U.S. Congress - Text of H.R.3162 as Placed on Calendar Senate Children's Health and Medicare Protection Act of 2007
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Donate NowH.R.3162 - Children's Health and Medicare Protection Act of 2007
To amend titles XVIII, XIX, and XXI of the Social Security Act to extend and improve the children's health insurance program, to improve beneficiary protections under the Medicare, Medicaid, and the CHIP program, and for other purposes.
| Version | Word Count | Changes From Previous Version | Percent Change |
|---|---|---|---|
| Introduced in House | 80,176 | n/a | n/a |
| Reported in House | 83,703 | 271 | 9% |
| Engrossed in House | 87,087 | 226 | 9% |
| Placed on Calendar Senate | 86,681 | 8 Show Changes Hide Changes | 0% |
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HR 3162 EHPCSCommentsClose CommentsPermalink
September 4, 2007
Received; read twice and placed on the calendarCommentsClose CommentsPermalink
To amend titles XVIII, XIX, and XXI of the Social Security Act to extend and improve the children's health insurance program, to improve beneficiary protections under the Medicare, Medicaid, and the CHIP program, and for other purposes.CommentsClose CommentsPermalink
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, CommentsClose CommentsPermalink
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title- This Act may be cited as the `Children's Health and Medicare Protection Act of 2007'.CommentsClose CommentsPermalink
(b) Table of Contents- The table of contents of this Act is as follows:CommentsClose CommentsPermalink
Sec. 1. Short title; table of contents.CommentsClose CommentsPermalink
TITLE I--CHILDREN'S HEALTH INSURANCE PROGRAM
Sec. 100. Purpose.CommentsClose CommentsPermalink
Subtitle A--Funding
Sec. 101. Establishment of new base CHIP allotments.CommentsClose CommentsPermalink
Sec. 102. 2-year initial availability of CHIP allotments.CommentsClose CommentsPermalink
Sec. 103. Redistribution of unused allotments to address State funding shortfalls.CommentsClose CommentsPermalink
Sec. 104. Extension of option for qualifying States.CommentsClose CommentsPermalink
Subtitle B--Improving Enrollment and Retention of Eligible Children
Sec. 111. CHIP performance bonus payment to offset additional enrollment costs resulting from enrollment and retention efforts.CommentsClose CommentsPermalink
Sec. 112. State option to rely on findings from an express lane agency to conduct simplified eligibility determinations.CommentsClose CommentsPermalink
Sec. 113. Application of medicaid outreach procedures to all children and pregnant women.CommentsClose CommentsPermalink
Sec. 114. Encouraging culturally appropriate enrollment and retention practices.CommentsClose CommentsPermalink
Sec. 115. Continuous coverage under CHIP.CommentsClose CommentsPermalink
Subtitle C--Coverage
Sec. 121. Ensuring child-centered coverage.CommentsClose CommentsPermalink
Sec. 122. Improving benchmark coverage options.CommentsClose CommentsPermalink
Sec. 123. Premium grace period.CommentsClose CommentsPermalink
Subtitle D--Populations
Sec. 131. Optional coverage of children up to age 21 under CHIP.CommentsClose CommentsPermalink
Sec. 132. Optional coverage of legal immigrants under the Medicaid program and CHIP.CommentsClose CommentsPermalink
Sec. 133. State option to expand or add coverage of certain pregnant women under CHIP.CommentsClose CommentsPermalink
Sec. 134. Limitation on waiver authority to cover adults.CommentsClose CommentsPermalink
Sec. 135. No Federal funding for illegal aliens.CommentsClose CommentsPermalink
Sec. 136. Auditing requirement to enforce citizenship restrictions on eligibility for Medicaid and CHIP benefits.CommentsClose CommentsPermalink
Subtitle E--Access
Sec. 141. Children's Access, Payment, and Equality Commission.CommentsClose CommentsPermalink
Sec. 142. Model of Interstate coordinated enrollment and coverage process.CommentsClose CommentsPermalink
Sec. 143. Medicaid citizenship documentation requirements.CommentsClose CommentsPermalink
Sec. 144. Access to dental care for children.CommentsClose CommentsPermalink
Sec. 145. Prohibiting initiation of new health opportunity account demonstration programs.CommentsClose CommentsPermalink
Subtitle F--Quality and Program Integrity
Sec. 151. Pediatric health quality measurement program.CommentsClose CommentsPermalink
Sec. 152. Application of certain managed care quality safeguards to CHIP.CommentsClose CommentsPermalink
Sec. 153. Updated Federal evaluation of CHIP.CommentsClose CommentsPermalink
Sec. 154. Access to records for IG and GAO audits and evaluations.CommentsClose CommentsPermalink
