Sec. 201 Work geographic adjustment
Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w–4(e)(1)(E)) is amended by striking “and before January 1, 2014,”.
Title II — Extensions and Other Provisions
II Extensions and Other Provisions
A Medicare Extensions
Sec. 202 Medicare payment for therapy services
Repeal of therapy cap and 1-year extension of threshold for manual medical review— Section 1833(g) of the Social Security Act (42 U.S.C. 1395l(g)) is amended—
in paragraph (4)—
by striking “This subsection” and inserting “Except as provided in paragraph (5)(C), this subsection”; and
by inserting the following before the period at the end: “or with respect to services furnished on or after the date of enactment of the SGR Repeal and Medicare Beneficiary Access Act of 2013”.
in paragraph (5)(C)—
in clause (i), by inserting “and before January 1, 2015,” after “2012,”; and
by adding at the end the following new clause:
“(iii) With respect to services furnished during the period beginning on the date of enactment of the SGR Repeal and Medicare Beneficiary Access Act of 2013, and ending on December 31, 2014, the provisions of this paragraph shall only apply to the extent necessary to carry out the manual medical review process under this subparagraph.”
Medical review of outpatient therapy services—
Medical review of outpatient therapy services— Section 1833 of the Social Security Act (42 U.S.C. 1395l), as amended by section 101(e), is amended by adding at the end the following new subsection:
“(aa) Medical review of outpatient therapy services
“(1) In general
“(A) Process for medical review—The Secretary shall implement a process for the medical review (as described in paragraph (2)) of outpatient therapy services (as defined in paragraph (10)) and, subject to paragraph (12), apply such process to such services furnished on or after January 1, 2015, focusing on services identified under subparagraph (B).
“(B) Identification of services for review—Under the process, the Secretary shall identify services for medical review, using such factors as the Secretary determines appropriate, which may include the following:
“(i) Services furnished by a therapy provider (as defined in paragraph (10)) whose pattern of billing is higher compared to peers.
“(ii) Services furnished by a therapy provider who, in a prior period, has a high claims denial percentage or is least compliant with other applicable requirements under this title.
“(iii) Services furnished by a therapy provider that is newly enrolled under this title.
“(iv) Services furnished by a therapy provider who has questionable billing practices, such as billing medically unlikely units of services in a day.
“(v) Services furnished to treat a type of medical condition.
“(vi) Services identified by use of the standardized data elements required to be reported under section 1834(p).
“(vii) Services furnished by a single therapy provider or a group that includes a therapy provider identified by factors described in this subparagraph.
“(viii) Other services as determined appropriate by the Secretary.
“(2) Medical review
“(A) Prior authorization medical review
“(i) In general—Subject to the succeeding provisions of this subparagraph, the Secretary shall use prior authorization medical review for outpatient therapy services furnished to an individual above one or more thresholds established by the Secretary, such as a dollar threshold or a threshold based on factors such as the type of outpatient therapy service or setting.
“(ii) Ending application of prior authorization for a therapy provider—The Secretary shall end the application of prior authorization medical review to outpatient therapy services furnished by a therapy provider if the Secretary determines that the provider has a low denial rate under such prior authorization. The Secretary may subsequently reapply prior authorization medical review to such therapy provider if the Secretary determines it to be appropriate.
“(iii) Prior authorization of multiple services—The Secretary shall, where practicable, provide for prior authorization medical review for multiple services at a single time, such as services in a therapy plan of care described in section 1861(p)(2).
“(B) Other types of medical review—The Secretary may use pre-payment review or post-payment review for services identified under paragraph (1)(B) that are not subject to prior authorization medical review under subparagraph (A).
“(C) Limitation for law enforcement activities—The Secretary may determine that medical review under this subsection does not apply in the case where fraud may be involved.
“(3) Review contractors—The Secretary shall conduct prior authorization medical review of outpatient therapy services under this subsection using medicare administrative contractors (as described in section 1874A) or other review contractors (other than contractors under section 1893(h) or contractors paid on a contingent basis).
“(4) No payment without prior authorization—With respect to an outpatient therapy service for which prior authorization medical review under this subsection applies, no payment shall be made under this part for the service unless a prior authorization determination is made, in advance of furnishing such service, that such service would meet the applicable requirements of section 1862(a)(1)(A).
“(5) Submission of information—A therapy provider may submit the information necessary for medical review by fax, by mail, or by electronic means. The Secretary shall make available the electronic means described in the preceding sentence as soon as practicable, but not later than 24 months after the date of enactment of this subsection.
“(6) Timeliness—The Secretary shall make a prior authorization determination under this subsection within 10 business days of the date of the Secretary’s receipt of medical documentation needed to make such determination or the Secretary shall be deemed to have found the services to meet the applicable requirements of section 1862(a)(1)(A).
“(7) Construction—With respect to an outpatient therapy service that has been affirmed by medical review under this subsection, nothing in this subsection shall be construed to preclude the subsequent denial of a claim for such service that does not meet other applicable requirements under this Act.
“(8) Beneficiary protections—With respect to services furnished on or after January 1, 2015, where payment may not be made as a result of application of medical review under this subsection, section 1879 shall apply in the same manner as such section applies to a denial that is made by reason of section 1862(a)(1).
“(9) Implementation
“(A) Authority—The Secretary may implement the provisions of this subsection by interim final rule with comment period.
“(B) Administration—Chapter 35 of title 44, United States Code, shall not apply to medical review under this subsection.
“(10) Definitions—For purposes of this subsection:
“(A) Outpatient therapy services—The term outpatient therapy services means the following services for which payment is made under section 1848, 1834(g), or 1834(k):
“(i) Physical therapy services of the type described in section 1861(p).
“(ii) Speech-language pathology services of the type described in such section though the application of section 1861(ll)(2).
“(iii) Occupational therapy services of the type described in section 1861(p) through the operation of section 1861(g).
“(B) Therapy provider—The term therapy provider means a provider of services (as defined in section 1861(u)) or a supplier (as defined in section 1861(d)) who submits a claim for outpatient therapy services.
“(11) Funding—For purposes of implementing this subsection, the Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under section 1841, of $35,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for each fiscal year (beginning with fiscal year 2014). Amounts transferred under this paragraph shall remain available until expended.
“(12) Scaling back
“(A) Periodic determinations—Beginning with 2017, and every two years thereafter, the Secretary shall—
“(i) make a determination of the improper payment rate for outpatient therapy services for a 12-month period; and
“(ii) make such determination publicly available.
“(B) Scaling back—If the improper payment rate for outpatient therapy services determined for a 12-month period under subparagraph (A) is 50 percent or less of the Medicare fee-for-service improper payment rate for such period, the Secretary shall—
“(i) reduce the amount and extent of medical review conducted for a prospective year under the process established in this subsection; and
“(ii) return an appropriate portion of the funding provided for such year under paragraph (11).”
GAO study and report—
Study— The Comptroller General of the United States shall conduct a study on the effectiveness of medical review of outpatient therapy services under section 1833(aa) of the Social Security Act, as added by paragraph (2). Such study shall include an analysis of—
aggregate data on—
the number of individuals, therapy providers, and claims subject to such review; and
the number of reviews conducted under such section; and
the outcomes of such reviews.
Report— Not later than 3 years after the date of enactment of this Act, the Comptroller General shall submit to Congress a report containing the results of the study under subparagraph (A), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate.
Collection of standardized data elements for outpatient therapy services—
Collection of standardized data elements for outpatient therapy services— Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:
“(p) Collection of standardized data elements for outpatient therapy services
“(1) Standardized data elements
“(A) In general—Not later than 6 months after the date of enactment of this subsection, the Secretary shall post on the Internet website of the Centers for Medicare & Medicaid Services a draft list of standardized data elements for individuals receiving outpatient therapy services.
“(B) Domains—Such standardized data elements shall include information with respect to the following domains, as determined appropriate by the Secretary:
“(i) Demographic information.
“(ii) Diagnosis.
“(iii) Severity.
“(iv) Affected body structures and functions.
“(v) Limitations with activities of daily living and participation.
“(vi) Functional status.
“(vii) Other domains determined to be appropriate by the Secretary.
“(C) Solicitation of input—The Secretary shall accept comments from stakeholders through the date that is 60 days after the date the Secretary posts the draft list of standardized data elements pursuant to subparagraph (A). In seeking such comments, the Secretary shall use one or more mechanisms to solicit input from stakeholders that may include use of open door forums, town hall meetings, requests for information, or other mechanisms determined appropriate by the Secretary.
“(D) Operational list of standardized data elements—Not later than 120 days after the end of the comment period described in subparagraph (C), the Secretary, taking into account such comments, shall post on the Internet website of the Centers for Medicare & Medicaid Services an operational list of standardized data elements.
“(E) Subsequent revisions—Subsequent revisions to the operational list of standardized data elements shall be made through rulemaking. Such revisions may be based on experience and input from stakeholders.
“(2) System to report standardized data elements
“(A) In general—Not later than 18 months after the date the Secretary posts the operational list of standardized data elements pursuant to paragraph (1)(D), the Secretary shall develop and implement an electronic system (which may be a web portal) for therapy providers to report the standardized data elements for individuals with respect to outpatient therapy services.
“(B) Consultation—The Secretary shall seek comments from stakeholders regarding the best way to report the standardized data elements.
“(3) Reporting
“(A) Frequency of reporting—The Secretary shall specify the frequency of reporting standardized data elements. The Secretary shall seek comments from stakeholders regarding the frequency of the reporting of such data elements.
“(B) Reporting requirement—Beginning on the date the system to report standardized data elements under this subsection is operational, no payment shall be made under this part for outpatient therapy services furnished to an individual unless a therapy provider reports the standardized data elements for such individual.
“(4) Report on new payment system for outpatient therapy services
“(A) In general—Not later than 18 months after the date described in paragraph (3)(B), the Secretary shall submit to Congress a report on the design of a new payment system for outpatient therapy services. The report shall include an analysis of the standardized data elements collected and other appropriate data and information.
“(B) Features—Such report shall consider—
“(i) appropriate adjustments to payment (such as case mix and outliers);
“(ii) payments on an episode of care basis; and
“(iii) reduced payment for multiple episodes.
“(C) Consultation—The Secretary shall consult with stakeholders regarding the design of such a new payment system.
“(5) Implementation
“(A) Funding—For purposes of implementing this subsection, the Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under section 1841, of $7,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for each of fiscal years 2014 through 2018. Amounts transferred under this subparagraph shall remain available until expended.
“(B) Administration—Chapter 35 of title 44, United States Code, shall not apply to specification of the standardized data elements and implementation of the system to report such standardized data elements under this subsection.
“(C) Limitation—There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the specification of standardized data elements required under this subsection or the system to report such standardized data elements.
“(D) Definition of outpatient therapy services and therapy provider—In this subsection, the terms “outpatient therapy services” and therapy provider have the meaning given those term in section 1833(aa).”
Sunset of current claims-based collection of therapy data— Section 3005(g)(1) of the Middle Class Tax Extension and Job Creation Act of 2012 (42 U.S.C. 1395l note) is amended, in the first sentence, by inserting “and ending on the date the system to report standardized data elements under section 1834(p) of the Social Security Act (42 U.S.C. 1395m(p)) is implemented,” after “January 1, 2013,”.
Reporting of certain information— Section 1842(t) of the Social Security Act (42 U.S.C. 1395u(t)) is amended by adding at the end the following new paragraph:
“(3) Each request for payment, or bill submitted, by a therapy provider (as defined in section 1833(aa)(10)) for an outpatient therapy service (as defined in such section) furnished by a therapy assistant on or after January 1, 2015, shall include (in a form and manner specified by the Secretary) an indication that the service was furnished by a therapy assistant.”
Sec. 203 Medicare ambulance services
Extension of certain ambulance add-on payments—
Ground Ambulance— Section 1834(l)(13)(A) of the Social Security Act (42 U.S.C. 1395m(l)(13)(A)) is amended by striking “January 1, 2014” and inserting “January 1, 2019” each place it appears.
Super Rural Ambulance— Section 1834(l)(12)(A) of the Social Security Act (42 U.S.C. 1395m(l)(12)(A)) is amended, in the first sentence, by striking “January 1, 2014” and inserting “January 1, 2019”.
Requiring ambulance providers To submit cost and other information— Section 1834(l) of the Social Security Act (42 U.S.C. 1395m(l)) is amended by adding at the end the following new paragraph:
“(16) Submission of cost and other information
“(A) Development of data collection system—The Secretary shall develop a data collection system (which may include use of a cost survey and standardized definitions) for providers and suppliers of ambulance services to collect cost, revenue, utilization, and other information determined appropriate by the Secretary. Such system shall be designed to submit information—
“(i) needed to evaluate the appropriateness of payment rates under this subsection;
“(ii) on the utilization of capital equipment and ambulance capacity; and
“(iii) on different types of ambulance services furnished in different geographic locations, including rural areas and low population density areas described in paragraph (12).
“(B) Specification of data collection system
“(i) In general—Not later than January 1, 2015, the Secretary shall—
“(I) specify the data collection system under subparagraph (A); and
“(II) identify the providers and suppliers of ambulance services who would be required to submit the information under such data collection system.
“(ii) Respondents—Subject to subparagraph (D)(ii), the Secretary shall determine an appropriate sample of providers and suppliers of ambulance services to submit information under the data collection system each year.
“(C) Reporting of cost information—Beginning July 1, 2015, a 5 percent reduction to payments under this part shall be made for a 1-year period to a provider or supplier of ambulance services who—
“(i) is identified under subparagraph (B)(i)(II) as being required to submit the information under the data collection system; and
“(ii) does not submit such information.
“(D) Ongoing data collection
“(i) Revision of data collection system—The Secretary may revise, as the Secretary determines appropriate, the data collection system. The Secretary shall consult with providers and suppliers of ambulance services when revising such system.
“(ii) Subsequent data collection—In order to continue to evaluate the appropriateness of payment rates under this subsection, the Secretary shall require providers and suppliers of ambulance services to submit information for years after 2015 as the Secretary determines appropriate, but in no case less often than once every 3 years.
“(E) Consultation—The Secretary shall consult with stakeholders in carrying out the development of the system and collection of information under this paragraph, including the activities described in subparagraphs (A) and (D). Such consultation shall include the use of requests for information and other mechanisms determined appropriate by the Secretary.
“(F) Administration—Chapter 35 of title 44, United States Code, shall not apply to the collection of information required under this subsection.
“(G) Limitations on review—There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the data collection system or identification of respondents under this paragraph.
“(H) Funding for implementation—For purposes of carrying out subparagraph (A), the Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under section 1841, of $1,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for fiscal year 2014. Amounts transferred under this subparagraph shall remain available until expended.”
Sec. 204 Revision of the Medicare-dependent hospital (MDH) program
Permanent extension of payment methodology—
In general— Section 1886(d)(5)(G) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(G)) is amended—
in clause (i), by striking “and before October 1, 2013,”; and
in clause (ii)(II), by striking “and before October 1, 2013,”.
Conforming amendments—
Target amount— Section 1886(b)(3)(D) of the Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is amended—
in the matter preceding clause (i), by striking “and before October 1, 2013,”; and
in clause (iv), by striking “through fiscal year 2013” and inserting “or a subsequent fiscal year”.
