H.R. 3417 — what changed

“(4) Medicare eligibility information

“(A) In general—In the case of statements provided on or after the date that is 2 years after the date of the enactment of this paragraph to individuals who are attaining ages 63, 64, and 65, the statement shall also include a notice containing the information described in subparagraph (B).

“(B) Contents of notice—The notice required under subparagraph (A) shall include a clear, simple explanation of—

“(i) eligibility for benefits under the Medicare program under title XVIII, and in particular benefits under part B of such title;

“(ii) the reasons a late enrollment penalty for failure to timely enroll could be assessed and how such late enrollment penalty is calculated, in particular for benefits under part B;

“(iii) the availability of relief from the late enrollment penalty and retroactive enrollment under section 1837(h) (including as such section is applied under sections 1818(c) and 1818A(c)(3)), with examples of circumstances under which such relief may be granted and examples of circumstances under which such relief would not be granted;

changed “(iv) the need for coordination of benefits (including primary and secondary coverage scenarios) pursuant to section 1862, 1862(b), in particular for benefits under part B of such title; and

changed “(v) information for populations, such as residents of Puerto Rico and veterans, for whom there are special considerations with respect to enrollment enrollment, eligibility, and coordination of benefits under title XVIII.

“(C) Development of notice

“(i) In general—The Secretary, in coordination with the Commissioner of Social Security, and taking into consideration information collected pursuant to clause (ii), shall, not later than 12 months after the last day of the period for the request of information described in clause (ii), develop the notice to be provided pursuant to subparagraph (A).

“(ii) Request for information—Not later than 6 months after the date of the enactment of this paragraph, the Secretary shall request written information, including recommendations, from stakeholders (including the groups described in subparagraph (D)) on the information to be included in the notice.

“(iii) Notice improvement—Beginning 4 years after the date of enactment of this paragraph, and not less than once every two years thereafter, the Secretary, in coordination with the Commissioner of Social Security, shall—

“(I) review the content of the notice to be provided under subparagraph (A);

“(II) solicit recommendations on the notice through a request for information process as described in clause (ii); and

“(III) update and revise such notice as the Secretary deems appropriate.

“(D) Groups for consultation—For purposes of subparagraph (C)(ii), the groups described in this clause include the following:

“(i) Individuals who are 60 years of age or older.

“(ii) Veterans.

“(iii) Individuals with disabilities.

“(iv) Individuals with end stage renal disease.

“(v) Low-income individuals and families.

“(vi) Employers (including human resources professionals).

“(vii) States (including representatives of State-run Health Insurance Exchanges, Medicaid offices, and Departments of Insurance).

“(viii) State Health Insurance Assistance Programs.

“(ix) Health insurers.

“(x) Health insurance agents and brokers.

“(xi) Such other groups as specified by the Secretary.

changed “(E) Posting of notice on websites—The Commissioner of Social Security and the Secretary shall ensure that post the notice being used required under subparagraph (A) is posted in a prominent location on the public Internet website of the Social Security Administration and on the public Internet website of the Centers for Medicare & Medicaid Services, respectively.

“(F) Reimbursement of costs

“(i) In general—Effective for fiscal years beginning in the year in which the date of enactment of this paragraph occurs, the Commissioner of Social Security and the Secretary shall enter into an agreement which shall provide funding to cover the administrative costs of the Commissioner’s activities under this paragraph. Such agreement shall—

changed “(I) provide funds to the Commissioner for the full cost of the Social Security Administration’s work related to the implementation of this paragraph, including any initial costs incurred prior to the finalization of such agreement;

“(II) provide such funding quarterly in advance of the applicable quarter based on estimating methodology agreed to by the Commissioner and the Secretary; and

“(III) require an annual accounting and reconciliation of the actual costs incurred and funds provided under this paragraph.

changed “(ii) Limitation—In no case shall funds from the Social Security Administration’s Limitation on Administrative Expenses be used to carry out activities related to the implementation of this paragraph.paragraph, except as the Commissioner determines is necessary in developing the agreement under clause (i).