Sec. 155. References to title XXI.CommentsClose CommentsPermalink
Sec. 156. Reliance on law; exception for State legislation.CommentsClose CommentsPermalink
TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A--Improvements in Benefits
Sec. 201. Coverage and waiver of cost-sharing for preventive services.CommentsClose CommentsPermalink
Sec. 202. Waiver of deductible for colorectal cancer screening tests regardless of coding, subsequent diagnosis, or ancillary tissue removal.CommentsClose CommentsPermalink
Sec. 203. Parity for mental health coinsurance.CommentsClose CommentsPermalink
Subtitle B--Improving, Clarifying, and Simplifying Financial Assistance for Low Income Medicare Beneficiaries
Sec. 211. Improving assets tests for Medicare Savings Program and low-income subsidy program.CommentsClose CommentsPermalink
Sec. 212. Making QI program permanent and expanding eligibility.CommentsClose CommentsPermalink
Sec. 213. Eliminating barriers to enrollment.CommentsClose CommentsPermalink
Sec. 214. Eliminating application of estate recovery.CommentsClose CommentsPermalink
Sec. 215. Elimination of part D cost-sharing for certain non-institutionalized full-benefit dual eligible individuals.CommentsClose CommentsPermalink
Sec. 216. Exemptions from income and resources for determination of eligibility for low-income subsidy.CommentsClose CommentsPermalink
Sec. 217. Cost-sharing protections for low-income subsidy-eligible individuals.CommentsClose CommentsPermalink
Sec. 218. Intelligent assignment in enrollment.CommentsClose CommentsPermalink
Subtitle C--Part D Beneficiary Improvements
Sec. 221. Including costs incurred by AIDS drug assistance programs and Indian Health Service in providing prescription drugs toward the annual out of pocket threshold under Part D.CommentsClose CommentsPermalink
Sec. 222. Permitting mid-year changes in enrollment for formulary changes adversely impact an enrollee.CommentsClose CommentsPermalink
Sec. 223. Removal of exclusion of benzodiazepines from required coverage under the Medicare prescription drug program.CommentsClose CommentsPermalink
Sec. 224. Permitting updating drug compendia under part D using part B update process.CommentsClose CommentsPermalink
Sec. 225. Codification of special protections for six protected drug classifications.CommentsClose CommentsPermalink
Sec. 226. Elimination of Medicare part D late enrollment penalties paid by low-income subsidy-eligible individuals.CommentsClose CommentsPermalink
Sec. 227. Special enrollment period for subsidy eligible individuals.CommentsClose CommentsPermalink
Subtitle D--Reducing Health Disparities
Sec. 231. Medicare data on race, ethnicity, and primary language.CommentsClose CommentsPermalink
Sec. 232. Ensuring effective communication in Medicare.CommentsClose CommentsPermalink
Sec. 233. Demonstration to promote access for Medicare beneficiaries with limited English proficiency by providing reimbursement for culturally and linguistically appropriate services.CommentsClose CommentsPermalink
Sec. 234. Demonstration to improve care to previously uninsured.CommentsClose CommentsPermalink
Sec. 235. Office of the Inspector General report on compliance with and enforcement of national standards on culturally and linguistically appropriate services (CLAS) in medicare.CommentsClose CommentsPermalink
Sec. 236. IOM report on impact of language access services.CommentsClose CommentsPermalink
Sec. 237. Definitions.CommentsClose CommentsPermalink
TITLE III--PHYSICIANS' SERVICE PAYMENT REFORM
Sec. 301. Establishment of separate target growth rates for service categories.CommentsClose CommentsPermalink
Sec. 302. Improving accuracy of relative values under the Medicare physician fee schedule.CommentsClose CommentsPermalink
Sec. 303. Feedback mechanism on practice patterns.CommentsClose CommentsPermalink
Sec. 304. Payments for efficient areas.CommentsClose CommentsPermalink
Sec. 305. Recommendations on refining the physician fee schedule.CommentsClose CommentsPermalink
Sec. 306. Improved and expanded medical home demonstration project.CommentsClose CommentsPermalink
Sec. 307. Repeal of Physician Assistance and Quality Initiative Fund.CommentsClose CommentsPermalink
Sec. 308. Adjustment to Medicare payment localities.CommentsClose CommentsPermalink
Sec. 309. Payment for imaging services.CommentsClose CommentsPermalink
Sec. 310. Reducing frequency of meetings of the Practicing Physicians Advisory Council.CommentsClose CommentsPermalink
TITLE IV--MEDICARE ADVANTAGE REFORMS
Subtitle A--Payment Reform