Hospital value-based purchasing program— Section 1886(o)(7)(D)(ii)(I) of the Social Security Act (42 U.S.C. 1395ww(o)(7)(D)(ii)(I)) is amended by striking “(with respect to discharges occurring during fiscal year 2012 and 2013)”.
Hospital readmission reduction program— Section 1886(q)(2)(B)(i) of the Social Security Act (42 U.S.C. 1395ww(q)(2)(B)(i)) is amended by striking “(with respect to discharges occurring during fiscal years 2012 and 2013)”.
Permitting hospitals to decline reclassification— Section 13501(e)(2) of the Omnibus Budget Reconciliation Act of 1993 (42 U.S.C. 1395ww note) is amended by striking “fiscal year 1998, fiscal year 1999, or fiscal year 2000 through fiscal year 2013” and inserting “or fiscal year 1998 or a subsequent fiscal year”.
GAO study and report on Medicare-dependent hospitals—
Study— The Comptroller General of the United States shall conduct a study on the following:
The payor mix of medicare-dependent, small rural hospitals (as defined in section 1886(d)(5)(G)(iv)), how such mix will trend in future years, and whether or not the requirement under subclause (IV) of such section should be revised.
The characteristics of medicare-dependent, small rural hospitals that meet the requirement of such subclause (IV) through the application of paragraph (a)(iii)(A) or (a)(iii)(B) of section 412.108 of the Code of Federal Regulations, including Medicare inpatient and outpatient utilization, payor mix, and financial status, including Medicare and total margins, and whether or not Medicare payments for such hospitals should be revised.
Such other items related to medicare-dependent, small rural hospitals as the Comptroller General determines appropriate.
Report— Not later than 12 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 as the Comptroller General determines appropriate.
Implementation— Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement the provisions of, and the amendments made by, this section through program instruction or otherwise.
Sec. 205 Revision of Medicare inpatient hospital payment adjustment for low-volume hospitals
in subparagraph (B)—
in the subparagraph heading, by inserting “for fiscal years 2005 through 2010” after “increase”; and
in the matter preceding clause (i), by striking “and for discharges occurring in fiscal year 2014 and subsequent years”;
in subparagraph (C)(i), by striking “fiscal years 2011, 2012, and 2013” and inserting “fiscal year 2011 and subsequent fiscal years” each place it appears; and
in subparagraph (D)—
in the heading, by striking “Temporary applicable percentage increase” and inserting “Applicable percentage increase for fiscal year 2011 and subsequent fiscal years”; and
by striking “fiscal years 2011, 2012, and 2013” and inserting “fiscal year 2011 or a subsequent fiscal year”;
Implementation— Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement the provisions of, and the amendments made by, this section through program instruction or otherwise.
Sec. 206 Specialized Medicare Advantage plans for special needs individuals
by striking “enrollment.—In the case” and inserting “enrollment.—
“(A) In general—Subject to subparagraphs (B) and (C), in the case”
in subparagraph (A), as added by paragraph (1), by striking “and for periods before January 1, 2015”; and
by adding at the end the following new subparagraphs:
“(B) Application to dual SNPs—Subparagraph (A) shall only apply to a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii) for periods before January 1, 2021.
“(C) Application to severe or disabling chronic condition SNPs—Subparagraph (A) shall only apply to a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(iii) for periods before January 1, 2018.”
Increased integration of dual SNPs—
in paragraph (3), by adding at the end the following new subparagraph:
“(F) The plan meets the requirements applicable under paragraph (8).”
by adding at the end the following new paragraph:
“(8) Increased integration of dual SNPs
“(A) Designated contact—The Secretary, acting through the Federal Coordinated Health Care Office (Medicare-Medicaid Coordination Office) established under section 2602 of the Patient Protection and Affordable Care Act (in this paragraph referred to as the “MMCO”), shall serve as a dedicated point of contact for States to address misalignments that arise with the integration of specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) under this paragraph. Consistent with such role, the MMCO shall—
“(i) establish a uniform process for disseminating to State Medicaid agencies information under this title impacting contracts between such agencies and such plans under this subsection; and
“(ii) establish basic resources for States interested in exploring such plans as a platform for integration.
“(B) Unified appeals process
“(i) In general—Not later than April 1, 2015, the Secretary shall establish procedures unifying the appeals procedures under sections 1852(g), 1902(a)(3), and 1902(a)(5) for items and services provided by specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) under this title and title XIX. The Secretary shall solicit comment in developing such procedures from States, plans, beneficiary representatives, and other relevant stakeholders.
“(ii) Procedures—To the extent compatible with a unified process, the procedures established under clause (i) shall—
“(I) adopt the most protective provisions for the enrollee under current law, including continuation of benefits under title XIX pending appeal if an appeal is filed in a timely manner;
“(II) take into account differences in State plans under title XIX;
“(III) be easily navigable by an enrollee; and
“(IV) include the elements described in clause (iii).
“(iii) Elements described—The following elements are described in this clause:
“(I) Single notification of all applicable appeal rights under this title and title XIX.
“(II) Notices written in plain language and available in a language and format that is accessible to the enrollee.
“(III) Unified timeframes for internal and external appeals processes, such as an individual's filing of appeals, a plan’s acknowledgment and resolution of appeals, and notification of appeals decisions.
“(IV) Mechanisms to allow the plan to track and resolve grievances.
“(C) Requirement for unified appeals
“(i) In general—For 2016 and subsequent years, the contract of a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii) with a State Medicaid agency under this subsection shall require the use of unified appeals procedures as described in subparagraph (B).
“(ii) Consideration of application for other SNPs—The Secretary shall consider applying the unified appeals process described in subparagraph (B) to specialized MA plans for special needs individuals described in subsection (b)(6)(B)(i) and subsection (b)(6)(B)(iii).
“(D) Requirement for full integration for certain dual SNPs
“(i) Requirement—Subject to the succeeding provisions of this subparagraph, for 2018 and subsequent years, a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii) shall—
“(I) integrate all benefits under this title and title XIX; and
“(II) meet the requirements of a fully integrated plan described in section 1853(a)(1)(B)(iv)(II) (other than the requirement that the plan have similar average levels of frailty, as determined by the Secretary, as the PACE program), including with respect to long-term care services or behavioral health services to the extent State law permits capitation of those services under such plan.
“(ii) Initial sanctions for failure to meet requirement for 2018 or 2019—For each of 2018 and 2019, if the Secretary determines that a plan has failed to meet the requirement described in clause (i), the Secretary shall impose one of the following on the plan:
“(I) A reduction in payments under this part.
“(II) Closing enrollment in the plan.
“(III) Sanctioning the plan in accordance with section 1857(g).
“(IV) Other reasonable action (other than the sanction described in clause (iii)) the Secretary determines appropriate.
“(iii) Sanctions for failure to meet requirement for 2020 and subsequent years—For 2020 and subsequent years, if the Secretary determines that a plan has failed to meet the requirement described in clause (i), the plan shall be deemed to no longer meet the definition of a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii).
“(iv) Limitation—This subparagraph shall not apply to a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii) that only enrolls individuals for whom the only medical assistance to which the individuals are entitled under the State plan is medicare cost sharing described in section 1905(p)(3)(A)(ii).”
Conforming amendment to responsibilities of Federal Coordinated Health Care Office (MMCO)— Section 2602(d) of the Patient Protection and Affordable Care Act (42 U.S.C. 1315b(d)) is amended by adding at the end the following new paragraph:
“(6) To act as a designated contact for States under subsection (f)(8)(A) of section 1859 of the Social Security Act (42 U.S.C. 1395w–28) with respect to the integration of specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) of such section.”
Improvements to care management requirements for severe or disabling chronic condition SNPs— Section 1859(f)(5) of the Social Security Act (42 U.S.C. 1395w–28(f)(5)) is amended—
by striking “all SNPs.—The requirements” and inserting “all SNPs.—
“(A) In general—Subject to subparagraph (B), the requirements”
by redesignating subparagraphs (A) and (B) as clauses (i) and (ii), respectively, and indenting appropriately;
in clause (ii), as redesignated by paragraph (2), by redesignating clauses (i) through (iii) as subclauses (I) through (III), respectively, and indenting appropriately; and
by adding at the end the following new subparagraph:
“(B) Improvements to care management requirements for severe or disabling chronic condition SNPs—For 2016 and subsequent years, in the case of a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(iii), the requirements described in this paragraph include the following:
“(i) The interdisciplinary team under subparagraph (A)(ii)(III) includes a team of providers with demonstrated expertise, including training in an applicable specialty, in treating individuals similar to the targeted population of the plan.
“(ii) Requirements developed by the Secretary to provide face-to-face encounters with individuals enrolled in the plan.
“(iii) As part of the model of care under clause (i) of subparagraph (A), the results of the initial assessment and annual reassessment under clause (ii)(I) of such subparagraph of each individual enrolled in the plan are addressed in the individual’s individualized care plan under clause (ii)(II) of such subparagraph.
“(iv) As part of the annual evaluation and approval of such model of care, the Secretary shall take into account whether the plan fulfilled the previous year’s goals (as required under the model of care).
“(v) The Secretary shall establish a minimum benchmark for each element of the model of care of a plan. The Secretary shall only approve a plan's model of care under this paragraph if each element of the model of care meets the minimum benchmark applicable under the preceding sentence.”
GAO Study on Quality Improvement—
Study— The Comptroller General of the United States shall conduct a study on how the Secretary of Health and Human Services could change the quality measurement system under the Medicare Advantage program under part C of title XVIII of the Social Security Act (42 U.S.C. 1395w–21 et seq.) to allow an accurate comparison of the quality of care provided by specialized MA plans for special needs individuals (as defined in section 1859(b)(6) of such Act (42 U.S.C. 1395w–28(b)(6)), both for individual plans and such plans overall, compared to the quality of care delivered by the original Medicare fee-for-service program under parts A and B of such title and other Medicare Advantage plans under such part C across similar populations.
Report— Not later than July 1, 2016, the Comptroller General shall submit to Congress a report containing the results of the study under paragraph (1), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate.
Changes to quality ratings and measurement of SNPs— Section 1853(o) of the Social Security Act (42 U.S.C. 1395w–23(o)) is amended by adding at the end the following new paragraph:
“(6) Changes to quality ratings of SNPs
“(A) Emphasis on improvement across SNPs—Subject to subparagraph (B), beginning in plan year 2016, in the case of a specialized MA plan for special needs individuals, the Secretary shall increase the emphasis on the plan’s improvement or decline in performance when determining the star rating of the plan under this subsection for the year as follows:
“(i) At least 25 percent, but not more than 33 percent, of the total star rating of the plan shall be based on improvement or decline in performance.
“(ii) Improvement or decline in performance under this subparagraph shall be measured based on net change in the individual star rating measures of the plan, with appropriate weight given to specific individual star ratings measures, such as readmission rates, as determined by the Secretary.
“(iii) The Secretary shall make an appropriate adjustment to the improvement rating of a plan under this subparagraph if the plan has achieved a 5-star rating or the highest rating possible overall or for an individual measure in order to ensure that the plan is not punished in cases where it is not possible to improve.
“(B) No application to certain plans—Subparagraph (A) shall not apply, with respect to a year, to a specialized MA plan for special needs individuals that has a rating that does not exceed two-and-one-half stars.
“(C) Quality Measurement at the Plan Level
“(i) In general—The Secretary may require reporting for and apply under this subsection quality measures at the plan level for specialized MA plan for special needs individuals instead of at the contract level.
“(ii) Consideration—The Secretary shall take into consideration the minimum number of enrollees in a specialized MA plan for special needs individuals in order to determine if a valid measurement of quality at the plan level is possible under clause (i).
“(iii) Application—If the Secretary applies quality measurement at the plan level under this subparagraph—
“(I) such quality measurement shall include Medicare Health Outcomes Survey (HOS), Healthcare Effectiveness Data and Information Set (HEDIS), and Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures; and
“(II) payment and other administrative actions linked to quality measurement (including the 5-star rating system under this subsection) shall be applied at the plan level in accordance with this subparagraph.”
Sec. 207 Reasonable cost reimbursement contracts
One-year transition and notice regarding transition— Section 1876(h)(5)(C) of the Social Security Act (42 U.S.C. 1395mm(h)(5)(C)) is amended—
in clause (ii), in the matter preceding subclause (I), by striking “For any” and inserting “Subject to clause (iv), for any”; and
by adding at the end the following new clauses:
“(iv) In the case of an eligible organization that is offering a reasonable cost reimbursement contract that may no longer be extended or renewed because of the application of clause (ii)—
“(I) notwithstanding such clause, such contract may be extended or renewed for one last reasonable cost reimbursement contract year;
“(II) the organization may not enroll any new enrollees under such contract during such last reasonable cost reimbursement contract year; and
“(III) on a date determined by the Secretary prior to the beginning of such last reasonable cost reimbursement contract year, the organization shall provide notice to the Secretary as to whether or not the organization will apply to have the contract converted over and offered as a Medicare Advantage plan under part C for the year following such last reasonable cost reimbursement contract year.
“(v) If an eligible organization that is offering a reasonable cost reimbursement contract that is extended or renewed pursuant to clause (iv) provides the notice described in clause (iv)(III) that the contract will be converted—
“(I) the deemed enrollment under section 1851(c)(4) shall apply; and
“(II) the special rule for quality increases under 1853(o)(3)(A)(iv) shall apply.”
Deemed enrollment from reasonable cost reimbursement contracts converted to Medicare Advantage plans—
in paragraph (1), by striking “Such elections” and inserting “Subject to paragraph (4), such elections”; and
by adding at the end the following:
“(4) Deemed enrollment relating to converted reasonable cost reimbursement contracts
“(A) In general—On the first day of the annual, coordinated election period under subsection (e)(3) for plan years beginning on or after January 1, 2016, an MA eligible individual described in clause (i) or (ii) of subparagraph (B) is deemed to have elected to receive benefits under this title through an applicable MA plan (and shall be enrolled in such plan) beginning with such plan year, if—
“(i) the individual is enrolled in a reasonable cost reimbursement contract under section 1876(h) in the previous plan year;
“(ii) such reasonable cost reimbursement contract was extended or renewed for one last reasonable cost reimbursement contract year pursuant to section 1876(h)(5)(C)(iv);
“(iii) the eligible organization that is offering such reasonable cost reimbursement contract provided the notice described in subclause (III) of such section that the contract was to be converted;
“(iv) the applicable MA plan—
“(I) is the plan that was converted from the reasonable cost reimbursement contract described in clause (iii);
“(II) is offered by the same entity (or an organization affiliated with such entity) that entered into such contract; and
“(III) is offered in the service area where the individual resides;
“(v) the amount of the MA monthly basic beneficiary premium for such applicable MA plan with respect to the plan year does not exceed monthly premiums under such reasonable cost reimbursement contract for the previous plan year by more than 10 percent;
“(vi) the applicable MA plan provides benefits, premiums, and access to providers that are comparable to the benefits, premiums, and access to providers under such reasonable cost reimbursement contract for the previous plan year; and
“(vii) the applicable MA plan—
“(I) allows enrollees transitioning from the converted reasonable cost contract to such plan to maintain current providers and course of treatment at the time of enrollment for at least 90 days after enrollment; and
“(II) during such period, pays non-contracting providers for items and services furnished to the enrollee an amount that is not less than the amount of payment applicable for those items and services under the original medicare fee-for-service program under parts A and B.
