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 April 1, 2014,”.
Title II — Extensions
II Extensions
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)(iii), 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 Commonsense Medicare SGR Repeal and Beneficiary Access Improvement Act of 2014”; and
in paragraph (5)(C), by adding at the end the following new clause:
“(iii) Beginning on the date of enactment of the Commonsense Medicare SGR Repeal and Beneficiary Access Improvement Act of 2014 and ending on the day before the date that is 12 months after such date of enactment, the manual medical review process described in clause (i) shall apply with respect to expenses incurred in a year for services described in paragraphs (1) and (3) that exceed the threshold described in clause (ii) for the year.”
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)(2), 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 the date that is 12 months after the date of enactment of the Commonsense Medicare SGR Repeal and Beneficiary Access Improvement Act of 2014, 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 aberrant compared to peers.
“(ii) Services furnished by a therapy provider who, in a prior period, has a high claims denial percentage or is less 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 other factors.
“(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 potential 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, the following shall apply:
“(A) Prior authorization determination—The Secretary shall make a determination, prior to the service being furnished, of whether the service would or would not meet the applicable requirements of section 1862(a)(1)(A).
“(B) Denial of payment—Subject to paragraph (6), no payment shall be made under this part for the service unless the Secretary determines pursuant to subparagraph (A) that the service would meet the applicable requirements of such section.
“(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—If the Secretary does not make a prior authorization determination under paragraph (4)(A) within 10 business days of the date of the Secretary’s receipt of medical documentation needed to make such determination, paragraph (4)(B) shall not apply.
“(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.
“(C) Limitation—There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the identification of services for medical review or the process for 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 (1). 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 24 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 “April 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 “April 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 July 1, 2015, the Secretary shall—
“(I) specify the data collection system under subparagraph (A) and the time period during which such data is required to be submitted; 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 for each period for which reporting of data is required.
“(C) Penalty for failure to report cost and other information—Beginning on July 1, 2016, a 5 percent reduction to payments under this part shall be made for a 1-year prospective period specified by the Secretary 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 during the period specified under subparagraph (B)(i)(I).
“(D) Ongoing data collection
“(i) Revision of data collection system—The Secretary may, as determined appropriate, periodically revise the data collection system.
“(ii) Subsequent data collection—In order to continue to evaluate the appropriateness of payment rates under this subsection, the Secretary shall, for years after 2016 (but not less often than once every 3 years), require providers and suppliers of ambulance services to submit information for a period the Secretary determines appropriate. The penalty described in subparagraph (C) shall apply to such subsequent data collection periods.
“(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 April 1, 2014,”; and
in clause (ii)(II), by striking “and before April 1, 2014,”.
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 April 1, 2014,”; and
in clause (iv), by striking “through fiscal year 2013 and the portion of fiscal year 2014 before April 1, 2014” 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 the first 2 quarters of fiscal year 2014” 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, for purposes of fiscal year 2014, 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 the portion of fiscal year 2014 beginning on April 1, 2014, fiscal year 2015, and subsequent years”;
in subparagraph (C)(i)—
by striking “fiscal years 2011, 2012, and 2013, and the portion of fiscal year 2014 before” and inserting “fiscal year 2011 and subsequent fiscal years,” each place it appears; and
by striking “or portion of fiscal year” after “during the fiscal year”; 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”;
by striking “fiscal years 2011, 2012, and 2013, and the portion of fiscal year 2014 before April 1, 2014” and inserting “fiscal year 2011 or a subsequent fiscal year”; and
by striking “or the portion of fiscal year” after “in the fiscal year”.
Implementation— Notwithstanding any other provision of law, for purposes of fiscal year 2014, 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, 2016”; 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 grievances and appeals process
“(i) In general—Not later than April 1, 2015, the Secretary shall establish procedures unifying the grievances and appeals procedures under sections 1852(f), 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, beneficiaries and their representatives, and other relevant stakeholders.
“(ii) Procedures—The procedures established under clause (i) shall—
“(I) adopt the provisions for the enrollee under current law that are most protective for the enrollee and are compatible with unified timeframes and consolidated access to external review under an integrated process;
“(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), as applicable, to both unified appeals and unified grievance procedures.