Sec. 401. Equalizing payments between Medicare Advantage plans and fee-for-service Medicare.CommentsClose CommentsPermalink
Subtitle B--Beneficiary Protections
Sec. 411. NAIC development of marketing, advertising, and related protections.CommentsClose CommentsPermalink
Sec. 412. Limitation on out-of-pocket costs for individual health services.CommentsClose CommentsPermalink
Sec. 413. MA plan enrollment modifications.CommentsClose CommentsPermalink
Sec. 414. Information for beneficiaries on MA plan administrative costs.CommentsClose CommentsPermalink
Subtitle C--Quality and Other Provisions
Sec. 421. Requiring all MA plans to meet equal standards.CommentsClose CommentsPermalink
Sec. 422. Development of new quality reporting measures on racial disparities.CommentsClose CommentsPermalink
Sec. 423. Strengthening audit authority.CommentsClose CommentsPermalink
Sec. 424. Improving risk adjustment for MA payments.CommentsClose CommentsPermalink
Sec. 425. Eliminating special treatment of private fee-for-service plans.CommentsClose CommentsPermalink
Sec. 426. Renaming of Medicare Advantage program.CommentsClose CommentsPermalink
Subtitle D--Extension of Authorities
Sec. 431. Extension and revision of authority for special needs plans (SNPs).CommentsClose CommentsPermalink
Sec. 432. Extension and revision of authority for Medicare reasonable cost contracts.CommentsClose CommentsPermalink
TITLE V--PROVISIONS RELATING TO MEDICARE PART A
Sec. 501. Inpatient hospital payment updates.CommentsClose CommentsPermalink
Sec. 502. Payment for inpatient rehabilitation facility (IRF) services.CommentsClose CommentsPermalink
Sec. 503. Long-term care hospitals.CommentsClose CommentsPermalink
Sec. 504. Increasing the DSH adjustment cap.CommentsClose CommentsPermalink
Sec. 505. PPS-exempt cancer hospitals.CommentsClose CommentsPermalink
Sec. 506. Skilled nursing facility payment update.CommentsClose CommentsPermalink
Sec. 507. Revocation of unique deeming authority of the Joint Commission for the Accreditation of Healthcare Organizations.CommentsClose CommentsPermalink
Sec. 508. Treatment of Medicare hospital reclassifications.CommentsClose CommentsPermalink
Sec. 509. Medicare critical access hospital designations.CommentsClose CommentsPermalink
TITLE VI--OTHER PROVISIONS RELATING TO MEDICARE PART B
Subtitle A--Payment and Coverage Improvements
Sec. 601. Payment for therapy services.CommentsClose CommentsPermalink
Sec. 602. Medicare separate definition of outpatient speech-language pathology services.CommentsClose CommentsPermalink
Sec. 603. Increased reimbursement rate for certified nurse-midwives.CommentsClose CommentsPermalink
Sec. 604. Adjustment in outpatient hospital fee schedule increase factor.CommentsClose CommentsPermalink
Sec. 605. Exception to 60-day limit on Medicare substitute billing arrangements in case of physicians ordered to active duty in the Armed Forces.CommentsClose CommentsPermalink
Sec. 606. Excluding clinical social worker services from coverage under the medicare skilled nursing facility prospective payment system and consolidated payment.CommentsClose CommentsPermalink
Sec. 607. Coverage of marriage and family therapist services and mental health counselor services.CommentsClose CommentsPermalink
Sec. 608. Rental and purchase of power-driven wheelchairs.CommentsClose CommentsPermalink
Sec. 609. Rental and purchase of oxygen equipment.CommentsClose CommentsPermalink
Sec. 610. Adjustment for Medicare mental health services.CommentsClose CommentsPermalink
Sec. 611. Extension of brachytherapy special rule.CommentsClose CommentsPermalink
Sec. 612. Payment for part B drugs.CommentsClose CommentsPermalink
Subtitle B--Extension of Medicare Rural Access Protections
Sec. 621. 2-year extension of floor on medicare work geographic adjustment.CommentsClose CommentsPermalink
Sec. 622. 2-year extension of special treatment of certain physician pathology services under Medicare.CommentsClose CommentsPermalink
Sec. 623. 2-year extension of medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural areas.CommentsClose CommentsPermalink
Sec. 624. 2-year extension of Medicare incentive payment program for physician scarcity areas.CommentsClose CommentsPermalink
Sec. 625. 2-year extension of medicare increase payments for ground ambulance services in rural areas.CommentsClose CommentsPermalink
Sec. 626. Extending hold harmless for small rural hospitals under the HOPD prospective payment system.CommentsClose CommentsPermalink
Subtitle C--End Stage Renal Disease Program
Sec. 631. Chronic kidney disease demonstration projects.CommentsClose CommentsPermalink
Sec. 632. Medicare coverage of kidney disease patient education services.CommentsClose CommentsPermalink