“(B) MA eligible individuals described
“(i) Without prescription drug coverage—An MA eligible individual described in this clause, with respect to a plan year, is an MA eligible individual who is enrolled in a reasonable cost reimbursement contract under section 1876(h) in the previous plan year and who does not, for such previous plan year, receive any prescription drug coverage under part D, including coverage under section 1860D–22.
“(ii) With prescription drug coverage—An MA eligible individual described in this clause, with respect to a plan year, is an MA eligible individual who is enrolled in a reasonable cost reimbursement contract under section 1876(h) in the previous plan year and who, for such previous plan year, receives prescription drug coverage under part D—
“(I) through such contract; or
“(II) through a prescription drug plan, if the sponsor of such plan is the same entity (or an organization affiliated with such entity) that entered into such contract.
“(C) Applicable MA plan defined—In this paragraph, the term “applicable MA plan” means, in the case of an individual described in—
“(i) subparagraph (B)(i), an MA plan that is not an MA–PD plan; and
“(ii) subparagraph (B)(ii), an MA–PD plan.
“(D) Identification of deemed individuals—Not later than 30 days before the first day of the annual, coordinated election period under subsection (e)(3) for plan years beginning on or after January 1, 2016, the Secretary shall identify the individuals who will be subject to deemed elections under subparagraph (A) on the first day of such period.”
Beneficiary option to discontinue or change MA plan or MA–PD plan after deemed enrollment—
In general— Section 1851(e)(2) of the Social Security Act (42 U.S.C. 1395w–21(e)(4)) is amended by adding at the end the following:
“(F) Special period for certain deemed elections
“(i) In general—At any time during the period beginning after the last day of the annual, coordinated election period under paragraph (3) in which an individual is deemed to have elected to enroll in an MA plan or MA–PD plan under subsection (c)(4) and ending on the last day of February of the first plan year for which the individual is enrolled in such plan, such individual may change the election under subsection (a)(1) (including changing the MA plan or MA–PD plan in which the individual is enrolled).
“(ii) Limitation of one change—An individual may exercise the right under clause (i) only once during the applicable period described in such clause. The limitation under this clause shall not apply to changes in elections effected during an annual, coordinated election period under paragraph (3) or during a special enrollment period under paragraph (4).”
Conforming amendments—
Plan requirement for open enrollment— Section 1851(e)(6)(A) of the Social Security Act (42 U.S.C. 1395w–21(e)(6)(A)) is amended by striking “paragraph (1), ” and inserting “paragraph (1), during the period described in paragraph (2)(F), ”.
in clause (ii), by adding “and paragraph (4)” after “paragraph (3)(A)”; and
in clause (iii) by striking “and (E)” and inserting “(E), and (F)”.
Treatment of ESRD for deemed enrollment— Section 1851(a)(3)(B) of the Social Security Act (42 U.S.C. 1395w–21(a)(3)(B)) is amended by adding at the end the following flush sentence:
Information requirements— Section 1851(d)(2)(B) of the Social Security Act (42 U.S.C. 1395w–21(d)(2)(B)) is amended—
by striking the subparagraph heading and inserting the following: “(i) Notification to newly eligible Medicare Advantage eligible individuals.—”; and
by adding at the end the following:
“(ii) Notification related to certain deemed elections—The Secretary shall, not later than 15 days prior to the first day of the annual, coordinated election period under subsection (e)(3) of a year, mail to any individual identified by the Secretary under subsection (c)(4)(D) for such year—
“(I) a notification that such individual will, on such day, be deemed to have made an election to receive benefits under this title through an MA plan or MA–PD plan (and shall be enrolled in such plan) for the next plan year under subsection (c)(4)(A), but that the individual may make a different election during the annual, coordinated election period for such year;
“(II) the information described in subparagraph (A);
“(III) a description of the differences between such MA plan or MA–PD plan and the reasonable cost reimbursement contract in which the individual was most recently enrolled with respect to benefits covered under such plans, including cost-sharing, premiums, drug coverage, and provider networks; and
“(IV) information about the special period for elections under subsection (e)(2)(F).”
Treatment of transition plan for quality rating for payment purposes— Section 1853(o)(3)(A) of the Social Security Act (42 U.S.C. 1395w–23(o)(3)(A)) is amended by adding at the end the following new clause:
“(iv) Special rule for first 2 plan years for plans that were converted from a reasonable cost reimbursement contract—In applying paragraph (1) for the first 2 plan years under this part in the case of a plan that is a new MA plan (as defined in clause (iii)(II)) to which deemed enrollment applies under section 1851(e)(4), the Secretary shall use the star rating that applied to the converted reasonable cost reimbursement contract for the year preceding the first plan year for such plan under this part.”
Sec. 208 Quality measure endorsement and selection
Contract with an entity regarding input on the selection of measures—
by redesignating section 1890A as section 1890B; and
by inserting after section 1890 the following new section:
“1890A Contract with an entity regarding input on the selection of measures
“(a) Contract
“(1) In general—For purposes of activities conducted under this Act, the Secretary shall identify and have in effect a contract with an entity 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—The first contract under paragraph (1) shall begin on October 1, 2014.
“(3) Period of contract—A contract under paragraph (1) shall be for a period of 3 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:
“(c) Requirements described—The requirements described in this subsection are the following:
“(1) Private nonprofit, board membership, membership fees, and not a measure developer—The requirements described in paragraphs (1), (2), (7), and (8) of section 1890(c).
“(2) Experience—The entity has at least 4 years of experience working with quality and efficiency measures.”
Duties of entity—
Transfer of priority setting process— Paragraph (1) of section 1890(b) of the Social Security Act (42 U.S.C. 1395aaa(b)) is redesignated as paragraph (1) of section 1890A(b) of such Act, as added by paragraph (1).
Transfer of multi-stakeholder process— Paragraphs (7) and (8) of such section 1890(b) are redesignated as paragraphs (2) and (3), respectively, of section 1890A(b) of such Act, as added by paragraph (1) and amended by subparagraph (A).
Additional duties— Section 1890A(b) of such Act, as added by paragraph (1) and amended by subparagraphs (A) and (B), is amended by adding at the end the following new paragraphs:
“(4) Facilitation to better coordinate and align public and private sector use of quality measures
“(A) In general—The entity shall facilitate increased coordination and alignment between the public and private sector with respect to quality and efficiency measures.
“(B) Reports—The entity shall prepare and make available to the public annual reports on its findings under this paragraph. Such public availability shall include posting each report on the Internet website of the entity.
“(5) Gap analysis—The entity shall conduct an ongoing analysis of—
“(A) gaps in endorsed quality and efficiency measures, which shall include measures that are within priority areas identified by the Secretary under the national strategy established under section 399HH of the Public Health Service Act; and
“(B) areas where quality measures are unavailable or inadequate to identify or address such gaps.
“(6) Annual report to congress and the Secretary; Secretarial publication and comment
“(A) Annual report—By not later than March 1 of each year, the entity shall submit to Congress and the Secretary a report containing—
“(i) a description of—
“(I) the recommendations made under paragraph (1);
“(II) the matters described in clauses (i) and (ii) of paragraph (2)(A);
“(III) the results of the analysis under paragraph (5); and
“(IV) the performance by the entity of the duties required under the contract entered into with the Secretary under subsection (a); and
“(ii) any other items determined appropriate by the Secretary.
“(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.”
Additional amendments— Section 1890A(b) of such Act, as so added and amended, is amended—
in paragraph (2)—
in the heading of subparagraph (B) by inserting “and efficiency” after “Quality”;
in subparagraph (B)(i)(III), by striking “this Act” and inserting “this title”; and
by adding at the end the following new subparagraphs:
“(E) Input—In providing the input described in subparagraph (A), the multi-stakeholder groups—
“(i) shall include a detailed description of the rationale for each recommendation made by the multi-stakeholder group, including in areas relating to—
“(I) the expected impact that implementing the measure will have on individuals;
“(II) the burden on providers of services and suppliers;
“(III) the expected influence over the behavior of providers of services and suppliers;
“(IV) the applicability of a measure for more than one setting or program; and
“(V) other areas determined in consultation with the Secretary; and
“(ii) may consider whether it is appropriate to provide separate recommendations with respect to measures for internal use, public reporting, and payment provisions.
“(F) Equal representation—In convening multi-stakeholder groups pursuant to this paragraph, the entity shall, to the extent feasible, make every effort to ensure such groups are balanced across stakeholders.”
in paragraph (3), by striking “Not later” and all that follows through the period at the end and inserting the following: “Not later than the applicable dates described in section 1890B(a)(3) of each year (or, as applicable, the timeframe described in section 1890A(a)(4)), the entity shall transmit to the Secretary the input of the multi-stakeholder group under paragraph (2).”.
Revisions to contract with consensus-based entity—
in paragraph (1), by striking “, such as the National Quality Forum,”; and
in paragraph (3), by striking “4 years” and inserting “3 years”.
Duties— Section 1890(b) of the Social Security Act (42 U.S.C. 1395aaa(b)), as amended by subsection (a)(2), is amended—
by redesignating paragraphs (2) and (3) as paragraphs (1) and (2), respectively;
in paragraph (2), as redesignated by subparagraph (A), by striking “paragraph (2)” and inserting “paragraph (1)”;
by striking paragraphs (5) and (6); and
by adding at the end the following new paragraphs:
“(3) Facilitation to better coordinate and align public and private sector use of quality measures
“(A) In general—The entity shall facilitate increased coordination and alignment between the public and private sector with respect to quality and efficiency measures.
“(B) Reports—The entity shall prepare and make available to the public annual reports on its findings under this paragraph. Such public availability shall include posting each report on the Internet website of the entity.
“(4) Annual report to congress and the Secretary; secretarial publication and comment
“(A) Annual report—By not later than March 1 of each year, the entity shall submit to Congress and the Secretary a report containing—
“(i) a description of—
“(I) the coordination of quality initiatives under this Act with quality initiatives implemented by other payers;
“(II) areas in which evidence is insufficient to support endorsement of quality measures in priority areas identified by the Secretary under the national strategy established under section 399HH of the Public Health Service Act and where targeted research may address such gaps; and
“(III) the performance by the entity of the duties required under the contract entered into with the Secretary under subsection (a); and
“(ii) any other items determined appropriate by the Secretary.
“(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.”
Requirements— Section 1890(c) of the Social Security Act (42 U.S.C. 1395aaa(c)) is amended by adding at the end the following new paragraph:
“(8) Not a measure developer—The entity is not a measure developer.”
Revisions to duties of the Secretary regarding use of measures—
In general— Section 1890B(a) of the Social Security Act (42 U.S.C. 1395aaa–1(a)), as redesignated by subsection (a)(1)(A), is amended—
by striking “section 1890(b)(7)(B)” each place it appears and inserting “section 1890A(b)(2)(B)”;
in paragraph (1)—
by striking “section 1890(b)(7)” and inserting “section 1890A(b)(2)”; and
by striking “section 1890” and inserting “section 1890A”;
by striking paragraphs (2) and (3) and inserting the following:
“(2) Public availability of measures considered for selection—Subject to paragraph (4), not later than October 1 or December 31 of each year, the Secretary shall make available to the public a list of quality and efficiency measures described in section 1890A(b)(2)(B) that the Secretary is considering under this title. The Secretary shall provide for an appropriate balance of the number of measures to be made available by each such date in a year.
“(3) Transmission of multi-stakeholder input
“(A) In general—Subject to paragraph (4), not later than the applicable date described in subparagraph (B) of each year, the entity with a contract under section 1890A shall, pursuant to subsection (b)(3) of such section, transmit to the Secretary the input of multi-stakeholder groups described in paragraph (1).
“(B) Applicable date described—The applicable date described in this subparagraph for a year is—
“(i) February 1 with respect to quality and efficiency measures made available under paragraph (2) by October 1 of the preceding year; and
“(ii) April 1 with respect to quality and efficiency measures made available under paragraph (2) by December 31 of the preceding year.”
by redesignating—
paragraph (6) as paragraph (8); and
paragraphs (4) and (5) as paragraphs (5) and (6), respectively;
by inserting after paragraph (3) the following new paragraph:
“(4) Limited process for additional multi-stakeholder input—In addition to the Secretary making measures publically available pursuant to the dates described in paragraph (2) and multi-stakeholder groups transmitting the input pursuant to the applicable dates described in paragraph (3)—
“(A) the Secretary may, at times that do not meet the time requirements described in paragraph (2), make available to the public a limited number of quality and efficiency measures described in section 1890A(b)(2) that the Secretary is considering under this title; and
“(B) if the Secretary uses the authority under subparagraph (A), the entity with a contract under section 1890A shall, pursuant to section 1890A(b)(3), transmit to the Secretary on a timely basis the input from a multi-stakeholder group described in paragraph (1) with respect to such measures.”
in paragraph (6), as redesignated by subparagraph (D)(ii), by inserting “or that has not been recommended by the multi-stakeholder group under section 1890A(b)(2)” before the period at the end; and
by inserting after paragraph (6) the following new paragraph:
“(7) Concordance rates—For each year (beginning with 2015), the Secretary shall include a list of concordance rates for each type of provider of services and supplier in the annual final rule applicable to such type of provider or supplier.”
Review— Section 1890B(c) of the Social Security Act (42 U.S.C. 1395aaa–1(c)), as redesignated by subsection (a)(1)(A), is amended—
in paragraph (1)(A), by striking “section 1890(b)(7)(B)” and inserting “section 1890A(b)(2)(B)”; and
in paragraph (2)—
in subparagraph (A), by striking “and” at the end;
in subparagraph (B), by striking the period at the end and inserting “; and”; and
by adding at the end the following new subparagraph:
“(C) take into consideration the benefits of the alignment of measures between the public and private sector.”
Funding for quality measure endorsement and selection—
Fiscal year 2014— In addition to amounts transferred under section 3014(c) of the Patient Protection and Affordable Care Act (Public Law 111–148), for purposes of carrying out section 1890 and section 1890A (other than subsections (e) and (f)), the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 and the Federal Supplementary Medical Insurance Trust Fund under section 1841, in such proportion as the Secretary determines appropriate, to the Centers for Medicare & Medicaid Services Program Management Account of $7,000,000 for fiscal year 2014. Amounts transferred under the preceding sentence shall remain available until expended.
Fiscal years 2015 through 2017— Section 1890B of the Social Security Act (42 U.S.C. 1395aaa–1), as redesignated by subsection (a)(1)(A), is amended by adding at the end the following new subsection:
“(g) Funding
“(1) In general—For purposes of carrying out this section (other than subsections (e) and (f)) and sections 1890 and 1890A, the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 and the Federal Supplementary Medical Insurance Trust Fund under section 1841, in such proportion as the Secretary determines appropriate, to the Centers for Medicare & Medicaid Services Program Management Account of $25,000,000 for each of fiscal years 2015 through 2017.
“(2) Availability—Amounts transferred under paragraph (1) shall remain available until expended.”
Conforming amendment— Subsection (d) of section 1890 of the Social Security Act (42 U.S.C. 1395aaa) is repealed.
Conforming amendments—
Section 1848(m)(3)(E)(iii) of the Social Security Act (42 U.S.C. 1395w–4(m)(3)(E)(iii)) is amended by striking “section 1890(b)(7) and 1890A(a)” and inserting “section 1890A(b)(2) and 1890B(a)”.