“(iii) Elements described—The following elements are described in this clause:
“(I) Single notification of all applicable grievances and appeal rights under this title and title XIX.
“(II) Single pathways for resolution of any grievance or appeal related to a particular item or service provided by specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) under this title and title XIX.
“(III) Notices written in plain language and available in a language and format that is accessible to the enrollee.
“(IV) Unified timeframes for grievances and appeals processes, such as an individual’s filing of a grievance or appeal, a plan’s acknowledgment and resolution of a grievance or appeal, and notification of decisions with respect to a grievance or appeal.
“(V) Guidelines for how the plan must process, track, and resolve grievances and appeals, to ensure beneficiaries are notified on a timely basis of decisions that are made throughout the grievance or appeals process and are able to easily determine the status of a grievance or appeal.
“(iv) Incorporation of beneficiary protections and implementing regulations—The unified procedures under clause (i) shall incorporate beneficiary protections under current law and implementing regulations that provide continuation of benefits pending appeal under title XIX.
“(C) Requirement for unified grievances and appeals
“(i) In general—For 2017 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 grievances and appeals procedures as described in subparagraph (B).
“(ii) Consideration of application for other SNPs—The Secretary shall consider applying the unified grievances and 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) that have a substantial portion of enrollees who are dually eligible for benefits under this title and title XIX and are at risk for full benefits under title XIX.
“(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 payment to the plan under this part in an amount at least equal to the portion of the monthly rebate computed under section 1854(b)(1)(C)(i) for the plan and year.
“(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).”
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 paragraphs:
“(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.
“(7) To be responsible for developing regulations and guidance related to the implementation of a unified grievance and appeals process as described in subparagraphs (B) and (C) of section 1859(f)(8) of the Social Security Act (42 U.S.C. 1395w–28(f)(8)).”
Improvements to 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 not less frequently than on an annual basis.
“(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 and determination of feasability of quality measurement at the plan level— 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 paragraphs:
“(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)
“(I) For plan year 2016, at least 10 percent, but not more than 15 percent, of the total star rating of the plan shall be based on improvement or decline in performance.
“(II) For plan year 2017 and subsequent plan years, at least 12 percent, but not more than 17 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 4-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 is less than 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 statistically significant or 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 may include Medicare Health Outcomes Survey (HOS), Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures and quality measures under part D; 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.
“(7) Determination of feasibility of quality measurement at the plan level
“(A) Determination of feasibility—The Secretary shall determine the feasibility of requiring reporting for and applying under this subsection quality measures at the plan level for all MA plans under this part.
“(B) Consideration of change—After making a determination under subparagraph (A), the Secretary shall consider requiring such reporting and applying such quality measures at the plan level as described in such 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), the following shall apply:
“(I) Notwithstanding such clause, such contract may be extended or renewed for the two years subsequent to the previous year described in clause (ii). The second of the two years described in the preceding sentence with respect to a contract is referred to in this subsection as the “last reasonable cost reimbursement contract year for the contract”.
“(II) The organization may not enroll any new enrollees under such contract during the last reasonable cost reimbursement contract year for the contract.
“(III) Not later than a date determined appropriate by the Secretary prior to the beginning of the last reasonable cost reimbursement contract year for the contract, 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 the last reasonable cost reimbursement contract year for the contract.
“(IV) If the organization provides the notice described in subclause (III) that the contract will be converted, the organization shall, not later than a date determined appropriate by the Secretary, provide the Secretary with such information as the Secretary determines appropriate in order to carry out sections 1851(c)(4) and 1854(a)(5), including subparagraph (C) of such section.
“(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, the following provisions shall apply:
“(I) The deemed enrollment under section 1851(c)(4).
“(II) The special rule for quality increases under 1853(o)(3)(A)(iv).”