Sec. 633. Required training for patient care dialysis technicians.CommentsClose CommentsPermalink
Sec. 634. MedPAC report on treatment modalities for patients with kidney failure.CommentsClose CommentsPermalink
Sec. 635. Adjustment for erythropoietin stimulating agents (ESAs).CommentsClose CommentsPermalink
Sec. 636. Site neutral composite rate.CommentsClose CommentsPermalink
Sec. 637. Development of ESRD bundling system and quality incentive payments.CommentsClose CommentsPermalink
Sec. 638. MedPAC report on ESRD bundling system.CommentsClose CommentsPermalink
Sec. 639. OIG study and report on erythropoietin.CommentsClose CommentsPermalink
Subtitle D--Miscellaneous
Sec. 651. Limitation on exception to the prohibition on certain physician referrals for hospitals.CommentsClose CommentsPermalink
TITLE VII--PROVISIONS RELATING TO MEDICARE PARTS A AND B
Sec. 701. Home health payment update for 2008.CommentsClose CommentsPermalink
Sec. 702. 2-year extension of temporary Medicare payment increase for home health services furnished in a rural area.CommentsClose CommentsPermalink
Sec. 703. Extension of Medicare secondary payer for beneficiaries with end stage renal disease for large group plans.CommentsClose CommentsPermalink
Sec. 704. Plan for Medicare payment adjustments for never events.CommentsClose CommentsPermalink
Sec. 705. Reinstatement of residency slots.CommentsClose CommentsPermalink
Sec. 706. Studies relating to home health.CommentsClose CommentsPermalink
Sec. 707. Rural home health quality demonstration projects.CommentsClose CommentsPermalink
TITLE VIII--MEDICAID
Subtitle A--Protecting Existing Coverage
Sec. 801. Modernizing transitional Medicaid.CommentsClose CommentsPermalink
Sec. 802. Family planning services.CommentsClose CommentsPermalink
Sec. 803. Authority to continue providing adult day health services approved under a State Medicaid plan.CommentsClose CommentsPermalink
Sec. 804. State option to protect community spouses of individuals with disabilities.CommentsClose CommentsPermalink
Sec. 805. County medicaid health insuring organizatios.CommentsClose CommentsPermalink
Subtitle B--Payments
Sec. 811. Payments for Puerto Rico and territories.CommentsClose CommentsPermalink
Sec. 812. Medicaid drug rebate.CommentsClose CommentsPermalink
Sec. 813. Adjustment in computation of Medicaid FMAP to disregard an extraordinary employer pension contribution.CommentsClose CommentsPermalink
Sec. 814. Moratorium on certain payment restrictions.CommentsClose CommentsPermalink
Sec. 815. Tennessee DSH.CommentsClose CommentsPermalink
Sec. 816. Clarification treatment of regional medical center.CommentsClose CommentsPermalink
Sec. 817. Extension of SSI web-based asset demonstration project to the Medicaid program.CommentsClose CommentsPermalink
Subtitle C--Miscellaneous
Sec. 821. Demonstration project for employer buy-in.CommentsClose CommentsPermalink
Sec. 822. Diabetes grants.CommentsClose CommentsPermalink
Sec. 823. Technical correction.CommentsClose CommentsPermalink
TITLE IX--MISCELLANEOUS
Sec. 901. Medicare Payment Advisory Commission status.CommentsClose CommentsPermalink
Sec. 902. Repeal of trigger provision.CommentsClose CommentsPermalink
Sec. 903. Repeal of comparative cost adjustment (CCA) program.CommentsClose CommentsPermalink
Sec. 904. Comparative effectiveness research.CommentsClose CommentsPermalink
Sec. 905. Implementation of Health information technology (IT) under Medicare.CommentsClose CommentsPermalink
Sec. 906. Development, reporting, and use of health care measures.CommentsClose CommentsPermalink
Sec. 907. Improvements to the Medigap program.CommentsClose CommentsPermalink
Sec. 908. Implementation funding.CommentsClose CommentsPermalink
Sec. 909. Access to data on prescription drug plans and medicare advantage plans.CommentsClose CommentsPermalink
Sec. 910. Abstinence education.CommentsClose CommentsPermalink
TITLE X--REVENUES
Sec. 1001. Increase in rate of excise taxes on tobacco products and cigarette papers and tubes.CommentsClose CommentsPermalink
Sec. 1002. Exemption for emergency medical services transportation.CommentsClose CommentsPermalink
TITLE I--CHILDREN'S HEALTH INSURANCE PROGRAM
SEC. 100. PURPOSE.
It is the purpose of this title to provide dependable and stable funding for children's health insurance under titles XXI and XIX of the Social Security Act in order to enroll all six million uninsured children who are eligible, but not enrolled, for coverage today through such titles.CommentsClose CommentsPermalink
Subtitle A--Funding
SEC. 101. ESTABLISHMENT OF NEW BASE CHIP ALLOTMENTS.