Section 1866D(b)(2)(C) of the Social Security Act (42 U.S.C. 1395cc–4(b)(2)(C)) is amended by striking “section 1890 and 1890A” and inserting “sections 1890, 1890A, and 1890B”.
Section 1899A(n)(2)(A) of the Social Security Act (42 U.S.C. 1395cc–4(n)(2)(A)) is amended by striking “section 1890(b)(7)(B)” and inserting “section 1890A(b)(2)(B)”.
Effective date—
In general— The amendments made by this section shall take effect on October 1, 2014, and shall apply with respect to contract periods under sections 1890 and 1890A of the Social Security Act that begin on or after such date.
New contracts beginning with fiscal year 2015— The Secretary of Health and Human Services shall enter into a new contract under both sections 1890 and 1890A of the Social Security Act, as amended by this Act, for a contract period beginning on October 1, 2014.
Sec. 209 Permanent extension of funding outreach and assistance for low-income programs
Additional funding for State health insurance programs— Subsection (a)(1)(B)(iii) of section 119 of the Medicare Improvements for Patients and Providers Act of 2008 (42 U.S.C. 1395b–3 note), as amended by section 3306 of the Patient Protection and Affordable Care Act (Public Law 111–148) and section 610 of the American Taxpayer Relief Act of 2012 (Public Law 112–240), is amended by inserting “and for each subsequent fiscal year” after “fiscal year 2013”.
Additional funding for area agencies on aging— Subsection (b)(1)(B) of such section 119, as so amended, is amended by inserting “and for each subsequent fiscal year” after “fiscal year 2013”.
Additional funding for aging and disability resource centers— Subsection (c)(1)(B) of such section 119, as so amended, is amended by inserting “and for each subsequent fiscal year” after “fiscal year 2013”.
Additional funding for contract with the national center for benefits and outreach enrollment— Subsection (d)(2) of such section 119, as so amended, is amended by inserting “and for each subsequent fiscal year” after “fiscal year 2013”.
B Medicaid and Other Extensions
Sec. 211 Qualifying individual program
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 “December 2013” and inserting “December 2018”.
Eliminating limitations on eligibility— Section 1933 of the Social Security Act (42 U.S.C. 1396u–3) is amended by striking subsections (b) and (e).
Eliminating allocations— Section 1933 of the Social Security Act (42 U.S.C. 1396u–3) is amended by striking subsections (c) and (g).
Conforming amendments—
In general— Section 1933 of the Social Security Act (42 U.S.C. 1396u–3), as amended by subsections (b) and (c), is further amended—
by striking subsection (a) and inserting the following new subsection:
“(a) Applicable FMAP—With respect to assistance described in section 1902(a)(10)(E)(iv) furnished in a State, the Federal medical assistance percentage shall be equal to 100 percent.”
by striking subsection (d); and
by redesignating subsection (f) as subsection (b).
Definition of FMAP— Section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) is amended by striking “section 1933(d)” and inserting “section 1933(a)”.
Effective date— The amendments made by this section shall take effect on January 1, 2014, and shall apply with respect to calendar quarters beginning on or after such date.
Sec. 212 Transitional Medical Assistance
Extension— Sections 1902(e)(1)(B) and 1925(f) of the Social Security Act (42 U.S.C. 1396a(e)(1)(B), 1396r–6(f)) are each amended by striking “December 31, 2013” and inserting “December 31, 2018”.
Opt-out option for States that expand adult coverage and provide 12-month continuous eligibility under Medicaid and CHIP—
In general— Section 1925 of the Social Security Act (42 U.S.C. 1396r–6), as amended by subsection (a), is further amended—
in subsection (a)—
in paragraph (1)(A), by striking “paragraph (5)” and inserting “paragraphs (5) and (6)”; and
by adding at the end the following:
“(6) Opt-out option for States that expand adult coverage and provide 12-month continuous eligibility under Medicaid and CHIP
“(A) In general—In the case of a State described in subparagraph (B), the State may elect through a State plan amendment to have this section and sections 408(a)(11)(A), 1902(a)(52), 1902(e)(1), and 1931(c)(2) not apply to the State.
“(B) State described—A State is described in this subparagraph if the State is one of the 50 States or the District of Columbia and—
“(i) has elected to provide medical assistance to individuals under subclause (VIII) of section 1902(a)(10)(A)(i);
“(ii) has elected under section 1902(e)(12)(A) the option to provide continuous eligibility for a 12-month period for individuals under 19 years of age;
“(iii) has elected under section 1902(e)(12)(B) the option to provide continuous eligibility for a 12-month period for all categories of individuals described in that section; and
“(iv) has elected to apply section 1902(e)(12)(A) to the State child health plan under title XXI.”
in subsection (b)(1), by striking “subsection (a)(5)” and inserting “paragraphs (5) and (6) of subsection (a)”.
Conforming amendment to 4-month requirement— Section 1902(e)(1) of the Social Security Act (42 U.S.C. 1396a(e)(1)), as amended by subsection (a), is further amended—
in subparagraph (B), by striking “Subparagraph (A)” and inserting “Subject to subparagraph (C), subparagraph (A)”; and
by adding at the end the following:
“(C) If a State has made an election under section 1925(a)(6), subparagraph (A) and section 1925 shall not apply to the State.”
Extension of 12-month continuous eligibility option to certain adult enrollees under Medicaid; clarification of application to CHIP—
by redesignating subparagraphs (A) and (B) as clauses (i) and (ii), respectively;
by inserting “(A)” after “(12)”; and
by adding at the end the following:
“(B) At the option of the State, the plan may provide that an individual who is determined to be eligible for benefits under a State plan approved under this title under any of the following eligibility categories, or who is redetermined to be eligible for such benefits under any of such categories, shall be considered to meet the eligibility requirements met on the date of application and shall remain eligible for those benefits until the end of the 12–month period following the date of the determination or redetermination of eligibility:
“(i) Section 1902(a)(10)(A)(i)(VIII).
“(ii) Section 1931.”
Application to CHIP— Section 2107(e)(1) of the Social Security Act (42 U.S.C. 1397gg(e)(1)) is amended—
by redesignating subparagraphs (E) through (O) as subparagraphs (F) through (P), respectively; and
by inserting after subparagraph (D), the following:
“(E) Section 1902(e)(12)(A) (relating to the State option for 12-month continuous eligibility and enrollment).”
Conforming and technical amendments relating to section 1931 transitional coverage requirements—
in paragraph (1)—
in the paragraph heading, by striking “child” and inserting “spousal”;
by striking “The provisions” and inserting “Subject to paragraph (3), the provisions”; and
by striking “child or”;
in paragraph (2), by striking “For continued” and inserting “Subject to paragraph (3), for continued”; and
by adding at the end the following:
“(3) Opt-out option for States that expand adult coverage and provide 12-month continuous eligibility under Medicaid and CHIP
“(A) In general—In the case of a State described in subparagraph (B), the State may elect through a State plan amendment to have paragraphs (1) and (2) of this subsection and sections 408(a)(11), 1902(a)(52), 1902(e)(1), and 1925 not apply to the State.
“(B) State described—A State is described in this subparagraph if the State is one of the 50 States or the District of Columbia and—
“(i) has elected to provide medical assistance to individuals under subclause (VIII) of section 1902(a)(10)(A)(i);
“(ii) has elected under section 1902(e)(12)(A) the option to provide continuous eligibility for a 12-month period for individuals under 19 years of age;
“(iii) has elected under section 1902(e)(12)(B) the option to provide continuous eligibility for a 12-month period for all categories of individuals described in that section; and
“(iv) has elected to apply section 1902(e)(12)(A) to the State child health plan under title XXI.”
Conforming amendment to section 408— Section 408(a)(11) of the Social Security Act (42 U.S.C. 608(a)(11) is amended—
in the paragraph heading, by striking “child” and inserting “spousal”; and
in subparagraph (B)—
in the subparagraph heading, by striking “Child” and inserting “Spousal”; and
by striking “child or”.
Conforming amendment relating to maintenance of effort for children— Section 1902(gg)(4) of the Social Security Act (42 U.S.C. 1396a(gg)(4)) is amended by adding at the end the following:
“(C) States that expand adult coverage and elect to opt-out of transitional coverage
“(i) In general—For purposes of determining compliance with the requirements of paragraph (2), a State which exercises the option under sections 1925(a)(6) and 1931(c)(3) to provide no transitional medical assistance or other extended eligibility (as applicable) shall not, as a result of exercising such option, be considered to have in effect eligibility standards, methodologies, or procedures described in clause (ii) that are more restrictive than the standards, methodologies, or procedures in effect under the State plan or under a waiver of the plan on the date of enactment of the Patient Protection and Affordable Care Act.
“(ii) Standards, methodologies, or procedures described—The eligibility standards, methodologies, or procedures described in this clause are those standards, methodologies, or procedures applicable to determining the eligibility for medical assistance of any child under 19 years of age (or such higher age as the State may have elected).”
Effective date— The amendments made by this section shall take effect on January 1, 2014.
Sec. 213 Express lane eligibility
Section 1902(e)(13)(I) of the Social Security Act (42 U.S.C. 1396a(e)(13)(I)) is amended by striking “September 30, 2014” and inserting “September 30, 2015”.
Sec. 214 Pediatric quality measures
Continuation of funding for pediatric quality measures for improving the quality of children's health care— Section 1139B(e) of the Social Security Act (42 U.S.C. 1320b–9b(e)) is amended by adding at the end the following: “Of the funds appropriated under this subsection, not less than $15,000,000 shall be used to carry out section 1139A(b).”.
Elimination of restriction on medicaid quality measurement program— Section 1139B(b)(5)(A) of the Social Security Act (42 U.S.C. 1320b–9b(b)(5)(A)) is amended by striking “The aggregate amount awarded by the Secretary for grants and contracts for the development, testing, and validation of emerging and innovative evidence-based measures under such program shall equal the aggregate amount awarded by the Secretary for grants under section 1139A(b)(4)(A)” .
Sec. 215 Special diabetes programs
Special diabetes programs for type I diabetes— Section 330B(b)(2)(C) of the Public Health Service Act (42 U.S.C. 254c–2(b)(2)(C)) is amended by striking “2014” and inserting “2019”.
Special diabetes programs for indians— Section 330C(c)(2)(C) of the Public Health Service Act (42 U.S.C. 254c–3(c)(2)(C)) is amended by striking “2014” and inserting “2019”.
C Human Services Extensions
Sec. 221 Abstinence education grants
in subsection (a), in the matter preceding paragraph (1), by striking “2010 through 2014” and inserting “2015 through 2019”; and
in subsection (d)—
by striking “2010 through 2014” and inserting “2015 through 2019”; and
by striking the second sentence.
Effective date— The amendments made by this section shall take effect on October 1, 2014.
Sec. 222 Personal responsibility education program
in subsection (a)—
in paragraph (1)(A), by striking “2010 through 2014” and inserting “2015 through 2019”;
in paragraph (4)—
in subparagraph (A)—
by striking “2010 or 2011” and inserting “2015 or 2016”;
by striking “2010 through 2014” and inserting “2015 through 2019”; and
by striking “2012 through 2014” and inserting “2017 through 2019”; and
in subparagraph (B)(i)—
by striking “2012, 2013, and 2014” and inserting “2017, 2018, and 2019”; and
by striking “2010 or 2011” and inserting “2015 or 2016”; and
in paragraph (5), by striking “2009” and inserting “2014”;
in subsection (b)(2)(A), in the matter preceding clause (i), by inserting “and youth at risk of becoming victims of sex trafficking (as defined in section 103(10) of the Trafficking Victims Protection Act of 2000 (22 U.S.C. 7102(10))) or victims of a severe form of trafficking in persons described in paragraph (9)(A) of that Act (22 U.S.C. 7102(9)(A)” after “adolescents”;
in subsection(c)(1), by inserting “youth at risk of becoming victims of sex trafficking (as defined in section 103(10) of the Trafficking Victims Protection Act of 2000 (22 U.S.C. 7102(10))) or victims of a severe form of trafficking in persons described in paragraph (9)(A) of that Act (22 U.S.C. 7102(9)(A),” after “youth in foster care,”; and
in subsection (f), by striking “2010 through 2014” and inserting “2015 through 2019”.
Effective date— The amendments made by this section shall take effect on October 1, 2014.
Sec. 223 Family-to-family health information centers
in paragraph (1)(A)—
in clause (ii), by striking “and” after the semicolon;
in clause (iii), by striking the period and inserting “; and”; and
by adding at the end the following:
“(iv) $6,000,000 for each of fiscal years 2014 through 2018.”
by striking paragraph (5).
Effective date— The amendments made by this section shall take effect as if enacted on October 1, 2013.
Sec. 224 Health workforce demonstration project for low-income individuals
Section 2008(c)(1) of the Social Security Act (42 U.S.C. 1397g(c)(1)) is amended by striking “ through 2014” and inserting “2012, and only to carry out subsection (a), $85,000,000 for each of fiscal years 2013 through 2016”.
D Program Integrity
Sec. 231 Reducing improper Medicare payments
Medicare administrative contractor improper payment outreach and education program—
in subsection (a)(4)—
by redesignating subparagraph (G) as subparagraph (H); and
by inserting after subparagraph (F) the following new subparagraph:
“(G) Improper payment outreach and education program—Having in place an improper payment outreach and education program described in subsection (h).”
by adding at the end the following new subsection:
“(h) Improper payment outreach and education program
“(1) In general—In order to reduce improper payments under this title, each medicare administrative contractor shall establish and have in place an improper payment outreach and education program under which the contractor, through outreach, education, training, and technical assistance activities, shall provide providers of services and suppliers located in the region covered by the contract under this section with the information described in paragraph (3). The activities described in the preceding sentence shall be conducted on a regular basis.
“(2) Forms of outreach, education, training, and technical assistance activities—The outreach, education, training, and technical assistance activities under a payment outreach and education program shall be carried out through any of the following:
“(A) Emails and other electronic communications.
“(B) Webinars.
“(C) Telephone calls.
“(D) In-person training.
“(E) Other forms of communications determined appropriate by the Secretary.
“(3) Information to be provided through activities—The information to be provided to providers of services and suppliers under a payment outreach and education program shall include all of the following information:
“(A) A list of the provider’s or supplier's most frequent and expensive payment errors over the last quarter.
“(B) Specific instructions regarding how to correct or avoid such errors in the future.
“(C) A notice of all new topics that have been approved by the Secretary for audits conducted by recovery audit contractors under section 1893(h).
“(D) Specific instructions to prevent future issues related to such new audits.
“(E) Other information determined appropriate by the Secretary.
“(4) Error rate reduction training
“(A) In general—The activities under a payment outreach and education program shall include error rate reduction training.
“(B) Requirements
“(i) In general—The training described in subparagraph (A) shall—
“(I) be provided at least annually; and
“(II) focus on reducing the improper payments described in paragraph (5).
“(C) Invitation—A medicare administrative contractor shall ensure that all providers of services and suppliers located in the region covered by the contract under this section are invited to attend the training described in subparagraph (A) either in person or online.
“(5) Priority—A medicare administrative contractor shall give priority to activities under the improper payment outreach and education program that will reduce improper payments for items and services that—
“(A) have the highest rate of improper payment;
“(B) have the greatest total dollar amount of improper payments;
“(C) are due to clear misapplication or misinterpretation of Medicare policies;
“(D) are clearly due to common and inadvertent clerical or administrative errors; or
“(E) are due to other types of errors that the Secretary determines could be prevented through activities under the program.
