EVALUATION- Not later than 18 months after the date of the
enactment of this section, the Secretary shall submit to Congress a report
on the evaluation conducted under subsection (a). Such report shall, taking
into consideration the results of such evaluation--
`(A) identify approaches (including defining methodologies) for identifying
and collecting and evaluating data on health care disparities on the basis
of race, ethnicity, and gender for the original Medicare fee-for-service
program under parts A and B, the Medicare Advantage program under part
C, and the Medicare prescription drug program under part D; and
`(B) include recommendations on the most effective strategies and approaches
to reporting HEDIS quality measures as required under section 1852(e)(3)
and other nationally recognized quality performance measures, as appropriate,
on the basis of race, ethnicity, and gender.
`(2) REPORTS ON DATA ANALYSES- Not later than 4 years after the date of
the enactment of this section, and 4 years thereafter, the Secretary shall
submit to Congress a report that includes recommendations for improving
the identification of health care disparities for Medicare beneficiaries
based on analyses of the data collected under subsection (c).
`(c) Implementing Effective Approaches- Not later than 24 months after the
date of the enactment of this section, the Secretary shall implement the approaches
identified in the report submitted under subsection (b)(1) for the ongoing,
accurate, and timely collection and evaluation of data on health care disparities
on the basis of race, ethnicity, and gender.'.
SEC. 186. DEMONSTRATION TO IMPROVE CARE TO PREVIOUSLY UNINSURED.
(a) Establishment- Within one year after the date of the enactment of this
Act, the Secretary (in this section referred to as the `Secretary') shall
establish a demonstration project to determine the greatest needs and most
effective methods of outreach to medicare beneficiaries who were previously
uninsured.
(b) Scope- The demonstration shall be in no fewer than 10 sites, and shall
include state health insurance assistance programs, community health centers,
community-based organizations, community health workers, and other service
providers under parts A, B, and C of title XVIII of the Social Security Act.
Grantees that are plans operating under part C shall document that enrollees
who were previously uninsured receive the `Welcome to Medicare' physical exam.
(c) Duration- The Secretary shall conduct the demonstration project for a
period of 2 years.
(d) Report and Evaluation- The Secretary shall conduct an evaluation of the
demonstration and not later than 1 year after the completion of the project
shall submit to Congress a report including the following:
(1) An analysis of the effectiveness of outreach activities targeting beneficiaries
who were previously uninsured, such as revising outreach and enrollment
materials (including the potential for use of video information), providing
one-on-one counseling, working with community health workers, and amending
the Medicare and You handbook.
(2) The effect of such outreach on beneficiary access to care, utilization
of services, efficiency and cost-effectiveness of health care delivery,
patient satisfaction, and select health outcomes.
SEC. 187. OFFICE OF THE INSPECTOR GENERAL REPORT ON COMPLIANCE WITH AND
ENFORCEMENT OF NATIONAL STANDARDS ON CULTURALLY AND LINGUISTICALLY APPROPRIATE
SERVICES (CLAS) IN MEDICARE.
(a) Report- Not later than two years after the date of the enactment of this
Act, the Inspector General of the Department of Health and Human Services
shall prepare and publish a report on--
(1) the extent to which Medicare providers and plans are complying with
the Office for Civil Rights' Guidance to Federal Financial Assistance Recipients
Regarding Title VI Prohibition Against National Origin Discrimination Affecting
Limited English Proficient Persons and the Office of Minority Health's Culturally
and Linguistically Appropriate Services Standards in health care; and
(2) a description of the costs associated with or savings related to the
provision of language services.
Such report shall include recommendations on improving compliance with CLAS
Standards and recommendations on improving enforcement of CLAS Standards.
(b) Implementation- Not later than one year after the date of publication
of the report under subsection (a), the Department of Health and Human Services
shall implement changes responsive to any deficiencies identified in the report.
SEC. 188. MEDICARE IMPROVEMENT FUNDING.
(a) Medicare Improvement Fund- Title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) is amended by adding at the end the following new section:
`MEDICARE IMPROVEMENT FUND
`Sec. 1898. (a) Establishment-
`The Secretary shall establish under this title a Medicare Improvement Fund
(in this section referred to as the `Fund') which shall be available to
the Secretary to make improvements under the original fee-for-service program
under parts A and B for individuals entitled to, or enrolled for, benefits
under part A or enrolled under part B.
`(1) IN GENERAL- There shall be available to the Fund, for expenditures
from the Fund for services furnished during fiscal years 2013-2017, $22,450,000,000.