“(G) No effect on obligation to mail statements—Nothing in this paragraph shall be construed to relieve the Commissioner of Social Security from any requirement under subsection (c), including the requirement to mail a statement on an annual basis to each eligible individual who is not receiving benefits under title II and for whom a mailing address can be determined through such methods as the Commissioner determines to be appropriate.”

“1144A. Medicare enrollment notification and eligibility notices for individuals in medicare waiting period

“(a) Notices

“(1) In general—The Commissioner of Social Security shall distribute the notice to be provided pursuant to section 1143(a)(4), as may be modified under paragraph (2), to individuals in the 24-month waiting period under section 226(b).

changed “(2) Authority To to modify notice—The Secretary, in coordination with the Commissioner of Social Security, may modify the notice to be distributed under paragraph (1) as necessary to take into account the individuals described in such paragraph.

changed “(3) Posting of notice on websites—The Commissioner of Social Security and the Secretary shall ensure that post the notice being used required to be distributed under paragraph (1) is posted in a prominent location on the public Internet website of the Social Security Administration and on the public Internet website of the Centers for Medicare & Medicaid Services, respectively.

“(b) Timing—Beginning not later than 2 years after the date of the enactment of this section, a notice required under subsection (a)(1) shall be mailed to an individual no less than two times in accordance with the following:

“(1) The notice shall be provided to such individual not later than 3 months prior to the date on which such individual’s enrollment period begins as provided under section 1837.

“(2) The notice shall subsequently be provided to such individual not later than one month prior to such date.

“(c) Reimbursement of costs

“(1) In general—Effective for fiscal years beginning in the year in which the date of enactment of this section occurs, the Commissioner of Social Security and the Secretary shall enter into an agreement which shall provide funding to cover the administrative costs of the Commissioner’s activities under this section. Such agreement shall—

changed “(A) provide funds to the Commissioner for the full cost of the Social Security Administration’s work related to the implementation of this section, including any initial costs incurred prior to the finalization of such agreement;

“(B) provide such funding quarterly in advance of the applicable quarter based on estimating methodology agreed to by the Commissioner and the Secretary; and

“(C) require an annual accounting and reconciliation of the actual costs incurred and funds provided under this section.

changed “(2) Limitation—In no case shall funds from the Social Security Administration’s Limitation on Administrative Expenses be used to carry out activities related to the implementation of this section.”section, except as the Commissioner determines is necessary in developing the agreement under paragraph (1).”

“(2)

“(A) in the case of an individual who enrolls pursuant to subsection (d) of section 1837 before the month in which he first satisfies paragraph (1) or (2) of section 1836, the first day of such month,

“(B) in the case of an individual who first satisfies such paragraph in a month beginning before January 2021 and who enrolls pursuant to such subsection (d)—

“(i) in such month in which he first satisfies such paragraph, the first day of the month following the month in which he so enrolls,

“(ii) in the month following such month in which he first satisfies such paragraph, the first day of the second month following the month in which he so enrolls, or

“(iii) more than one month following such month in which he satisfies such paragraph, the first day of the third month following the month in which he so enrolls,

“(C) in the case of an individual who first satisfies such paragraph in a month beginning on or after January 1, 2021, and who enrolls pursuant to such subsection (d) in such month in which he first satisfies such paragraph or in any subsequent month of his initial enrollment period, the first day of the month following the month in which he so enrolls, or

“(D) in the case of an individual who enrolls pursuant to subsection (e) of section 1837 in a month beginning—

“(i) before January 1, 2021, the July 1 following the month in which he so enrolls, or

“(ii) on or after January 1, 2021, the first day of the month following the month in which he so enrolls, or”

“(3) in the case of an individual who is deemed to have enrolled—

“(A) on or before the last day of the third month of his initial enrollment period, the first day of the month in which he first meets the applicable requirements of section 1836 or July 1, 1973, whichever is later, or

“(B) on or after the first day of the fourth month of his initial enrollment period, and where such month begins—

“(i) before January 1, 2021, as prescribed under subparagraphs (B)(i), (B)(ii), (B)(iii), and (D) of paragraph (2), or

“(ii) on or after January 1, 2021, as prescribed under paragraph (2)(C).”