“(6) Information on improper payments from recovery audit contractors
“(A) In general—In order to assist medicare administrative contractors in carrying out improper payment outreach and education programs, the Secretary shall provide each contractor with a complete list of improper payments identified by recovery audit contractors under section 1893(h) with respect to providers of services and suppliers located in the region covered by the contract under this section. Such information shall be provided on a quarterly basis.
“(B) Information—The information described in subparagraph (A) shall include the following information:
“(i) The providers of services and suppliers that have the highest rate of improper payments.
“(ii) The providers of services and suppliers that have the greatest total dollar amounts of improper payments.
“(iii) The items and services furnished in the region that have the highest rates of improper payments.
“(iv) The items and services furnished in the region that are responsible for the greatest total dollar amount of improper payments.
“(v) Other information the Secretary determines would assist the contractor in carrying out the improper payment outreach and education program.
“(C) Format of information—The information furnished to medicare administrative contractors by the Secretary under this paragraph shall be transmitted in a manner that permits the contractor to easily identify the areas of the Medicare program in which targeted outreach, education, training, and technical assistance would be most effective. In carrying out the preceding sentence, the Secretary shall ensure that—
“(i) the information with respect to improper payments made to a provider of services or supplier clearly displays the name and address of the provider or supplier, the amount of the improper payment, and any other information the Secretary determines appropriate; and
“(ii) the information is in an electronic, easily searchable database.
“(7) Communications—All communications with providers of services and suppliers under a payment outreach and education program are subject to the standards and requirements of subsection (g).
“(8) Funding—After application of paragraph (1)(C) of section 1893(h), the Secretary shall retain a portion of the amounts recovered by recovery audit contractors under such section which shall be available to the program management account of the Centers for Medicare & Medicaid Services for purposes of carrying out this subsection and to implement corrective actions to help reduce the error rate of payments under this title. The amount retained under the preceding sentence shall not exceed an amount equal to 25 percent of the amounts recovered under section 1893(h).”
Funding conforming amendment— Section 1893(h)(2) of the Social Security Act (42 U.S.C. 1395ddd(h)(2)) is amended by inserting “or section 1874(h)(8)” after “paragraph (1)(C)”.
Effective date— The amendments made by this subsection take effect on January 1, 2015.
by striking “report.—The Secretary” and inserting “report.—
“(A) In general—The Secretary”
by adding at the end the following new subparagraph:
“(B) Inclusion of certain information
“(i) In general—For reports submitted under this paragraph for 2015 or a subsequent year, each such report shall include the information described in clause (ii) with respect to each of the following categories of audits carried out by recovery audit contractors under this subsection:
“(I) Automated.
“(II) Complex.
“(III) Medical necessity review.
“(IV) Part A.
“(V) Part B.
“(VI) Durable medical equipment.
“(ii) Information described—For purposes of clause (i), the information described in this clause, with respect to a category of audit described in clause (i), is the result of all appeals for each individual level of appeals in such category.”
Recovery Audit Contractor Demonstration Project—
In general— The Secretary shall conduct a demonstration project under title XVIII of the Social Security Act that—
targets audits by recovery audit contractors under section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)) with respect to high error providers of services and suppliers identified under paragraph (3); and
rewards low error providers of services and suppliers identified under such paragraph.
Scope—
Duration— The demonstration project shall be implemented not later than January 1, 2015, and shall be conducted for a period of three years.
Demonstration area— In determining the geographic area of the demonstration project, the Secretary shall consider the following:
The total number of providers of services and suppliers in the region.
The diversity of types of providers of services and suppliers in the region.
The level and variation of improper payment rates of and among individual providers of services and suppliers in the region.
The inclusion of a mix of both urban and rural areas.
Identification of low error and high error providers of services and suppliers—
In general— In conducting the demonstration project, the Secretary shall identify the following two groups of providers in accordance with this paragraph:
Low error providers of services and suppliers.
High error providers of services and suppliers.
Analysis— For purposes of identifying the groups under subparagraph (A), the Secretary shall analyze the following as they relate to the total number and amount of claims submitted in the area and by each provider:
The improper payment rates of individual providers of services and suppliers.
The amount of improper payments made to individual providers of services and suppliers.
The frequency of errors made by the provider of services or supplier over time.
Other information determined appropriate by the Secretary.
Assignment based on composite score— The Secretary shall assign selected providers of services and suppliers under the demonstration program based on a composite score determined using the analysis under subparagraph (B) as follows:
Providers of services and suppliers with high, expensive, and frequent errors shall receive a high score and be identified as high error providers of services and suppliers under subparagraph (A).
Providers of services and suppliers with few, inexpensive, and infrequent errors shall receive a low score and be identified as low error providers of services and suppliers under such subparagraph.
Only a small proportion of the total providers of services and suppliers and individual types of providers of services and suppliers in the geographic area of the demonstration project shall be assigned to either group identified under such subparagraph.
Timeframe of identification—
In general— Any identification of a provider of services or a supplier under subparagraph (A) shall be for a period of 12 months.
Reevaluation— The Secretary shall reevaluate each such identification at the end of such period.
Use of most current information— In carrying out the reevaluation under clause (ii) with respect to a provider of services or supplier, the Secretary shall—
consider the most current information available with respect to the provider of services or supplier under the analysis under subparagraph (B); and
take into account improvement or regression of the provider of services or supplier.
Adjustment of record request maximum— Under the demonstration project, the Secretary shall establish procedures to—
increase the maximum record request made by recovery audit contractors to providers of services and suppliers identified as high error providers of services and suppliers under paragraph (3); and
decrease the maximum record request made by recovery audit contractors to providers of services and suppliers identified as low error providers of services and supplier under such paragraph.
Additional adjustments—
In general— Under the demonstration project, the Secretary may make additional adjustments to requirements for recovery audit contractors under section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)) and the conduct of audits with respect to low error providers of services and suppliers identified under paragraph (3) and high error providers of services and suppliers identified under such paragraph as the Secretary determines necessary in order to incentivize reductions in improper payment rates under title XVIII of such Act (42 U.S.C. 1395 et seq.).
Limitation— The Secretary shall not exempt any group of providers of services or suppliers in the demonstration project from being subject to audit by a recovery audit contractor under such section 1893(h).
Evaluation and report—
Evaluation— The Inspector General of the Department of Health and Human Services shall conduct an evaluation of the demonstration project under this subsection. The evaluation shall include an analysis of—
the error rates of providers of services and suppliers—
identified under paragraph (3) as low error providers of services and suppliers;
identified under such paragraph as high error providers of services and suppliers; and
that are located in the geographic area of the demonstration project and are not identified as either a low error or high error provider of services or supplier under such paragraph; and
any improvements in the error rates of those high error providers of services and suppliers identified under such paragraph.
Report— Not later than 12 months after completion of the demonstration project, the Inspector General shall submit to Congress a report containing the results of the evaluation conducted under subparagraph (A), together with recommendations on whether the demonstration project should be continued or expanded, including on a permanent or nationwide basis.
Funding—
Funding for implementation— For purposes of carrying out the demonstration project under this subsection (other than the evaluation and report under paragraph (6)), the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 (42 U.S.C. 1395i) and the Federal Supplementary Medical Insurance Trust Fund under section 1841 (42 U.S.C. 1395t), in such proportion as the Secretary determines appropriate, of $10,000,000 to the Centers for Medicare & Medicaid Services Program Management Account.
Funding for Inspector General evaluation and report— For purposes of carrying out the evaluation and report under paragraph (6), the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under such section 1817 and the Federal Supplementary Medical Insurance Trust Fund under such section 1841, in such proportion as the Secretary determines appropriate, of $245,000 to the Inspector General of the Department of Health and Human Services.
Availability— Amounts transferred under subparagraph (A) or (B) shall remain available until expended.
Definitions— In this section:
Demonstration project— The term “demonstration project” means the demonstration project under this subsection.
Provider of services— The term “provider of services” has the meaning given that term in section 1861(u).
Recovery audit contractor— The term recovery audit contractor means an entity with a contract under section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)).
Secretary— The term Secretary means the Secretary of Health and Human Services.
Supplier— The term supplier has the meaning given that term in section 1861(d).
Sec. 232 Authority for Medicaid fraud control units to investigate and prosecute complaints of abuse and neglect of Medicaid patients in home and community-based settings
In general— Section 1903(q)(4)(A) of the Social Security Act (42 U.S.C. 1396b(q)(4)(A)) is amended to read as follows:
“(4)
“(A) The entity’s function includes a statewide program for the—
“(i) investigation and prosecution, or referral for prosecution or other action, of complaints of abuse or neglect of patients in health care facilities which receive payments under the State plan under this title or under a waiver of such plan;
“(ii) at the option of the entity, investigation and prosecution, or referral for prosecution or other action, of complaints of abuse or neglect of individuals in connection with any aspect of the provision of medical assistance and the activities of providers of such assistance in a home or community based setting that is paid for under the State plan under this title or under a waiver of such plan; and
“(iii) at the option of the entity, investigation and prosecution, or referral for prosecution or other action, of complaints of abuse or neglect of patients residing in board and care facilities.”
Effective date— The amendment made by subsection (a) shall take effect on January 1, 2015.
Sec. 233 Improved use of funds received by the HHS Inspector General from oversight and investigative activities
In general— Section 1128C(b) of the Social Security Act (42 U.S.C. 1320a–7c(b)) is amended to read as follows:
“(b) Additional use of funds by Inspector General
“(1) Collections from Medicare and Medicaid recovery actions—Notwithstanding section 3302 of title 31, United States Code, or any other provision of law affecting the crediting of collections, the Inspector General of the Department of Health and Human Services may receive and retain three percent of all amounts collected pursuant to civil debt collection actions related to false claims or frauds involving the Medicare program under title XVIII or the Medicaid program under title XIX.
“(2) Crediting—Funds received by the Inspector General under paragraph (1) shall be deposited to the credit of any appropriation available for oversight and enforcement activities of the Inspector General permitted under subsection (a), and shall remain available until expended.”
Effective date— The amendment made by subsection (a) shall apply to funds received from settlements finalized, or judgements entered, on or after the date of the enactment of this Act.
Sec. 234 Preventing and reducing improper Medicare and Medicaid expenditures
Requiring valid prescriber National Provider Identifiers on pharmacy claims— Section 1860D–4(c) of the Social Security Act (42 U.S.C. 1395w–104(c)) is amended by adding at the end the following new paragraph:
“(4) Requiring valid prescriber National Provider Identifiers on pharmacy claims
“(A) In general—For plan year 2015 and subsequent plan years, subject to subparagraph (B), the Secretary shall prohibit PDP sponsors of prescription drug plans from paying claims for prescription drugs under this part that do not include a valid prescriber National Provider Identifier.
“(B) Procedures—The Secretary shall establish procedures for determining the validity of prescriber National Provider Identifiers under subparagraph (A).
“(C) Report—Not later than January 1, 2017, the Inspector General of the Department of Health and Human Services shall submit to Congress a report on the effectiveness of the procedures established under subparagraph (B).”
Reforming how CMS tracks and corrects the vulnerabilities identified by Recovery Audit Contractors— Section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)) is amended—
in paragraph (8), as amended by section 231, by adding at the end the following new subparagraphs:
“(C) Inclusion of improper payment vulnerabilities identified—For reports submitted under this paragraph for 2015 or a subsequent year, each such report shall include—
“(i) a description of—
“(I) the types and financial cost to the program under this title of improper payment vulnerabilities identified by recovery audit contractors under this subsection; and
“(II) how the Secretary is addressing such improper payment vulnerabilities; and
“(ii) an assessment of the effectiveness of changes made to payment policies and procedures under this title in order to address the vulnerabilities so identified.
“(D) Limitation—The Secretary shall ensure that each report submitted under subparagraph (A) does not include information that the Secretary determines would be sensitive or would otherwise negatively impact program integrity.”
by adding at the end the following new paragraph:
“(10) Addressing improper payment vulnerabilities—The Secretary shall address improper payment vulnerabilities identified by recovery audit contractors under this subsection in a timely manner, prioritized based on the risk to the program under this title.”
Strengthening Medicaid program integrity through flexibility— Section 1936 of the Social Security Act (42 U.S.C. 1396u–6) is amended—
in subsection (a), by inserting “, or otherwise,” after “entities”; and
in subsection (e)—
in paragraph (1), in the matter preceding subparagraph (A), by inserting “(including the costs of equipment, salaries and benefits, and travel and training)” after “Program under this section”; and
in paragraph (3), by striking “by 100” and inserting “by 100, or such number as determined necessary by the Secretary to carry out the Program under this section,”.
Access to the National Directory of New Hires— Section 453(j) of the Social Security Act (42 U.S.C. 653(j)) is amended by adding at the end the following new paragraph:
“(12) Information comparisons and disclosures to assist in administration of the Medicare program and State health subsidy programs
“(A) Disclosure to the Administrator of the Centers for Medicare & Medicaid Services—The Administrator of the Centers for Medicare & Medicaid shall have access to the information in the National Directory of New Hires for purposes of determining the eligibility of an applicant for, or enrollee in, the Medicare program under title XVIII or an applicable State health subsidy program (as defined in section 1413(e) of the Patient Protection and Affordable Care Act (42 U.S.C. 18083(e)).
“(B) Disclosure to the Inspector General of the Department of Health and Human Services
“(i) In general—If the Inspector General of the Department of Health and Human Services transmits to the Secretary the names and social security account numbers of individuals, the Secretary shall disclose to the Inspector General information on such individuals and their employers maintained in the National Directory of New Hires.
“(ii) Use of information—The Inspector General of the Department of Health and Human Services may use information provided under clause (i) only for purposes of —
“(I) determining the eligibility of an applicant for, or enrollee in, the Medicare program under title XVIII or an applicable State health subsidy program (as defined in section 1413(e) of the Patient Protection and Affordable Care Act (42 U.S.C. 18083(e)); or
“(II) evaluating the integrity of the Medicare program or an applicable State health subsidy program (as so defined).
“(C) Disclosure to State agencies
“(i) In general—If, for purposes of determining the eligibility of an applicant for, or an enrollee in, an applicable State health subsidy program (as defined in section 1413(e) of the Patient Protection and Affordable Care Act (42 U.S.C. 18083(e)), a State agency responsible for administering such program transmits to the Secretary the names, dates of birth, and social security account numbers of individuals, the Secretary shall disclose to such State agency information on such individuals and their employers maintained in the National Directory of New Hires, subject to this subparagraph.
“(ii) Condition on disclosure by the Secretary—The Secretary shall make a disclosure under clause (i) only to the extent that the Secretary determines that the disclosure would not interfere with the effective operation of the program under this part.
“(iii) Use and disclosure of information by State agencies
“(I) In general—A State agency may not use or disclose information provided under clause (i) except for purposes of determining the eligibility of an applicant for, or an enrollee in, a program referred to in clause (i).
“(II) Information security—The State agency shall have in effect data security and control policies that the Secretary finds adequate to ensure the security of information obtained under clause (i) and to ensure that access to such information is restricted to authorized persons for purposes of authorized uses and disclosures.
“(III) Penalty for misuse of information—An officer or employee of the State agency who fails to comply with this clause shall be subject to the sanctions under subsection (l)(2) to the same extent as if such officer or employee were an officer or employee of the United States.