Section 2104 of the Social Security Act (
(1) in subsection (a)--CommentsClose CommentsPermalink
(A) in paragraph (9), by striking `and' at the end;CommentsClose CommentsPermalink
(B) in paragraph (10), by striking the period at the end and inserting `; and'; andCommentsClose CommentsPermalink
(C) by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(11) for fiscal year 2008 and each succeeding fiscal year, the sum of the State allotments provided under subsection (i) for such fiscal year.'; andCommentsClose CommentsPermalink
(2) in subsections (b)(1) and (c)(1), by striking `subsection (d)' and inserting `subsections (d) and (i)'; andCommentsClose CommentsPermalink
(3) by adding at the end the following new subsection:CommentsClose CommentsPermalink
`(i) Allotments for States and Territories Beginning With Fiscal Year 2008-CommentsClose CommentsPermalink
`(1) GENERAL ALLOTMENT COMPUTATION- Subject to the succeeding provisions of this subsection, the Secretary shall compute a State allotment for each State for each fiscal year as follows:CommentsClose CommentsPermalink
`(A) FOR FISCAL YEAR 2008- For fiscal year 2008, the allotment of a State is equal to the greater of--CommentsClose CommentsPermalink
`(i) the State projection (in its submission on forms CMS--21B and CMS--37 for May 2007) of Federal payments to the State under this title for such fiscal year, except that, in the case of a State that has enacted legislation to modify its State child health plan during 2007, the State may substitute its projection in its submission on forms CMS--21B and CMS--37 for August 2007, instead of such forms for May 2007; orCommentsClose CommentsPermalink
`(ii) the allotment of the State under this section for fiscal year 2007 multiplied by the allotment increase factor under paragraph (2) for fiscal year 2008.CommentsClose CommentsPermalink
`(B) INFLATION UPDATE FOR FISCAL YEAR 2009 AND EACH SECOND SUCCEEDING FISCAL YEAR- For fiscal year 2009 and each second succeeding fiscal year, the allotment of a State is equal to the amount of the State allotment under this paragraph for the previous fiscal year multiplied by the allotment increase factor under paragraph (2) for the fiscal year involved.CommentsClose CommentsPermalink
`(C) REBASING IN FISCAL YEAR 2010 AND EACH SECOND SUCCEEDING FISCAL YEAR- For fiscal year 2010 and each second succeeding fiscal year, the allotment of a State is equal to the Federal payments to the State that are attributable to (and countable towards) the total amount of allotments available under this section to the State (including allotments made available under paragraph (3) as well as amounts redistributed to the State) in the previous fiscal year multiplied by the allotment increase factor under paragraph (2) for the fiscal year involved.CommentsClose CommentsPermalink
`(D) SPECIAL RULES FOR TERRITORIES- Notwithstanding the previous subparagraphs, the allotment for a State that is not one of the 50 States or the District of Columbia for fiscal year 2008 and for a succeeding fiscal year is equal to the Federal payments provided to the State under this title for the previous fiscal year multiplied by the allotment increase factor under paragraph (2) for the fiscal year involved (but determined by applying under paragraph (2)(B) as if the reference to `in the State' were a reference to `in the United States').CommentsClose CommentsPermalink
`(2) ALLOTMENT INCREASE FACTOR- The allotment increase factor under this paragraph for a fiscal year is equal to the product of the following:CommentsClose CommentsPermalink
`(A) PER CAPITA HEALTH CARE GROWTH FACTOR- 1 plus the percentage increase in the projected per capita amount of National Health Expenditures from the calendar year in which the previous fiscal year ends to the calendar year in which the fiscal year involved ends, as most recently published by the Secretary before the beginning of the fiscal year.CommentsClose CommentsPermalink
`(B) CHILD POPULATION GROWTH FACTOR- 1 plus the percentage increase (if any) in the population of children under 19 years of age in the State from July 1 in the previous fiscal year to July 1 in the fiscal year involved, as determined by the Secretary based on the most recent published estimates of the Bureau of the Census before the beginning of the fiscal year involved, plus 1 percentage point.CommentsClose CommentsPermalink
`(3) PERFORMANCE-BASED SHORTFALL ADJUSTMENT-CommentsClose CommentsPermalink
`(A) IN GENERAL- If a State's expenditures under this title in a fiscal year (beginning with fiscal year 2008) exceed the total amount of allotments available under this section to the State in the fiscal year (determined without regard to any redistribution it receives under subsection (f) that is available for expenditure during such fiscal year, but including any carryover from a previous fiscal year) and if the average monthly unduplicated number of children enrolled under the State plan under this title (including children receiving health care coverage through funds under this title pursuant to a waiver under section 1115) during such fiscal year exceeds its target average number of such enrollees (as determined under subparagraph (B)) for that fiscal year, the allotment under this section for the State for the subsequent fiscal year (or, pursuant to subparagraph (F), for the fiscal year involved) shall be increased by the product of--CommentsClose CommentsPermalink