“(m) Beginning January 1, 2021, the Secretary may establish special enrollment periods in the case of individuals who meet such exceptional conditions as the Secretary may provide, such as individuals who reside in an area with an emergency or disaster as determined by the Secretary.”

“(g) Notwithstanding subsection (a), in the case of an individual who enrolls during a special enrollment period pursuant to section 1837(m), the coverage period shall begin on a date the Secretary provides in a manner consistent (to the extent practicable) with protecting continuity of health benefit coverage.”

Section 1834(m) of the Social Security Act (42 U.S.C. 1395m(m)) is amended—

“(8) Treatment of mental health telehealth services

changed “(A) Non-application of originating site requirements—The requirements described in paragraph (4)(C)(i) shall not apply with respect to telehealth services furnished on or after January 1, 2020, 2021, that are mental health telehealth services. Nothing in the previous sentence shall waive any applicable State law requirements.

“(B) Inclusion of certain sites—With respect to telehealth services described in subparagraph (A), the term originating site shall include the home of the eligible telehealth individual at which the individual is located at the time the service is furnished via a telecommunications system.

“(C) No originating site facility fee—No facility fee shall be paid under paragraph (2)(B) to an originating site with respect to a telehealth service described in subparagraph (A) if the originating site does not otherwise meet the requirements for an originating site under paragraph (4)(C).

“(D) Face-to-face initial assessment; reassessments—Payment may not be made for mental health telehealth services under this paragraph (if such payment would not otherwise be allowed under this subsection without application of this paragraph or paragraph (7)) furnished to an eligible telehealth individual unless—

“(i) within the 6-month period prior to the provision of such mental health telehealth services, the individual receives a face-to-face clinical assessment, without the use of telehealth, by a physician described in subparagraph (F)(i) or a practitioner described in subparagraph (F)(ii) of the needs of such individual for such services; and

“(ii) the individual receives a reassessment (at a frequency specified by the Secretary) by a physician so described or a practitioner so described of the needs of such individual for such services.

changed “(E) Mental health telehealth services defined—For purposes of this paragraph, the term mental health telehealth service means services identified by CPT codes 90834 90832, 90834, and 90837 (and as subsequently modified by the Secretary).

“(F) Physician and practitioner described—For purposes of subparagraph (D):

“(i) Physician—A physician described in this clause is a physician, as defined in section 1861(r)(1).

“(ii) Practitioner—A practitioner described in this clause is a practitioner described in any of clauses (i), (iv), or (v) of section 1842(b)(18)(C).”

Section 1860D–4(e)(2) of the Social Security Act (42 U.S.C. 1395w–104(e)(2)) is amended—

“(F) Real-time benefit information

changed “(i) In general—Not later than January 1, 2021, the program shall provide for the implement real-time electronic transmission to prescribing health care professionals, using technology benefit tools that are capable of integrating with such professionals’ a prescribing health care professional’s electronic prescribing and or electronic health record systems, system for the transmission of individual-specific formulary and benefit information under a prescription drug plan with in real time to prescribing health care professionals. With respect to a covered part D drug, such tools shall be capable of transmitting such information specific to an individual enrolled in such a prescription drug plan. Such information shall include, with respect to the prescribing of a covered part D drug to such individual, include the following:

changed “(I) A description list of any clinically-appropriate alternatives to such drug included in the formulary of such plan.