“(iv) Procedural requirements—State agencies requesting information under clause (i) shall adhere to uniform procedures established by the Secretary governing information requests and data matching under this paragraph.
“(v) Reimbursement of costs—The State agency shall reimburse the Secretary, in accordance with subsection (k)(3), for the costs incurred by the Secretary in furnishing the information requested under this subparagraph.”
Improving the sharing of data between the Federal Government and State Medicaid programs—
In general— The Secretary of Health and Human Services (in this subsection referred to as the “Secretary”) shall establish a plan to encourage and facilitate the participation of States in the Medicare-Medicaid Data Match Program (commonly referred to as the “Medi-Medi Program”) under section 1893(g) of the Social Security Act (42 U.S.C. 1395ddd(g)).
Program revisions To improve Medi-Medi Data Match Program participation by States— Section 1893(g)(1)(A) of the Social Security Act (42 U.S.C. 1395ddd(g)(1)(A)) is amended—
in the matter preceding clause (i), by inserting “or otherwise” after “eligible entities”;
in clause (i)—
by inserting “to review claims data” after “algorithms”; and
by striking “service, time, or patient” and inserting “provider, service, time, or patient”;
in clause (ii)—
by inserting “to investigate and recover amounts with respect to suspect claims” after “appropriate actions”; and
by striking “; and” and inserting a semicolon;
in clause (iii), by striking the period and inserting “; and”; and
by adding at end the following new clause:
“(iv) furthering the Secretary’s design, development, installation, or enhancement of an automated data system architecture—
“(I) to collect, integrate, and assess data for purposes of program integrity, program oversight, and administration, including the Medi-Medi Program; and
“(II) that improves the coordination of requests for data from States.”
Providing states with data on improper payments made for items or services provided to dual eligible individuals—
In general— The Secretary shall develop and implement a plan that allows each State agency responsible for administering a State plan for medical assistance under title XIX of the Social Security Act access to relevant data on improper or fraudulent payments made under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) for health care items or services provided to dual eligible individuals.
Dual eligible individual defined— In this paragraph, the term dual eligible individual means an individual who is entitled to, or enrolled for, benefits under part A of title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.), or enrolled for benefits under part B of title XVIII of such Act (42 U.S.C. 1395j et seq.), and is eligible for medical assistance under a State plan under title XIX of such Act (42 U.S.C. 1396 et seq.) or under a waiver of such plan.
E Other Provisions
Sec. 241 Commission on Improving Patient Directed Health Care
Findings— Congress finds the following:
In order to elevate the role of patient choices in the health care system, the American public must engage in an informed, national, public debate on how the current health care system empowers and informs health care decision-making, and what can be done to improve the likelihood patients receive the care they want and need.
Research suggests that patients often do not receive the care they want. As a result, the end of life is associated with a substantial burden of suffering by the patient and negative health and financial consequences that extend to family members and society.
Patients face a complex and fragmented health care system that may decrease the likelihood that health care choices are known and carried out. The health care system should embed principles that take into account patient wishes.
Decisions concerning health care, including end-of-life issues, affect an increasing number of Americans.
Medical advances are prolonging life expectancy in the United States both in acute life-threatening situations and protracted battles with illness. These advances raise new challenges surrounding health care decision-making.
The United States health care system should promote consideration of a person’s preference in health care decision-making and end-of-life choices.
Commission— The Social Security Act is amended by inserting after section 1150B (42 U.S.C. 1320b–24) the following new section:
“1150C. Commission on Improving Patient Directed Health Care
“(a) Purposes—The purposes of this section are to—
“(1) provide a forum for a nationwide public debate on improving patient self-determination in health care decision-making;
“(2) identify strategies that ensure every American has the health care they want; and
“(3) provide recommendations to Congress that result from the debate.
“(b) Establishment—The Secretary shall establish an entity to be known as the Commission on Improving Patient Directed Health Care (referred to in this section as the “Commission”).
“(c) Membership
“(1) Number and appointment—The Commission shall be composed of 15 members. One member shall be the Secretary. The Comptroller General of the United States shall appoint 14 members.
“(2) Qualifications—The membership of the Commission shall include—
“(A) health care consumers impacted by decision-making in advance of a health care crisis, such as individuals of advanced age, individuals with chronic, terminal and mental illnesses, family care givers, and individuals with disabilities;
“(B) providers in settings where crucial health care decision-making occurs, such as those working in intensive care settings, emergency room departments, primary care settings, nursing homes, hospice, or palliative care settings;
“(C) payors ensuring patients get the level of care they want;
“(D) experts in advance care planning, hospice, palliative care, information technology, bioethics, aging policy, disability policy, pediatric ethics, cultural sensitivity, psychology, and health care financing;
“(E) individuals who represent culturally diverse perspectives on patient self-determination and end-of-life issues; and
“(F) members of the faith community.
“(d) Period of appointment—Members of the Commission shall be appointed for the life of the Commission. Any vacancies shall not affect the power and duties of the Commission but shall be filled in the same manner as the original appointment.
“(e) Designation of the chairperson—Not later than 15 days after the date on which all members of the Commission have been appointed, the Comptroller General shall designate the chairperson of the Commission.
“(f) Subcommittees—The Commission may establish subcommittees if doing so increases the efficiency of the Commission in completing tasks.
“(g) Duties
“(1) Hearings—Not later than 90 days after the date of designation of the chairperson under subsection (e), the Commission shall hold no fewer than 8 hearings to examine—
“(A) the current state of health care decision-making and advance care planning laws in the United States at the Federal level and across the States, as well as options for improving advance care planning tools, especially with regard to use, portability, and storage;
“(B) consumer-focused approaches that educate the American public about patient choices, care planning, and other end-of-life issues;
“(C) the use of comprehensive, patient-centered care plans by providers, the impact care plans have on health care delivery, and methods to expand the use of high quality care planning tools in both public and private health care systems;
“(D) the role of electronic medical records and other technologies in improving patient-directed health care;
“(E) innovative tools for improving patient experience with advanced illness, such as palliative care, hospice, and other models;
“(F) the role social determinants of health, such as socio-economic status, play in patient self-direction in health care;
“(G) the use of culturally-competent tools for health care decision-making;
“(H) strategies for educating providers on care planning, palliative care, hospice care, and other issues surrounding honoring patient choices;
“(I) the sociological and psychological factors that influence health care decision-making and end-of-life choices; and
“(J) the role of spirituality and religion in patient self-determination in health care.
“(2) Additional hearings—The Commission may hold additional hearings on subjects other than those listed in paragraph (1) so long as such hearings are determined necessary by the Commission in carrying out the purposes of this section. Such additional hearings do not have to be completed within the time period specified but shall not delay the other activities of the Commission under this section.
“(3) Number and location of hearings and additional hearings—The Commission shall hold no fewer than 8 hearings as indicated in paragraph (1) and in sufficient number in order to receive information that reflects—
“(A) the geographic differences throughout the United States;
“(B) diverse populations; and
“(C) a balance among urban and rural populations.
“(4) Interactive technology—The Commission may encourage public participation in hearings through interactive technology and other means as determined appropriate by the Commission.
“(5) Report to the american people on patient directed health care—Not later than 90 days after the hearings described in paragraphs (1) and (2) are completed, the Commission shall prepare and make available to health care consumers through the Internet and other appropriate public channels, a report to be entitled, “Report to the American People on Patient Directed Health Care”. Such a report shall be understandable to the general public and include—
“(A) a summary of—
“(i) the hearings described in such paragraphs;
“(ii) how the current health care system empowers and informs decision-making in advance of a health care crisis;
“(iii) factors that contribute to the provision of health care that does not adhere to patient wishes;
“(iv) the impact of care that does not follow patient choices, particularly at the end-of-life, on patients, families, providers, and the health care system;
“(v) the laws surrounding advance care planning and health care decision-making including issues of portability, use, and storage;
“(vi) consumer-focused approaches to education of the American public about patient choices, care planning, and other end-of-life issues;
“(vii) the role of care plans in health care decision-making;
“(viii) the role of providers in ensuring patients receive the care they want;
“(ix) the role of electronic medical records and other technologies in improving patient directed health care;
“(x) the impact of social determinants on patient self-direction in health care services;
“(xi) the use of culturally competent methods for health care decision-making;
“(xii) the sociological and psychological factors that influence patient self-determination; and
“(xiii) the role of spirituality and religion in health care decision-making and end-of-life care;
“(B) best practices from communities, providers, and payors that document patient wishes and provide health care that adheres to those wishes; and
“(C) information on educating providers about health care decision-making and end-of-life issues.
“(6) Interim requirements—Not later than 180 days after the date of completion of the hearings, the Commission shall prepare and make available to the public through the Internet and other appropriate public channels, an interim set of recommendations on patient self-determination in health care and ways to improve and strengthen the health care system based on the information and preferences expressed at the community meetings. There shall be a 90-day public comment period on such recommendations.
“(h) Recommendations—Not later than 120 days after the expiration of the public comment period described in subsection (g)(6), the Commission shall submit to Congress and the President a final set of recommendations. The recommendations must be comprehensive and detailed. The recommendations must contain recommendations or proposals for legislative or administrative action as the Commission deems appropriate, including proposed legislative language to carry out the recommendations or proposals.
“(i) Administration
“(1) Executive director—There shall be an Executive Director of the Commission who shall be appointed by the chairperson of the Commission in consultation with the members of the Commission.
“(2) Compensation—While serving on the business of the Commission (including travel time), a member of the Commission shall be entitled to compensation at the per diem equivalent of the rate provided for level IV of the Executive Schedule under section 5315 of title 5, United States Code, and while so serving away from home and the member’s regular place of business, a member may be allowed travel expenses, as authorized by the chairperson of the Commission. For purposes of pay and employment benefits, rights, and privileges, all personnel of the Commission shall be treated as if they were employees of the Senate.
“(3) Information from federal agencies—The Commission may secure directly from any Federal department or agency such information as the Commission considers necessary to carry out this section. Upon request of the Commission the head of such department or agency shall furnish such information.
“(4) Postal services—The Commission may use the United States mails in the same manner and under the same conditions as other departments and agencies of the Federal Government.
“(j) Detail—Not more than 5 Federal Government employees employed by the Department of Labor, 5 Federal Government employees employed by the Social Security Administration, and 10 Federal Government employees employed by the Department of Health and Human Services may be detailed to the Commission under this section without further reimbursement. Any detail of an employee shall be without interruption or loss of civil service status or privilege.
“(k) Temporary and intermittent services—The chairperson of the Commission may procure temporary and intermittent services under section 3109(b) of title 5, United States Code, at rates for individuals which do not exceed the daily equivalent of the annual rate of basic pay prescribed for level V of the Executive Schedule under section 5316 of such title.
“(l) Annual report—Not later than 1 year after the date of enactment of this Act, and annually thereafter during the existence of the Commission, the Commission shall report to Congress and make public a detailed description of the expenditures of the Commission used to carry out its duties under this section.
“(m) Sunset of commission—The Commission shall terminate on the date that is 4 years after the date on which all the members of the Commission have been appointed under subsection (c)(1) and appropriations are first made available to carry out this section.
“(n) Administration review and comments—Not later than 45 days after receiving the final recommendations of the Commission under subsection (h), the President shall submit a report to Congress which shall contain—
“(1) additional views and comments on such recommendations; and
“(2) recommendations for such legislation and administrative action as the President considers appropriate.
“(o) Required congressional action—Not later than 45 days after receiving the report submitted by the President under subsection (n), each committee of jurisdiction of Congress, the Committee on Finance of the Senate, the Committee on Health, Education, Labor, and Pensions of the Senate, the Committee on Ways and Means of the House of Representatives, the Committee on Energy and Commerce of the House of Representatives, and the Committee on Education and the Workforce of the House of Representatives, shall hold at least 1 hearing on such report and on the final recommendations of the Commission submitted under subsection (h).
“(p) Authorization of appropriations
“(1) In general—There are authorized to be appropriated to carry out this section, $3,000,000 for each of fiscal years 2014 and 2015.
“(2) Report to the American people on patient directed health care—There are authorized to be appropriated for the preparation and dissemination of the Report to the American People on Patient Directed Health Care described in subsection (g)(5), such sums as may be necessary for the fiscal year in which the report is required to be submitted.”
Sec. 242 Expansion of the definition of inpatient hospital services for certain cancer hospitals
Section 1861(b)(3) of the Social Security Act (42 U.S.C. 1395x(b)(3)) is amended—
by inserting “(A)” after “(3)”; and
by adding “and” after the semicolon at the end; and
by adding at the end the following new subparagraph:
“(B) with respect to a hospital that is described in section 1886(d)(1)(B)(v) and that, as of the date of the enactment of the SGR Repeal and Medicare Beneficiary Access Act of 2013, is located in the same building, or on the same campus, as another hospital, items and services described in paragraphs (1) and (2) furnished on or after such date of enactment by the hospital described in such section or by others under arrangements with them made by the hospital;”
Sec. 243 Quality measures for certain post-acute care providers relating to notice and transfer of patient health information and patient care preferences
Development— The Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall provide for the development of one or more quality measures under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) to accurately communicate the existence and provide for the transfer of patient health information and patient care preferences when an individual transitions from a hospital to return home or move to other post-acute care settings.
Use of measure developers— The Secretary shall arrange for the development of such measures by appropriate measure developers.
Endorsement— The Secretary shall arrange for such developed measures to be submitted for endorsement to a consensus-based entity as described in section 1890(a) of the Social Security Act (42 U.S.C. 1395aaa(a)), as amended by section 208.
Use of measures— The Secretary shall, through notice and comment rulemaking, use such measures under the quality reporting programs with respect to—
inpatient hospitals under section 1886(b)(3)(B)(viii) of the Social Security Act (42 U.S.C. 1395ww(b)(3)(B)(viii));
skilled nursing facilities under section 1888(e) of such Act (42 U.S.C. 1395yy(e));
home health services under section 1895(b)(3)(B)(v) of such Act (42 U.S.C. 1395fff(b)(3)(B)(v)); and
other providers of services (as defined in section 1861(u) of such Act) and suppliers (as defined in section 1861(d) of such Act) that the Secretary determines appropriate.
Sec. 244 Criteria for medically necessary, short inpatient hospital stays
In general— The Secretary of Health and Human Services shall consult with, and seek input from, interested stakeholders to determine appropriate criteria for payment under the Medicare program under title VIII of the Social Security Act of an inpatient hospital admission that—
is medically necessary; and
is an inpatient hospital stay that is less than two midnights, as described in section 412.3 of title 42, Code of Federal Regulation, as finalized in the final rule published by the Centers for Medicare & Medicaid Services in the Federal Register on August 19, 2013 (78 Federal Register 50496) entitled “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2014 Rates; Quality Reporting Requirements for Specific Providers; Hospital Conditions of Participation; Payment Policies Related to Patient Status”.
Interested stakeholders— In subsection (a), the term “interested stakeholders” means the following:
Hospitals.
Physicians
Medicare administrative contractors under section 1874A of the Social Security Act (42 U.S.C. 1395kk–1).
Recovery audit contractors under section 1893(h) of such Act (42 U.S.C. 1395ddd(h)).
Other parties determined appropriate by the Secretary.