`(i) the amount by which such average monthly caseload exceeds such target number of enrollees; andCommentsClose CommentsPermalink
`(ii) the projected per capita expenditures under the State child health plan (as determined under subparagraph (C) for the original fiscal year involved), multiplied by the enhanced FMAP (as defined in section 2105(b)) for the State and fiscal year involved.CommentsClose CommentsPermalink
`(B) TARGET AVERAGE NUMBER OF CHILD ENROLLEES- In this subsection, the target average number of child enrollees for a State--CommentsClose CommentsPermalink
`(i) for fiscal year 2008 is equal to the monthly average unduplicated number of children enrolled in the State child health plan under this title (including such children receiving health care coverage through funds under this title pursuant to a waiver under section 1115) during fiscal year 2007 increased by the population growth for children in that State for the year ending on June 30, 2006 (as estimated by the Bureau of the Census) plus 1 percentage point; orCommentsClose CommentsPermalink
`(ii) for a subsequent fiscal year is equal to the target average number of child enrollees for the State for the previous fiscal year increased by the population growth for children in that State for the year ending on June 30 before the beginning of the fiscal year (as estimated by the Bureau of the Census) plus 1 percentage point.CommentsClose CommentsPermalink
`(C) PROJECTED PER CAPITA EXPENDITURES- For purposes of subparagraph (A)(ii), the projected per capita expenditures under a State child health plan--CommentsClose CommentsPermalink
`(i) for fiscal year 2008 is equal to the average per capita expenditures (including both State and Federal financial participation) under such plan for the targeted low-income children counted in the average monthly caseload for purposes of this paragraph during fiscal year 2007, increased by the annual percentage increase in the per capita amount of National Health Expenditures (as estimated by the Secretary) for 2008; orCommentsClose CommentsPermalink
`(ii) for a subsequent fiscal year is equal to the projected per capita expenditures under such plan for the previous fiscal year (as determined under clause (i) or this clause) increased by the annual percentage increase in the per capita amount of National Health Expenditures (as estimated by the Secretary) for the year in which such subsequent fiscal year ends.CommentsClose CommentsPermalink
`(D) AVAILABILITY- Notwithstanding subsection (e), an increase in allotment under this paragraph shall only be available for expenditure during the fiscal year in which it is provided.CommentsClose CommentsPermalink
`(E) NO REDISTRIBUTION OF PERFORMANCE-BASED SHORTFALL ADJUSTMENT- In no case shall any increase in allotment under this paragraph for a State be subject to redistribution to other States.CommentsClose CommentsPermalink
`(F) INTERIM ALLOTMENT ADJUSTMENT- The Secretary shall develop a process to administer the performance-based shortfall adjustment in a manner so it is applied to (and before the end of) the fiscal year (rather than the subsequent fiscal year) involved for a State that the Secretary estimates will be in shortfall and will exceed its enrollment target for that fiscal year.CommentsClose CommentsPermalink
`(G) PERIODIC AUDITING- The Comptroller General of the United States shall periodically audit the accuracy of data used in the computation of allotment adjustments under this paragraph. Based on such audits, the Comptroller General shall make such recommendations to the Congress and the Secretary as the Comptroller General deems appropriate.CommentsClose CommentsPermalink
`(4) CONTINUED REPORTING- For purposes of paragraph (3) and subsection (f), the State shall submit to the Secretary the State's projected Federal expenditures, even if the amount of such expenditures exceeds the total amount of allotments available to the State in such fiscal year.'.CommentsClose CommentsPermalink
SEC. 102. 2-YEAR INITIAL AVAILABILITY OF CHIP ALLOTMENTS.
Section 2104(e) of the Social Security Act (
`(e) Availability of Amounts Allotted-CommentsClose CommentsPermalink
`(1) IN GENERAL- Except as provided in paragraph (2) and subsection (i)(3)(D), amounts allotted to a State pursuant to this section--CommentsClose CommentsPermalink
`(A) for each of fiscal years 1998 through 2007, shall remain available for expenditure by the State through the end of the second succeeding fiscal year; andCommentsClose CommentsPermalink
`(B) for fiscal year 2008 and each fiscal year thereafter, shall remain available for expenditure by the State through the end of the succeeding fiscal year.CommentsClose CommentsPermalink
`(2) AVAILABILITY OF AMOUNTS REDISTRIBUTED- Amounts redistributed to a State under subsection (f) shall be available for expenditure by the State through the end of the fiscal year in which they are redistributed, except that funds so redistributed to a State that are not expended by the end of such fiscal year shall remain available after the end of such fiscal year and shall be available in the following fiscal year for subsequent redistribution under such subsection.'.CommentsClose CommentsPermalink
SEC. 103. REDISTRIBUTION OF UNUSED ALLOTMENTS TO ADDRESS STATE FUNDING SHORTFALLS.