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, 2017, 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 the last reasonable cost reimbursement contract year of the contract 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 has a common ownership interest of control) that entered into such contract; and
“(III) is offered in the service area where the individual resides;
“(v) the applicable MA plan provides benefits, premiums, and access to in-network and out-of-network providers that are comparable to the benefits, premiums, and access to in-network and out-of-network providers under such reasonable cost reimbursement contract for the previous plan year; and
“(vi) 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 and notification 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, 2017, the Secretary shall identify and notify 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 require the converting cost plan to mail, not later than 15 days prior to the first day of the annual, coordinated election period under subsection (e)(3) of a year, 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;
“(IV) information about the special period for elections under subsection (e)(2)(F); and
“(V) other information the Secretary may specify”
Treatment of transition plan for quality rating for payment purposes— Section 1853(o)(4) of the Social Security Act (42 U.S.C. 1395w–23(o)(4)) is amended by adding at the end the following new subparagraph:
“(C) Special rule for first 3 plan years for plans that were converted from a reasonable cost reimbursement contract—For purposes of applying paragraph (1) and section 1854(b)(1)(C) for the first 3 plan years under this part in the case of an MA plan to which deemed enrollment applies under section 1851(c)(4)—
“(i) such plan shall not be treated as a new plan (as defined in paragraph (3)(A)(iii)(II)); and
“(ii) in determining the star rating of the plan under subparagraph (A), to the extent that Medicare Advantage data for such plan is not available for a measure used to determine such star rating, the Secretary shall use data from the period in which such plan was a reasonable cost reimbursement contract.”
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, or as soon as practicable after, 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 June 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), 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 subparagraph (A)(i)—
in subclause (I), by inserting “with a contract under section 1890” after “entity”; and
in subclause (II), by striking “such entity” and inserting “the entity with a contract under section 1890”;
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 1890B(a)(4)), the entity shall transmit to the Secretary the input of the multi-stakeholder groups under paragraph (2).”.
Revisions to contract with consensus-based entity—
Contract— Section 1890(a) of the Social Security Act (42 U.S.C. 1395aaa(a)) is amended—
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 title and titles XIX and XXI 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), 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 (or as soon as practicable after such dates for the first year of the contract), 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 (or as soon as practicable after such date for the first year of the contract) with respect to quality and efficiency measures made available under paragraph (2) by October 1 of the preceding year; and
“(ii) April 1 (or as soon as practicable after such dates for the first year of the contract) 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 with respect to the input provided under section 1890A(b)(2)(A) for those new measures adopted 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, input, 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— 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, or as soon as practicable after, 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)(iv) of section 119 of the Medicare Improvements for Patients and Providers Act of 2008 (42 U.S.C. 1395b–3 note), as amended by section 3306 of the Patient Protection and Affordable Care Act (Public Law 111–148), section 610 of the American Taxpayer Relief Act of 2012 (Public Law 112–240), and section 1110 of the Pathway for SGR Reform Act of 2013 (Public Law 113–67), is amended to read as follows:
“(iv) for fiscal year 2014 and for each subsequent fiscal year, $7,500,000.”
Additional funding for area agencies on aging— Subsection (b)(1)(B)(iv) of such section 119, as so amended, is amended to read as follows:
“(iv) for fiscal year 2014 and for each subsequent fiscal year, $7,500,000.”
Additional funding for aging and disability resource centers— Subsection (c)(1)(B)(iv) of such section 119, as so amended, is amended to read as follows:
“(iv) for fiscal year 2014 and for each subsequent fiscal year, $5,000,000.”
Additional funding for contract with the national center for benefits and outreach enrollment— Subsection (d)(2)(iv) of such section 119, as so amended, is amended to read as follows:
“(iv) for fiscal year 2014 and for each subsequent fiscal year, $5,000,000.”
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 “March 2104” 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 April 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 “March 31, 2014” 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 April 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), by striking clause (iv) and inserting the following:
“(iv) $6,000,000 for each of fiscal years 2014 through 2018.”
by striking paragraph (5).
Prevention of duplicate appropriations for fiscal year 2014— Expenditures made for fiscal year 2014 pursuant to section 501(c)(iv) of the Social Security Act (42 U.S.C. 701(c)(iv)), as amended by section 1203 of division B of the Bipartisan Budget Act of 2013 (Public Law 113–67), shall be charged to the appropriation for that fiscal year provided by the amendments made by this section.
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”.