Sec. 245 Transparency of reasons for excluding additional procedures from the Medicare ambulatory surgical center (ASC) approved list
Section 1833(i)(1) of the Social Security Act (42 U.S.C. 1395l(i)(1)) is amended by adding at the end the following: “In updating such lists for application in years beginning after December 31, 2014, for each procedure that was requested to be included on such lists during the public comment period but which the Secretary does not propose (in the final rule updating such lists) to so include, the Secretary shall describe in such final rule the specific safety criteria for not including such procedure on such lists.”.
Sec. 246 Supervision in critical access hospitals
General supervision in critical access hospitals— Section 1834(g) of the Social Security Act (42 U.S.C. 1395m(g)) is amended by adding at the end the following new paragraph:
“(6) Supervision—In the case of services furnished on or after the date of the enactment of this paragraph, the level of supervision with respect to outpatient critical access hospital services shall be general supervision (as defined by the Secretary).”
Supervision of cardiac and pulmonary rehabilitation programs in critical access hospitals— Section 1861(eee)(2)(B) of the Social Security Act (42 U.S.C. 1395x(eee)(2)(B)) is amended by inserting “, or in the case of a critical access hospital, a physician, or (beginning on the date of enactment of the SGR Repeal and Medicare Beneficiary Access Act of 2013) a nurse practitioner, clinical nurse specialist, or physician assistant (as such terms are defined in subsection (aa)(5)),” after “a physician”.
Sec. 247 Requiring State licensure of bidding entities under the competitive acquisition program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)
Section 1847(a)(1) of the Social Security Act (42 U.S.C. 1395w–3(a)(1)) is amended by adding at the end the following new subparagraph:
“(G) Requiring State licensure of bidding entities—With respect to rounds of competitions beginning on or after the date of enactment of this subparagraph, the Secretary may only accept a bid from an entity for an area if the entity meets applicable State licensure requirements for such area for all items in such bid.”
Sec. 248 Recognition of attending physician assistants as attending physicians To serve hospice patients
Recognition of attending physician assistants as attending physicians To serve hospice patients—
In general— Section 1861(dd)(3)(B) of the Social Security Act (42 U.S.C. 1395x(dd)(3)(B)) is amended—
by striking “or nurse” and inserting “, the nurse”; and
by inserting “, or the physician assistant (as defined in such subsection)” after “subsection (aa)(5))”.
Clarification of hospice role of physician assistants— Section 1814(a)(7)(A)(i)(I) of the Social Security Act (42 U.S.C. 1395f(a)(7)(A)(i)(I)) is amended by inserting “or a physician assistant” after “a nurse practitioner”.
Effective date— The amendments made by this section shall apply to items and services furnished on or after January 1, 2015.
Sec. 249 Remote patient monitoring pilot projects
Pilot projects—
In general— Not later than 9 months after the date of the enactment of this Act, the Secretary shall conduct pilot projects under title XVIII of the Social Security Act for the purpose of providing incentives to home health agencies to furnish remote patient monitoring services that reduce expenditures under such title.
Site requirements—
Urban and Rural— The Secretary shall conduct the pilot projects under this section in both urban and rural areas.
Site in a small state— The Secretary shall conduct at least 1 of the pilot projects in a State with a population of less than 1,000,000.
Medicare beneficiaries within the scope of projects—
In general— The Secretary shall specify the criteria for identifying those Medicare beneficiaries who shall be considered within the scope of the pilot projects under this section for purposes of the application of subsection (c) and for the assessment of the effectiveness of the home health agency in achieving the objectives of this section.
Criteria— The criteria specified under paragraph (1)—
shall include conditions and clinical circumstances, including congestive heart failure, diabetes, and chronic pulmonary obstructive disease, and other conditions determined appropriate by the Secretary; and
may provide for the inclusion in the projects of Medicare beneficiaries who begin receiving home health services under title XVIII of the Social Security Act after the date of the implementation of the projects.
Incentives—
Performance targets— The Secretary shall establish for each home health agency participating in a pilot project under this section a performance target using one of the following methodologies, as determined appropriate by the Secretary:
Adjusted historical performance target— The Secretary shall establish for the agency—
a base expenditure amount equal to the average total payments made under parts A, B, and D of title XVIII of the Social Security Act for Medicare beneficiaries determined to be within the scope of the pilot project in a base period determined by the Secretary; and
an annual per capita expenditure target for such beneficiaries, reflecting the base expenditure amount adjusted for risk, changes in costs, and growth rates.
Comparative performance target— The Secretary shall establish for the agency a comparative performance target equal to the average total payments made under such parts A, B, and D during the pilot project for comparable individuals in the same geographic area that are not determined to be within the scope of the pilot project.
Payment— Subject to paragraph (3), the Secretary shall pay to each home health agency participating in a pilot project a payment for each year under the pilot project equal to a 75 percent share of the total Medicare cost savings realized for such year relative to the performance target under paragraph (1).
Limitation on expenditures— The Secretary shall limit payments under this section in order to ensure that the aggregate expenditures under title XVIII of the Social Security Act (including payments under this subsection) do not exceed the amount that the Secretary estimates would have been expended if the pilot projects under this section had not been implemented, including any reasonable costs incurred by the Secretary in the administration of the pilot projects.
No duplication in participation in shared savings programs— A home health agency that participates in any of the following shall not be eligible to participate in the pilot projects under this section:
A model tested or expanded under section 1115A of the Social Security Act (42 U.S.C. 1315a) that involves shared savings under title XVIII of such Act or any other program or demonstration project that involves such shared savings.
The independence at home medical practice demonstration program under section 1866E of such Act (42 U.S.C. 1395cc–5).
Waiver authority— The Secretary may waive such provisions of titles XI and XVIII of the Social Security Act as the Secretary determines to be appropriate for the conduct of the pilot projects under this section.
Report to Congress— Not later than 3 years after the date that the first pilot project under this section is implemented, the Secretary shall submit to Congress a report on the projects. Such report shall contain—
a detailed description of the projects, including any changes in clinical outcomes for Medicare beneficiaries under the projects, Medicare beneficiary satisfaction under the projects, utilization of items and services under parts A, B, and D of title XVIII of the Social Security Act by Medicare beneficiaries under the projects, and Medicare per-beneficiary and Medicare aggregate spending under the projects;
a detailed description of issues related to the expansion of the projects under subsection (f);
recommendations for such legislation and administrative actions as the Secretary considers appropriate; and
other items considered appropriate by the Secretary.
Expansion— If the Secretary determines that any of the pilot projects under this section enhance health outcomes for Medicare beneficiaries and reduce expenditures under title XVIII of the Social Security Act, the Secretary shall initiate comparable projects in additional areas.
Payments have no effect on other Medicare payments to home health agencies— A payment under this section shall have no effect on the amount of payments that a home health agency would otherwise receive under title XVIII of the Social Security Act for the provision of home health services.
Study and report on the appropriate valuation for remote patient monitoring services under the Medicare physician fee schedule—
Study— The Secretary shall conduct a study on the appropriate valuation for remote patient monitoring services under the Medicare physician fee schedule under section 1848 of the Social Security Act (42 U.S.C. 1395w–4) in order to accurately reflect the resources involved in furnishing such services.
Report— Not later than 6 months after the date of the enactment of this Act, the Secretary shall submit to Congress a report on the study conducted under paragraph (1), together with such recommendations as the Secretary determines appropriate.
Definitions— In this section:
Home health agency— The term “home health agency” has the meaning given that term in section 1861(o) of the Social Security Act (42 U.S.C. 1395x(o)).
Remote patient monitoring services—
In general— The term remote patient monitoring services means services furnished in the home using remote patient monitoring technology which—
shall include patient monitoring or patient assessment; and
may include in-home technology-based professional consultations, patient training services, clinical observation, treatment, and any additional services that utilize technologies specified by the Secretary.
Limitation— The term “remote patient monitoring services” shall not include a telecommunication that consists solely of a telephone audio conversation, facsimile, or electronic text mail between a health care professional and a patient.
Remote patient monitoring technology— The term remote patient monitoring technology means a coordinated system that uses one or more home-based or mobile monitoring devices that automatically transmit vital sign data or information on activities of daily living and may include responses to assessment questions collected on the devices wirelessly or through a telecommunications connection to a server that complies with the Federal regulations (concerning the privacy of individually identifiable health information) promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996, as part of an established plan of care for that patient that includes the review and interpretation of that data by a health care professional.
Secretary— The term “Secretary” means the Secretary of Health and Human Services.
Sec. 250 Community-Based Institutional Special Needs Plan Demonstration Program
In general— The Secretary of Health and Human Services (referred to in this section as the “Secretary”) shall establish a Community-Based Institutional Special Needs Plan (CBI-SNP) demonstration program to prevent and delay institutionalization under Medicaid among targeted low-income Medicare beneficiaries.
Establishment— The Secretary shall enter into agreements with not more than 5 specialized MA plans for special needs individuals, as defined in section 1859(b)(6)(B)(i) of the Social Security Act (42 U.S.C. 1395w–28(b)(6)(B)(i)), to conduct the CBI-SNP demonstration program. Under the CBI-SNP demonstration program, a targeted low-income Medicare beneficiary shall receive, as supplemental benefits under section 1852(a)(3) of such Act (42 U.S.C. 1395w-22(a)(3)), long-term care services or supports that—
the Secretary determines appropriate for the purposes of the CBI-SNP demonstration program; and
for which payment may be made under the State plan under title XIX of such Act (42 U.S.C. 1396 et seq.) of the State in which the targeted low-income Medicare beneficiary is located.
Eligible plans— To be eligible to participate in the CBI-SNP demonstration program, a specialized MA plan for special needs individuals must—
serve special needs individuals (as defined in section 1859(b)(6)(B)(i) of the Social Security Act (42 U.S.C. 1395w–28(b)(6)(B)(i));
have experience in offering special needs plans for nursing home-eligible, non-institutionalized Medicare beneficiaries who live in the community;
be located in a State that the Secretary has determined will participate in the CBI-SNP demonstration program by agreeing to make available data necessary for purposes of conducting the independent evaluation required under subsection (f); and
meet such other criteria as the Secretary may require.
Targeted low-income Medicare beneficiary defined— In this section, the term targeted low-income Medicare beneficiary means a Medicare beneficiary who—
is enrolled in a specialized MA plan for special needs individuals that has been selected to participate in the CBI-SNP demonstration program;
is a subsidy eligible individual (as defined in section 1860D–14(a)(3)(A) of the Social Security Act (42 U.S.C. 1395w-114(a)(3)(A)); and
is unable to perform 2 or more activities of daily living (as defined in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986).
Implementation deadline; duration— The CBI-SNP demonstration program shall be implemented not later than January 1, 2016, and shall be conducted for a period of 3 years.
Independent evaluation and reports—
Independent evaluation— Not later than 2 years after the completion of the CBI-SNP demonstration program, the Secretary shall provide for the evaluation of the CBI-SNP demonstration program by an independent third party. The evaluation shall determine whether the CBI-SNP demonstration program has improved patient care and quality of life for the targeted low-income Medicare beneficiaries participating in the CBI-SNP demonstration program. Specifically, the evaluation shall determine if the CBI-SNP demonstration program has—
reduced hospitalizations or re-hospitalizations;
reduced Medicaid nursing home facility stays; and
reduced spenddown of income and assets for purposes of becoming eligible for Medicaid.
Reports— Not later than 3 years after the completion of the CBI-SNP demonstration program, the Secretary shall submit to Congress a report containing the results of the evaluation conducted under paragraph (1), together with such recommendations for legislative or administrative action as the Secretary determines appropriate.
Funding—
Funding for implementation— For purposes of carrying out the demonstration program under this section (other than the evaluation and report under subsection (f)), 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 such proportion as the Secretary determines appropriate, of $3,000,000 to the Centers for Medicare & Medicaid Services Program Management Account.
Funding for evaluation and report— For purposes of carrying out the evaluation and report under subsection (f), the Secretary shall provide for the transfer from the Federal Hospital Insurance Trust Fund under such section 1817 and the Federal Supplementary Medical Insurance Trust Fund under such section 1841, in such proportion as the Secretary determines appropriate, of $500,000.
Availability— Amounts transferred under paragraph (1) or (2) shall remain available until expended.
Budget neutrality— In conducting the CBI-SNP demonstration program, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary estimates would have been expended under titles XVIII and XIX of the Social Security Act (42 U.S.C. 1395 et seq., 1396 et seq.) if the CBI-SNP demonstration program had not been implemented.
Paperwork Reduction Act— Chapter 35 of title 44, United States Code, shall not apply to the testing and evaluation of the CBI-SNP demonstration program under this section.
Sec. 251 Applying CMMI waiver authority to PACE in order to foster innovations
CMMI waiver authority— Subsection (d)(1) of section 1115A of the Social Security Act (42 U.S.C. 1315a) is amended—
by inserting “(other than subsections (b)(1)(A) and (c)(5) of section 1894)” after “XVIII”; and
by striking “and 1903(m)(2)(A)(iii)” and inserting “1903(m)(2)(A)(iii), and 1934 (other than subsections (b)(1)(A) and (c)(5) of such section)”.
Sense of the Senate— It is the sense of the Senate that the Secretary of Health and Human Services should use the waiver authority provided under the amendments made by this section to provide, in a budget neutral manner, programs of all-inclusive care for the elderly (PACE programs) with increased operational flexibility to support the ability of such programs to improve and innovate and to reduce technical and administrative barriers that have hindered enrollment in such programs.
Sec. 252 Improve and modernize Medicaid data systems and reporting
In general— The Secretary of Health and Human Services shall implement a strategic plan to increase the usefulness of data about State Medicaid programs reported by States to the Centers for Medicare & Medicaid Services. The strategic plan shall address redundancies and gaps in Medicaid data systems and reporting through improvements to, and modernization of, computer and data systems. Areas for improvement under the plan shall include (but not be limited to) the following:
The reporting of encounter data by managed care plans.
The timeliness and quality of reported data, including enrollment data.
The consistency of data reported from multiple sources.
Information about State program policies.
Implementation status report— Not later than 1 year after the date of enactment of this Act, the Secretary of Health and Human Services shall submit a report to Congress on the status of the implementation of the strategic plan required under subsection (a).
Authorization of appropriations— There is authorized to be appropriated to the Secretary of Health and Human Services for the period of fiscal years 2015 through 2109, such sums as may be necessary to carry out this section.
Sec. 253 Fairness in Medicaid supplemental needs trusts
In general— Section 1917(d)(4)(A) of the Social Security Act (42 U.S.C. 1396p(d)(4)(A)) is amended by inserting “the individual,” after “for the benefit of such individual by”.
Effective date— The amendment made by subsection (a) shall apply to trusts established on or after the date of the enactment of this Act.
Sec. 254 Helping Ensure Life- and Limb-Saving Access to Podiatric Physicians
Including podiatrists as physicians under the Medicaid program—
In general— Section 1905(a)(5)(A) of the Social Security Act (42 U.S.C. 1396d(a)(5)(A)) is amended by striking “section 1861(r)(1)” and inserting “paragraphs (1) and (3) of section 1861(r)”.
Effective date—
In general— Except as provided in subparagraph (B), the amendment made by paragraph (1) shall apply to services furnished on or after the date of enactment of this Act.
Extension of effective date for State law amendment— In the case of a State plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) which the Secretary of Health and Human Services determines requires State legislation in order for the plan to meet the additional requirement imposed by the amendment made by paragraph (1), the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these additional 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 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.