changed “(II) Information relating to applicable cost-sharing requirements Cost-sharing information for such drug and such alternatives, including a description of any variance in such requirements cost sharing based on the pharmacy dispensing such drug or such alternatives.

changed “(III) Information relating to whether such drug is included in the formulary of such plan and any prior authorization or other utilization management requirements applicable to such drug and such alternatives within the formulary of such plan.so included.

changed “(ii) Special rule for 2021—The program Electronic transmission—The provisions of subclauses (I) and (II) of clause (ii) of subparagraph (E) shall be deemed apply to be an electronic transmission described in compliance with clause (i) for 2021 if the program complies with in the same manner as such provisions of section 423.160(b)(7) of title 42, Code apply with respect to an electronic transmission described in clause (i) of Federal Regulations (or a successor regulation), for such year.”subparagraph.

added “(iii) Special rule for 2021—The program shall be deemed to be in compliance with clause (i) for 2021 if the program complies with the provisions of section 423.160(b)(7) of title 42, Code of Federal Regulations (or a successor regulation), for such year.”

Section 1860D–14 of the Social Security Act (42 U.S.C. 1395w–114) is amended—

“(e) Limited income newly eligible transition program

“(1) In general—Beginning not later than January 1, 2021, the Secretary shall carry out a program to provide transitional coverage for covered part D drugs for LI NET eligible individuals in accordance with this subsection.

“(2) LI net eligible individual defined—For purposes of this subsection, the term LI NET eligible individual means a part D eligible individual who—

“(A) meets the requirements of clauses (ii) and (iii) of subsection (a)(3)(A); and

“(B) has not yet enrolled in a prescription drug plan or an MA–PD plan, or, who has so enrolled, but with respect to whom coverage under such plan has not yet taken effect.

“(3) Transitional coverage—For purposes of this subsection, the term transitional coverage means with respect to an LI NET eligible individual—

“(A) immediate access to covered part D drugs at the point of sale during the period that begins on the first day of the month such individual is determined to meet the requirements of clauses (ii) and (iii) of subsection (a)(3)(A) and ends on the date that coverage under a prescription drug plan or MA–PD plan takes effect with respect to such individual; and

“(B) in the case of an LI NET eligible individual who is a full-benefit dual eligible individual (as defined in section 1935(c)(6)) or a recipient of supplemental security income benefits under title XVI, retroactive coverage (in the form of reimbursement of the amounts that would have been paid under this part had such individual been enrolled in a prescription drug plan or MA–PD plan) of covered part D drugs purchased by such individual during the period that begins on the date that is the later of—

“(i) the date that such individual was first eligible for a low-income subsidy under this part; or

“(ii) the date that is 36 months prior to the date such individual enrolls in a prescription drug plan or MA–PD plan,

“(4) Program administration

“(A) Single point of contact—The Secretary shall, to the extent feasible, administer the program under this subsection through a contract with a single program administrator.

“(B) Benefit design—The Secretary shall ensure that the transitional coverage provided to LI NET eligible individuals under this subsection—

“(i) provides access to all covered part D drugs under an open formulary;

“(ii) permits all pharmacies determined by the Secretary to be in good standing to process claims under the program;

“(iii) is consistent with such requirements as the Secretary considers necessary to improve patient safety and ensure appropriate dispensing of medication; and

“(iv) meets such other requirements as the Secretary may establish.

“(5) Relationship to other provisions of this title; waiver authority

“(A) In general—The following provisions shall not apply with respect to the program under this subsection:

changed “(i) Paragraphs (1) and (3)(B) of section 1860D–4(a) (relating to dissemination of general information; availability of information on changes in formulary through the Internet).internet).

“(ii) Subparagraphs (A) and (B) of section 1860D–4(b)(3) (relating to requirements on development and application of formularies; formulary development).

“(iii) Paragraphs (1)(C) and (2) of section 1860D–4(c) (relating to medication therapy management program).