`(2) PAYMENT FROM TRUST FUNDS- The amount specified under paragraph (1)
shall be available to the Fund, as expenditures are made from the Fund,
from the Federal Hospital Insurance Trust Fund and the Federal Supplementary
Medical Insurance Trust Fund in such proportion as the Secretary determines
appropriate.
`(3) FUNDING LIMITATION- Amounts in the Fund shall be available in advance
of appropriations but only if the total amount obligated from the Fund does
not exceed the amount available to the Fund under paragraph (1). The Secretary
may obligate funds from the Fund only if the Secretary determines (and the
Chief Actuary of the Centers for Medicare & Medicaid Services and the
appropriate budget officer certify) that there are available in the Fund
sufficient amounts to cover all such obligations incurred consistent with
the previous sentence.'.
(b) Implementation- For purposes of carrying out the provisions of, and amendments
made by, this Act, in addition to any other amounts provided in such provisions
and amendments, the Secretary of Health and Human Services 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
Medical Insurance Trust Fund under section 1841 of such Act (42 U.S.C. 1395t),
in the same proportion as the Secretary determines under section 1853(f) of
such Act (42 U.S.C. 1395w-23(f)), of $140,000,000 to the Centers for Medicare
& Medicaid Services Program Management Account for the period of fiscal
years 2009 through 2013.
TITLE II--MEDICAID
SEC. 201. EXTENSION OF TRANSITIONAL MEDICAL ASSISTANCE (TMA).
Section 401 of division B of the Tax Relief and Health Care Act of 2006 (Public
Law 109-432, 120 Stat. 2994), as amended by section 1 of Public Law 110-48
(121 Stat. 244), section 2 of the TMA, Abstinence, Education, and QI Programs
Extension Act of 2007 (Public Law 110-90, 121 Stat. 984), and section 202
of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173)
is amended--
(1) by inserting after `June 30, 2008' the following `(or, in the case of
section 1925, through December 31, 2009)';
(2) by inserting after `the third quarter of fiscal year 2008' the following:
`(or, in the case of such section 1925, the first quarter of fiscal year
2010)'; and
(3) by inserting after `the third quarter of fiscal year 2007' the following:
`(or, in the case of such section 1925, the first quarter of fiscal year
2008)'.
SEC. 202. MEDICAID DSH EXTENSION.
Section 1923(f)(6) of the Social Security Act (42 U.S.C. 1396r-4(f)(6)) is
amended--
(1) in the heading, by striking `FISCAL YEAR 2007 AND PORTIONS OF FISCAL
YEAR 2008' and inserting `FISCAL YEARS 2007 THROUGH 2009 AND THE FIRST CALENDAR
QUARTER OF FISCAL YEAR 2010'; and
(2) in subparagraph (A)--
(i) in the second sentence--
(I) by striking `fiscal year 2008 for the period ending on June 30,
2008' and inserting `fiscal years 2008 and 2009'; and
(II) by striking ` 3/4 of'; and
(ii) by adding at the end the following new sentences: `Only with respect
to fiscal year 2010 for the period ending on December 31, 2009, the
DSH allotment for Tennessee for such portion of the fiscal year, notwithstanding
such table or terms, shall be 1/4 of the amount specified in the first
sentence for fiscal year 2007.';
(B) in clause (ii), by striking `or for a period in fiscal year 2008'
and inserting `, 2008, 2009, or for a period in fiscal year 2010';
(i) in the heading, by striking `FISCAL YEAR 2007 AND FISCAL YEAR 2008'
and inserting `FISCAL YEARS 2007 THROUGH 2009 AND THE FIRST CALENDAR
QUARTER OF FISCAL YEAR 2010';
(ii) in subclause (I), by striking `or for a period in fiscal year 2008'
and inserting `, 2008, 2009, or for a period in fiscal year 2010'; and
(iii) in subclause (II), by striking `or for a period in fiscal year
2008' and inserting `, 2008, 2009, or for a period in fiscal year 2010';
and
(3) in subparagraph (B)(i)--
(A) in the first sentence, by striking `fiscal year 2007' and inserting
`each of fiscal years 2007 through 2009'; and
(B) by striking the second sentence and inserting the following: `Only
with respect to fiscal year 2010 for the period ending on December 31,
2009, the DSH allotment for Hawaii for such portion of the fiscal year,
notwithstanding the table set forth in paragraph (2), shall be $2,500,000.'.
SEC. 203. PHARMACY REIMBURSEMENT UNDER MEDICAID.