Modifications to requirements for diabetic shoes to be included under medical and other health services under Medicare—
In general— Section 1861(s)(12) of the Social Security Act (42 U.S.C. 1395x(s)(12)) is amended to read as follows:
“(12) subject to section 4072(e) of the Omnibus Budget Reconciliation Act of 1987, extra-depth shoes with inserts or custom molded shoes (in this paragraph referred to as “therapeutic shoes”) with inserts for an individual with diabetes, if—
“(A) the physician who is managing the individual’s diabetic condition—
“(i) documents that the individual has diabetes;
“(ii) certifies that the individual is under a comprehensive plan of care related to the individual’s diabetic condition; and
“(iii) documents agreement with the prescribing podiatrist or other qualified physician (as established by the Secretary) that it is medically necessary for the individual to have such extra-depth shoes with inserts or custom molded shoes with inserts;
“(B) the therapeutic shoes are prescribed by a podiatrist or other qualified physician (as established by the Secretary) who—
“(i) examines the individual and determines the medical necessity for the individual to receive the therapeutic shoes; and
“(ii) communicates in writing the medical necessity to the physician described in subparagraph (A) for the individual to have therapeutic shoes along with findings that the individual has peripheral neuropathy with evidence of callus formation, a history of pre-ulcerative calluses, a history of previous ulceration, foot deformity, previous amputation, or poor circulation; and
“(C) the therapeutic shoes are fitted and furnished by a podiatrist or other qualified supplier (as established by the Secretary), such as a pedorthist or orthotist, who is not the physician described in subparagraph (A) (unless the Secretary finds that the physician is the only such qualified individual in the area);”
Effective date— The amendment made by paragraph (1) shall apply with respect to items and services furnished on or after January 1, 2015.
Sec. 255 Demonstration program to improve community mental health services
Establishment— Not later than January 1, 2016, the Secretary of Health and Human Services (referred to in this section as the “Secretary”), in coordination with the Administrator of the Substance Abuse and Mental Health Services Administration, shall award planning grants to not to exceed 10 States to enable such States to carry out 5-year demonstration programs to improve the provision of behavioral health services provided by certified community behavioral health clinics in the State.
Eligibility—
Application— To be eligible to receive a grant under subsection (a), a State shall—
submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require;
certify to the Secretary that behavioral health providers that are provided assistance under the demonstration program meet the criteria for certified community behavioral health clinics under subsection (c);
conduct a financial assessment of the demonstration program to be carried out under the grant by providing a detailed estimate of eligible clinics and Medicaid expenditures over the entire projected period of the demonstration program; and
comply with any other requirement determined appropriate by the Secretary.
Waiver of Medicaid requirement— In approving States to conduct demonstration programs under this section, the Secretary shall waive section 1902(a)(1) of the Social Security Act (42 U.S.C. 1396a(a)(1)) (relating to statewideness) as may be necessary to conduct the demonstration program in accordance with the requirements of this section
Criteria—
Criteria for certified community behavioral health clinics— The criteria referred to in subsection (b)(1)(B) are that the center performs each of the following:
Provide services in locations that ensure services will be available and accessible promptly and in a manner which preserves human dignity and assures continuity of care.
Provide services in a mode of service delivery appropriate for the target population.
Provide individuals with a choice of service options, including developmentally appropriate evidence based interventions, where there is more than one efficacious treatment.
Employ a core clinical staff that is trained to provide evidence-based practices and is multidisciplinary and culturally and linguistically competent, including the availability of translation or similar services and arrangements if the clinic is located in a geographic area of limited English-speaking ability.
Establish an emergency plan to support continuity of services for individuals during an emergency or disaster.
Demonstrate the capacity to comply with behavioral health and related health care quality measures promulgated by such entities as the National Quality Forum, the National Committee for Quality Assurance, or other nationally recognized accrediting bodies.
Provide services to any individual residing or employed in the service area of the clinic and ensure that no patient or consumer will be denied mental health or other health care services due to an individual’s inability to pay for such services.
Ensure that any fees or payments required by the clinic for such services will be imposed for individuals eligible for medical assistance under the State Medicaid plan under title XIX of the Social Security Act in accordance with the requirements of such State plan and for any other individuals will be reduced or waived to enable the clinic to comply with subparagraph (G), including preparing a schedule of fees or payments for the provision of services that is consistent with locally prevailing rates or charges designed to cover the reasonable costs to the clinic of operation along with a corresponding schedule of discounts to be applied to the payment of such fees or payments, such discounts to be adjusted on the basis of the patient’s ability to pay.
Report required encounter data, clinical outcomes data, and quality data.
Provide, directly or through contract, to the extent covered for adults in the State Medicaid plan under title XIX of the Social Security Act and for children in accordance with section 1905(r) of such Act regarding early and periodic screening, diagnosis, and treatment, each of the following services:
Screening, assessment, and diagnosis, including risk assessment.
Person-centered treatment planning or similar processes, including risk assessment and crisis planning.
Outpatient mental health and substance use services, including screening, assessment, diagnosis, psychotherapy, cognitive behavioral therapy, applied behavioral analysis, medication management, and integrated treatment for trauma, mental illness, and substance abuse which shall be evidence-based (including cognitive behavioral therapy, long acting injectable medications, and other such therapies which are evidence-based).
Outpatient clinic primary care screening and monitoring of key health indicators and health risk (including screening for diabetes, hypertension, and cardiovascular disease and monitoring of weight, height, body mass index (BMI), blood pressure, blood glucose or HbA1C, and lipid profile).
Crisis mental health services, including 24-hour mobile crisis teams, emergency crisis intervention services, and crisis stabilization.
Targeted case management (services to assist individuals gaining access to needed medical, social, educational, and other services and applying for income security and other benefits to which they may be entitled), and care coordination.
Psychiatric rehabilitation services including skills training, assertive community treatment, family psychoeducation, disability self-management, supported employment, supported housing services, therapeutic foster care services, and such other evidence-based practices as the Secretary may require.
Peer support and counselor services and family supports.
Maintain linkages, and where possible enter into formal contracts, agreements, or partnerships with at least one federally qualified health center, unless there is no such center serving the service area, in order to ensure that the delivery of behavioral health care is integrated with primary and preventive care services, so long as such linkages, contract, agreement, or partnership meets requirements as prescribed by the Secretary;
Maintain additional linkages and where possible enter into formal contracts with the following:
Inpatient psychiatric facilities and substance use detoxification, post-detoxification step-down services, and residential programs.
Adult and youth peer support and counselor services.
Family support services for families of children with serious mental or substance use disorders.
Other community or regional services, supports, and providers, including schools, child welfare agencies, juvenile and criminal justice agencies and facilities, Indian Health Service youth regional treatment centers, housing agencies and programs, employers, State licensed and nationally accredited child placing agencies for therapeutic foster care service, and other social and human services.
Onsite or offsite access to primary care services.
Enabling services, including outreach, transportation, and translation.
Health and wellness services, including services for tobacco cessation.
Department of Veterans Affairs medical centers, independent outpatient clinics, drop-in centers, and other facilities of the Department as defined in section 1801 of title 38, United States Code.
Inpatient acute care hospitals and hospital outpatient clinics.
Where feasible, provide outreach and engagement to encourage individuals who could benefit from mental health care to freely participate in receiving the administrative services described in this subsection.
Where feasible, provide intensive, community-based mental health care for members of the armed forces and veterans, particularly those members and veterans located in rural areas, such care to be consistent with minimum clinical mental health guidelines promulgated by the Veterans Health Administration including clinical guidelines contained in the Uniform Mental Health Services Handbook of such Administration.
Where feasible, require certified community behavioral health clinics to provide valid and reliable trauma screening and functional or developmental assessment to determine need, match services to needs, and to measure progress over time.
Regulations— Prior to the selection of participating States, and not later than 18 months after the date of the enactment of this Act, the Secretary, in consultation with the Substance Abuse and Mental Health Services Administration and the State Mental Health and Substance Abuse Authorities, shall issue final regulations for certifying non-profit and local government behavioral health authorities and Indian Health Service tribal facilities as community behavioral health clinics.
Requirements— In awarding grants under this section, the Secretary shall—
ensure the geographic diversity of grantee States;
ensure that certified community behavioral health clinics in such States that are located in rural areas, as defined by the Secretary, and other mental health professional shortage areas are fairly and appropriately considered with the objective of facilitating access to mental health services in such areas;
take into account the ability of clinics in such States to provide required services, and the ability of such clinics to report required data as required under this section; and
take into account the ability of such States to provide such required services on a statewide basis.
Exemption— For purposes of this section, certified community behavioral health clinics that receive payments under section 1902(bb) of the Social Security Act which are located in rural areas, as defined by the Secretary, shall be exempt from the requirements contained in subparagraphs (A) and (J)(v) of subsection (c)(1).
Treatment of certain services provided by community behavioral health clinics as medical assistance—
In general— For purposes of the demonstration program under this section, community behavioral health clinic services (as defined in subsection (h)(1)) that are provided by certified community behavioral health clinics receiving assistance under this section shall be considered medical assistance for purposes of payments to States under paragraph (3)(C).
Grant condition— As a condition of receiving a grant under this section, a State shall agree to provide for payment for community behavioral health clinic services in accordance with the prospective payment system established by the Secretary under paragraph (3).
Prospective payment system—
In general— Not later than 18 months after the date of enactment of this Act, the Secretary shall establish a prospective payment system for community behavioral health clinic services furnished by a community behavioral health clinic receiving assistance under this section in the same manner as payments are required to be made under section 1902(bb) of the Social Security Act (42 U.S.C. 1396a(bb)) for services described in section 1905(a)(2)(C) of such Act (42 U.S.C. 1396d(a)(2)(C)) furnished by a Federally-qualified health center and services described in section 1905(a)(2)(B) of such Act (42 U.S.C. 1396d(a)(2)(B)) furnished by a rural health clinic.
Requirements— The prospective payment system established by the Secretary under subparagraph (A) shall provide that—
no payment shall be made for inpatient care, residential treatment, room and board expenses, or any other non-ambulatory services, as determined by the Secretary; and
no payment shall be made to satellite facilities of community behavioral health clinics if such facilities are established after the date of enactment of this Act.
Payments to states— The Secretary shall pay each State awarded a grant under this section an amount each quarter equal to the enhanced FMAP (as defined in section 2105(b) of the Social Security Act (42 U.S.C. 1397dd(b)) but without regard to the second and third sentences of that section) of the State's expenditures in the quarter for medical assistance for community behavioral health clinic services provided by certified community behavioral health clinics in the State that receive assistance under this section. Payments to States made under this subparagraph shall be considered to have been under, and are subject to the requirements of, section 1903 of the Social Security Act (42 U.S.C. 1396b).
Annual report—
In general— Not later than 1 year after the date on which the first grants are awarded under this section, and annually thereafter, the Secretary shall submit to Congress an annual report on the use of funds provided under the demonstration program. Each such report shall include—
an assessment of access to community-based mental health services under the Medicaid program in the States awarded such grants;
an assessment of the quality and scope of services provided by certified community behavioral health clinics under the grants as compared against community-based mental health services provided in States that are not receiving such grants; and
an assessment of the impact of the demonstration programs on the costs of a full range of mental health services (including inpatient, emergency and ambulatory services).
Recommendations— Not later than December 31, 2019, the Secretary shall submit to Congress recommendations concerning whether the demonstration programs under this section should be continued and expanded on a national basis.
Definitions— In this section:
Community behavioral health clinic services— The term community behavioral health clinic services means ambulatory behavioral health services of the type described in subparagraphs (J), (M), (N), and (O) of subsection (c)(1) that are provided by certified community behavioral health clinics receiving assistance under this section.
State— The term State has the meaning given such term for purposes of title XIX of the Social Security Act (42 U.S.C. 1396 et seq.).
Authorization of appropriations— There is authorized to be appropriated to carry out this section, $50,000,000 for fiscal year 2016, to remain available until expended.
Sec. 256 Annual Medicaid DSH report
Section 1923 of the Social Security Act (42 U.S.C. 1396r–4) is amended by adding at the end the following:
“(k) Annual report to Congress
“(1) In general—Beginning January 1, 2015, and annually thereafter, the Secretary shall submit a report to Congress on the program established under this section for making payment adjustments to disproportionate share hospitals for the purpose of providing Congress with information relevant to determining an appropriate level of overall funding for such payment adjustments during and after the period in which aggregate reductions in the DSH allotments to States are required under paragraphs (7) and (8) of subsection (f).
“(2) Required report information—Except as otherwise provided, each report submitted under this subsection shall include the following:
“(A) Information and data relating to changes in the number of uninsured individuals for the most recent year for which such data are available as compared to 2013 and as compared to the Congressional Budget Office estimates of uninsured individuals made at the time of the enactment of the Patient Protection and Affordable Care Act (Public Law 111–148) and the Health Care and Education Reconciliation Act of 2010 (Public Law 111–152).
“(B) Information and data relating to the extent to which hospitals continue to incur uncompensated care costs from providing unreimbursed or under-reimbursed services to individuals who either are eligible for medical assistance under the State plan under this title or under a waiver of such plan or who have no health insurance (or other source of third party coverage) for such services.
“(C) Information and data relating to the extent to which hospitals continue to provide charity care and unreimbursed or under-reimbursed services, or otherwise incur bad debt, under the program established under this title, the State Children's Health Insurance Program established under title XXI, and State or local indigent care programs, as reported on cost reports submitted under title XVIII or such other data as the Secretary determines appropriate.
“(D) In the first report submitted under this section, a methodology for estimating the amount of unpaid patient deductibles, copayments and coinsurance incurred by hospitals for patients enrolled in qualified health plans through an American Health Benefits Exchange, using existing data and minimizing the administrative burden on hospitals to the extent possible, and in subsequent reports, data regarding such uncompensated care costs collected pursuant to such methodology.
“(E) For each State, information and data relating to the difference between the DSH allotment for the State for the fiscal year that began on October 1 of the year preceding the year in which the report is submitted and the aggregate amount of uncompensated care costs for all disproportionate share hospitals in the State.
“(F) Information and data relating to the extent to which there are certain vital hospital systems that are disproportionately experiencing high levels of uncompensated care and that have multiple other missions, such as a commitment to graduate medical education, the provision of tertiary and trauma care services, providing public health and essential community services, and providing comprehensive, coordinated care.
“(G) Such other information and data relevant to the determination of the level of funding for, and amount of, State DSH allotments as the Secretary determines appropriate
“(3) Authorization of appropriations—There is authorized to be appropriated to the Secretary for the period of fiscal years 2015 through 2109, such sums as may be necessary to carry out this subsection.”
Sec. 257 Implementation
To the extent the Secretary of Health and Human Services issues a regulation to carry out the provisions of this Act, the Secretary shall, unless otherwise specified in this Act—
issue a notice of proposed rulemaking that includes the proposed regulation;
provide a period of not less than 60 calendar days for comments on the proposed regulation;
not more than 24 months following the date of publication of the proposed rule, publish the final regulation or take alternative action (such as withdrawing the rule or proposing a revised rule with a new comment period) on the proposed regulation; and
not less than 30 days before the effective date of the final regulation, publish the final regulation or take alternative action (such as withdrawing the rule or proposing a revised rule with a new comment period) on the proposed regulation.