“(B) Waiver authority—The Secretary may waive such other requirements of title XI and this title as may be necessary to carry out the purposes of the program established under this subsection.”

changed “(ii) In applying this subparagraph in the case of a hospital that, on or after the date of the enactment of this clause, begins to train that trains residents and has not entered into a GME affiliation agreement (as defined by the Secretary for purposes of paragraph (4)(H)(ii)), on or after the date of the enactment of this clause, the Secretary shall not establish an FTE resident amount until such time as the Secretary determines that the hospital has trained at least 1.0 full-time-equivalent resident in an approved medical residency training program in a cost reporting period.

changed “(iii) In applying this subparagraph for cost reporting periods beginning on or after the date of enactment of this clause, in the case of a hospital that, as of such date of enactment, has an approved FTE resident amount based on the training in an approved medical residency program or programs of—

“(I) less than 1.0 full-time-equivalent resident in any cost reporting period beginning before October 1, 1997, as determined by the Secretary; or

“(II) no more than 3.0 full-time-equivalent residents in any cost reporting period beginning on or after October 1, 1997, and before the date of the enactment of this clause, as determined by the Secretary,

changed “(iv) For purposes of carrying out this subparagraph for cost reporting periods beginning on or after the date of the enactment of this clause, a hospital shall report full-time-equivalent residents on its cost report for a cost reporting period if the hospital trains at least 1.0 full-time-equivalent resident residents in an approved medical residency training program or programs in such period.

“(v) As appropriate, the Secretary may consider information from any cost reporting period necessary to establish a new FTE resident amount as described in clause (iii).”

changed “(II) In applying this clause in the case of a hospital that, on or after the date of the enactment of this subclause, begins to train training residents in a new approved medical residency training program or programs (as defined by the Secretary), the Secretary shall not determine a limitation applicable to the hospital under subparagraph (F) until such time as the Secretary determines that the hospital has trained at least 1.0 full-time-equivalent resident in such new approved medical residency training program or programs in a cost reporting period.

changed “(III) In applying this clause in the case of a hospital that, as of the date of the enactment of this subclause, has a limitation under subparagraph (F), based on a cost reporting period beginning before October 1, 1997, of less than 1.0 full-time-equivalent resident, the Secretary shall adjust the limitation in the manner applicable to a new approved medical residency training program if the Secretary determines the hospital trains begins training at least 1.0 full-time-equivalent resident residents in a program year beginning on or after such date of enactment and before the date that is 5 years after such date of enactment.

“(IV) In applying this clause in the case of a hospital that, as of the date of the enactment of this subclause, has a limitation under subparagraph (F), based on a cost reporting period beginning on or after October 1, 1997, and before such date of enactment, of no more than 3.0 full-time-equivalent residents, the Secretary shall adjust the limitation in the manner applicable to a new approved medical residency training program if the Secretary determines the hospital begins training more than 3.0 full-time-equivalent residents in a program year beginning on or after such date of enactment and before the date that is 5 years after such date of enactment.

“(V) An adjustment to the limitation applicable to a hospital made pursuant to subclause (III) or (IV) shall be made in a manner consistent with the methodology, as appropriate, in section 413.79(e) of title 42, Code of Federal Regulations (or any successor regulation). As appropriate, the Secretary may consider information from any cost reporting periods necessary to make such an adjustment to the limitation.”

“(4) Removal of Measures—The entity may provide input to the Secretary on quality and efficiency measures described in paragraph (7)(B) that could be considered for removal.”

changed “(9) Prioritization of measure endorsement—The Secretary—entity—

“(A) during the period beginning on the date of the enactment of this paragraph and ending on December 31, 2023, shall prioritize the endorsement of measures relating to maternal morbidity and mortality by the entity with a contract under subsection (a) in connection with endorsement of measures described in paragraph (2); and

“(B) on and after January 1, 2024, may prioritize the endorsement of such measures by such entity.”