(a) Delay in New Payment Limits for Multiple Source Drugs Under Medicaid-
Notwithstanding paragraphs (4) and (5) of subsection (e) of section 1927 of
the Social Security Act (42 U.S.C. 1396r-8) or part 447 of title 42, Code
of Federal Regulations (as in effect on the date of the enactment of this
Act), the Secretary of Health and Human Services shall not require a State
to establish prior to September 30, 2009, payment limits for multiple source
drugs under a State Medicaid plan that do not exceed the specific upper limit
established under section 447.514(b) of title 42, Code of Federal Regulations
(as so in effect) and shall permit any State to continue to receive Federal
financial participation for payments for such drugs that do not exceed the
specific upper limit that would have applied to such payments under section
447.332 of title 42, Code of Federal Regulations (as in effect on December
31, 2006).
(b) Temporary Suspension of Updated Publicly Available AMP Data- Notwithstanding
clause (v) of section 1927(b)(3)(D) of the Social Security Act (42 U.S.C.
1396r-8(b)(3)(D)), the Secretary of Health and Human Services shall not, prior
to September 30, 2009, make publicly available any AMP disclosed to the Secretary.
(c) Definitions- In this subsection:
(1) The term `multiple source drug' has the meaning given that term in section
1927(k)(7)(A)(i) of the Social Security Act (42 U.S.C. 1396r-8(k)(7)(A)(i));
and
(2) The term `AMP' has the meaning given `average manufacturer price' in
section 1927(k)(1) of the Social Security Act (42 U.S.C. 1396r-8(k)(1))
and `AMP' in section 447.504(a) of title 42, Code of Federal Regulations
(as in effect on the date of the enactment of this Act).
SEC. 204. REVIEW OF ADMINISTRATIVE CLAIM DETERMINATIONS.
(a) In General- Section 1116 of the Social Security Act (42 U.S.C. 1316) is
amended by adding at the end the following new subsection:
`(e)(1) Whenever the Secretary determines that any item or class of items
on account of which Federal financial participation is claimed under title
XIX shall be disallowed for such participation, the State shall be entitled
to and upon request shall receive a reconsideration of the disallowance, provided
that such request is made during the 60-day period that begins on the date
the State receives notice of the disallowance.
`(2)(A) A State may appeal a disallowance of a claim for federal financial
participation under title XIX by the Secretary, or an unfavorable reconsideration
of a disallowance, during the 60-day period that begins on the date the State
receives notice of the disallowance or of the unfavorable reconsideration,
in whole or in part, to the Departmental Appeals Board, established in the
Department of Health and Human Services (in this paragraph referred to as
the `Board'), by filing a notice of appeal with the Board.
`(B) The Board shall consider a State's appeal of a disallowance of such a
claim (or of an unfavorable reconsideration of a disallowance) on the basis
of such documentation as the State may submit and as the Board may require
to support the final decision of the Board. In deciding whether to uphold
a disallowance of such a claim or any portion thereof, the Board shall be
bound by all applicable laws and regulations and shall conduct a thorough
review of the issues, taking into account all relevant evidence. The Board's
decision of an appeal under subparagraph (A) shall be the final decision of
the Secretary and shall be subject to reconsideration by the Board only upon
motion of either party filed during the 60-day period that begins on the date
of the Board's decision or to judicial review in accordance with subparagraph
(C).
`(C) A State may obtain judicial review of a decision of the Board by filing
an action in any United States District Court located within the appealing
State (or, if several States jointly appeal the disallowance of claims for
Federal financial participation under section 1903, in any United States District
Court that is located within any State that is a party to the appeal) or the
United States District Court for the District of Columbia. Such an action
may only be filed--
`(i) if no motion for reconsideration was filed within the 60-day period
specified in subparagraph (B), during such 60-day period; or
`(ii) if such a motion was filed within such period, during the 60-day period
that begins on the date of the Board's decision on such motion.'.
(b) Conforming Amendment- Section 1116(d) of such Act (42 U.S.C. 1316(d))
is amended by striking `or XIX,'.
(c) Effective Date- The amendments made by this section take effect on the
date of the enactment of this Act and apply to any disallowance of a claim
for Federal financial participation under title XIX of the Social Security
Act (42 U.S.C. 1396 et seq.) made on or after such date or during the 60-day
period prior to such date.
TITLE III--MISCELLANEOUS
SEC. 301. EXTENSION OF TANF SUPPLEMENTAL GRANTS.
(a) Extension Through Fiscal Year 2009- Section 7101(a) of the Deficit Reduction
Act of 2005 (Public Law 109-171; 120 Stat. 135) is amended by striking `fiscal
year 2008' and inserting `fiscal year 2009'.