Section 2104(f) of the Social Security Act (
(1) by striking `The Secretary' and inserting the following:CommentsClose CommentsPermalink
`(1) IN GENERAL- The Secretary';CommentsClose CommentsPermalink
(2) by striking `States that have fully expended the amount of their allotments under this section.' and inserting `States that the Secretary determines with respect to the fiscal year for which unused allotments are available for redistribution under this subsection, are shortfall States described in paragraph (2) for such fiscal year, but not to exceed the amount of the shortfall described in paragraph (2)(A) for each such State (as may be adjusted under paragraph (2)(C)). The amount of allotments not expended or redistributed under the previous sentence shall remain available for redistribution in the succeeding fiscal year.'; andCommentsClose CommentsPermalink
(3) by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(2) SHORTFALL STATES DESCRIBED-CommentsClose CommentsPermalink
`(A) IN GENERAL- For purposes of paragraph (1), with respect to a fiscal year, a shortfall State described in this subparagraph is a State with a State child health plan approved under this title for which the Secretary estimates on the basis of the most recent data available to the Secretary, that the projected expenditures under such plan for the State for the fiscal year will exceed the sum of--CommentsClose CommentsPermalink
`(i) the amount of the State's allotments for any preceding fiscal years that remains available for expenditure and that will not be expended by the end of the immediately preceding fiscal year;CommentsClose CommentsPermalink
`(ii) the amount (if any) of the performance based adjustment under subsection (i)(3)(A); andCommentsClose CommentsPermalink
`(iii) the amount of the State's allotment for the fiscal year.CommentsClose CommentsPermalink
`(B) PRORATION RULE- If the amounts available for redistribution under paragraph (1) for a fiscal year are less than the total amounts of the estimated shortfalls determined for the year under subparagraph (A), the amount to be redistributed under such paragraph for each shortfall State shall be reduced proportionally.CommentsClose CommentsPermalink
`(C) RETROSPECTIVE ADJUSTMENT- The Secretary may adjust the estimates and determinations made under paragraph (1) and this paragraph with respect to a fiscal year as necessary on the basis of the amounts reported by States not later than November 30 of the succeeding fiscal year, as approved by the Secretary.'.CommentsClose CommentsPermalink
SEC. 104. EXTENSION OF OPTION FOR QUALIFYING STATES.
Section 2105(g)(1)(A) of the Social Security Act (
Subtitle B--Improving Enrollment and Retention of Eligible Children
SEC. 111. CHIP PERFORMANCE BONUS PAYMENT TO OFFSET ADDITIONAL ENROLLMENT COSTS RESULTING FROM ENROLLMENT AND RETENTION EFFORTS.
(a) In General- Section 2105(a) of the Social Security Act (
`(3) PERFORMANCE BONUS PAYMENT TO OFFSET ADDITIONAL MEDICAID AND CHIP CHILD ENROLLMENT COSTS RESULTING FROM ENROLLMENT AND RETENTION EFFORTS-CommentsClose CommentsPermalink
`(A) IN GENERAL- In addition to the payments made under paragraph (1), for each fiscal year (beginning with fiscal year 2008 and ending with fiscal year 2013) the Secretary shall pay to each State that meets the condition under paragraph (4) for the fiscal year, an amount equal to the amount described in subparagraph (B) for the State and fiscal year. The payment under this paragraph shall be made, to a State for a fiscal year, as a single payment not later than the last day of the first calendar quarter of the following fiscal year.CommentsClose CommentsPermalink
`(B) AMOUNT- The amount described in this subparagraph for a State for a fiscal year is equal to the sum of the following amounts:CommentsClose CommentsPermalink
`(i) FOR ABOVE BASELINE MEDICAID CHILD ENROLLMENT COSTS-CommentsClose CommentsPermalink
`(I) FIRST TIER ABOVE BASELINE MEDICAID ENROLLEES- An amount equal to the number of first tier above baseline child enrollees (as determined under subparagraph (C)(i)) under title XIX for the State and fiscal year multiplied by 35 percent of the projected per capita State Medicaid expenditures (as determined under subparagraph (D)(i)) for the State and fiscal year under title XIX.CommentsClose CommentsPermalink
`(II) SECOND TIER ABOVE BASELINE MEDICAID ENROLLEES- An amount equal to the number of second tier above baseline child enrollees (as determined under subparagraph (C)(ii)) under title XIX for the State and fiscal year multiplied by 90 percent of the projected per capita State Medicaid expenditures (as determined under subparagraph (D)(i)) for the State and fiscal year under title XIX.CommentsClose CommentsPermalink
`(ii) FOR ABOVE BASELINE CHIP ENROLLMENT COSTS-CommentsClose CommentsPermalink
`(I) FIRST TIER ABOVE BASELINE CHIP ENROLLEES- An amount equal to the number of first tier above baseline child enrollees under this title (as determined under subparagraph (C)(i)) for the State and fiscal year multiplied by 5 percent of the projected per capita State CHIP expenditures (as determined under subparagraph (D)(ii)) for the State and fiscal year under this title.CommentsClose CommentsPermalink
`(II) SECOND TIER ABOVE BASELINE CHIP ENROLLEES- An amount equal to the number of second tier above baseline child enrollees under this title (as determined under subparagraph (C)(ii)) for the State and fiscal year multiplied by 75 percent of the projected per capita State CHIP expenditures (as determined under subparagraph (D)(ii)) for the State and fiscal year under this title.CommentsClose CommentsPermalink
`(C) NUMBER OF FIRST AND SECOND TIER ABOVE BASELINE CHILD ENROLLEES; BASELINE NUMBER OF CHILD ENROLLEES- For purposes of this paragraph:CommentsClose CommentsPermalink