(b) Conforming Amendment- Section 403(a)(3)(H)(ii) of the Social Security
Act (42 U.S.C. 603(a)(3)(H)(ii)) is amended to read as follows:
`(ii) subparagraph (G) shall be applied as if `fiscal year 2009' were
substituted for `fiscal year 2001'; and'.
SEC. 302. 70 PERCENT FEDERAL MATCHING FOR FOSTER CARE AND ADOPTION ASSISTANCE
FOR THE DISTRICT OF COLUMBIA.
(a) In General- Section 474(a) of the Social Security Act (42 U.S.C. 674(a))
is amended in each of paragraphs (1) and (2) by striking `(as defined in section
1905(b) of this Act)' and inserting `(which shall be as defined in section
1905(b), in the case of a State other than the District of Columbia, or 70
percent, in the case of the District of Columbia)'.
(b) Effective Date- The amendment made by subsection (a) shall take effect
on October 1, 2008, and shall apply to calendar quarters beginning on or after
that date.
SEC. 303. EXTENSION OF SPECIAL DIABETES GRANT PROGRAMS.
(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)) is amended by striking
`2009' and inserting `2011'.
(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 `2009'
and inserting `2011'.
(c) Report on Grant Programs- Section 4923(b) of the Balanced Budget Act of
1997 (42 U.S.C. 1254c-2 note), as amended by section 931(c) of the Medicare,
Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, as enacted
into law by section 1(a)(6) of Public Law 106-554, and section 1(c) of Public
Law 107-360, is amended--
(1) in paragraph (1), by striking `and' at the end;
(A) by striking `a final report' and inserting `a second interim report';
and
(B) by striking the period at the end and inserting `; and'; and
(3) by adding at the end the following new paragraph:
`(3) a report on such evaluation not later than January 1, 2011.'.
SEC. 304. IOM REPORTS ON BEST PRACTICES FOR CONDUCTING SYSTEMATIC REVIEWS
OF CLINICAL EFFECTIVENESS RESEARCH AND FOR DEVELOPING CLINICAL PROTOCOLS.
(a) Systematic Reviews of Clinical Effectiveness Research-
(1) STUDY- Not later than 60 days after the date of the enactment of this
Act, the Secretary of Health and Human Services shall enter into a contract
with the Institute of Medicine of the National Academies (in this section
referred to as the `Institute') under which the Institute shall conduct
a study to identify the methodological standards for conducting systematic
reviews of clinical effectiveness research on health and health care in
order to ensure that organizations conducting such reviews have information
on methods that are objective, scientifically valid, and consistent.
(2) REPORT- Not later than 18 months after the effective date of the contract
under paragraph (1), the Institute, as part of such contract, shall submit
to the Secretary of Health and Human Services and the appropriate committees
of jurisdiction of Congress a report containing the results of the study
conducted under paragraph (1), together with recommendations for such legislation
and administrative action as the Institute determines appropriate.
(3) PARTICIPATION- The contract under paragraph (1) shall require that stakeholders
with expertise in conducting clinical effectiveness research participate
on the panel responsible for conducting the study under paragraph (1) and
preparing the report under paragraph (2).
(1) STUDY- Not later than 60 days after the date of the enactment of this
Act, the Secretary of Health and Human Services shall enter into a contract
with the Institute of Medicine of the National Academies (in this section
referred to as the `Institute') under which the Institute shall conduct
a study on the best methods used in developing clinical practice guidelines
in order to ensure that organizations developing such guidelines have information
on approaches that are objective, scientifically valid, and consistent.
(2) REPORT- Not later than 18 months after the effective date of the contract
under paragraph (1), the Institute, as part of such contract, shall submit
to the Secretary of Health and Human Services and the appropriate committees
of jurisdiction of Congress a report containing the results of the study
conducted under paragraph (1), together with recommendations for such legislation
and administrative action as the Institute determines appropriate.
(3) PARTICIPATION- The contract under paragraph (1) shall require that stakeholders
with expertise in making clinical recommendations participate on the panel
responsible for conducting the study under paragraph (1) and preparing the
report under paragraph (2).
(c) Funding- Out of any funds in the Treasury not otherwise appropriated,
there are appropriated for the period of fiscal years 2009 and 2010, $3,000,000
to carry out this section.
SEC. 305. INCREASING NUMBER OF PRIMARY CARE PHYSICIANS.
Not later than one year after the date of the enactment of this Act, the Secretary
of Health and Human Services, in coordination with the Association of American
Medical Colleges, shall submit to Congress an effective plan to increase the
number of primary care physicians, particularly those practicing in counties,
cities, or towns classified as underserved or with a disproportionate number
of Medicare beneficiaries.
END