`(i) FIRST TIER ABOVE BASELINE CHILD ENROLLEES- The number of first tier above baseline child enrollees for a State for a fiscal year under this title or title XIX is equal to the number (if any, as determined by the Secretary) by which--CommentsClose CommentsPermalink
`(I) the monthly average unduplicated number of qualifying children (as defined in subparagraph (E)) enrolled during the fiscal year under the State child health plan under this title or under the State plan under title XIX, respectively; exceedsCommentsClose CommentsPermalink
`(II) the baseline number of enrollees described in clause (iii) for the State and fiscal year under this title or title XIX, respectively;CommentsClose CommentsPermalink
but not to exceed 3 percent (in the case of title XIX) or 7.5 percent (in the case of this title) of the baseline number of enrollees described in subclause (II).CommentsClose CommentsPermalink
`(ii) SECOND TIER ABOVE BASELINE CHILD ENROLLEES- The number of second tier above baseline child enrollees for a State for a fiscal year under this title or title XIX is equal to the number (if any, as determined by the Secretary) by which--CommentsClose CommentsPermalink
`(I) the monthly average unduplicated number of qualifying children (as defined in subparagraph (E)) enrolled during the fiscal year under this title or under title XIX, respectively, as described in clause (i)(I); exceedsCommentsClose CommentsPermalink
`(II) the sum of the baseline number of child enrollees described in clause (iii) for the State and fiscal year under this title or title XIX, respectively, as described in clause (i)(II), and the maximum number of first tier above baseline child enrollees for the State and fiscal year under this title or title XIX, respectively, as determined under clause (i).CommentsClose CommentsPermalink
`(iii) BASELINE NUMBER OF CHILD ENROLLEES- The baseline number of child enrollees for a State under this title or title XIX--CommentsClose CommentsPermalink
`(I) for fiscal year 2008 is equal to the monthly average unduplicated number of qualifying children enrolled in the State child health plan under this title or in the State plan under title XIX, respectively, during fiscal year 2007 increased by the population growth for children in that State for the year ending on June 30, 2006 (as estimated by the Bureau of the Census) plus 1 percentage point; orCommentsClose CommentsPermalink
`(II) for a subsequent fiscal year is equal to the baseline number of child enrollees for the State for the previous fiscal year under this title or title XIX, respectively, increased by the population growth for children in that State for the year ending on June 30 before the beginning of the fiscal year (as estimated by the Bureau of the Census) plus 1 percentage point.CommentsClose CommentsPermalink
`(D) PROJECTED PER CAPITA STATE EXPENDITURES- For purposes of subparagraph (B)--CommentsClose CommentsPermalink
`(i) PROJECTED PER CAPITA STATE MEDICAID EXPENDITURES- The projected per capita State Medicaid expenditures for a State and fiscal year under title XIX is equal to the average per capita expenditures (including both State and Federal financial participation) for children under the State plan under such title, including under waivers but not including such children eligible for assistance by virtue of the receipt of benefits under title XVI, for the most recent fiscal year for which actual data are available (as determined by the Secretary), increased (for each subsequent fiscal year up to and including the fiscal year involved) by the annual percentage increase in per capita amount of National Health Expenditures (as estimated by the Secretary) for the calendar year in which the respective subsequent fiscal year ends and multiplied by a State matching percentage equal to 100 percent minus the Federal medical assistance percentage (as defined in section 1905(b)) for the fiscal year involved.CommentsClose CommentsPermalink
`(ii) PROJECTED PER CAPITA STATE CHIP EXPENDITURES- The projected per capita State CHIP expenditures for a State and fiscal year under this title is equal to the average per capita expenditures (including both State and Federal financial participation) for children under the State child health plan under this title, including under waivers, for the most recent fiscal year for which actual data are available (as determined by the Secretary), increased (for each subsequent fiscal year up to and including the fiscal year involved) by the annual percentage increase in per capita amount of National Health Expenditures (as estimated by the Secretary) for the calendar year in which the respective subsequent fiscal year ends and multiplied by a State matching percentage equal to 100 percent minus the enhanced FMAP (as defined in section 2105(b)) for the fiscal year involved.CommentsClose CommentsPermalink
`(E) QUALIFYING CHILDREN DEFINED- For purposes of this subsection, the term `qualifying children' means, with respect to this title or title XIX, children who meet the eligibility criteria (including income, categorical eligibility, age, and immigration status criteria) in effect as of July 1, 2007, for enrollment under this title or title XIX, respectively, taking into account criteria applied as of such date under this title or title XIX, respectively, pursuant to a waiver under section 1115.CommentsClose CommentsPermalink
`(4) ENROLLMENT AND RETENTION PROVISIONS FOR CHILDREN- For purposes of paragraph (3)(A), a State meets the condition of this paragraph for a fiscal year if it is implementing at least 4 of the following enrollment and retention provisions (treating each subparagraph as a separate enrollment and retention provision) throughout the entire fiscal year:CommentsClose CommentsPermalink
`(A) CONTINUOUS ELIGIBILITY- The State has elected the option of continuous eligibility for a full 12 months for all children described in section 1902(e)(12) under title XIX under 19 years of age, as well as applying such policy under its State child health plan under this title.CommentsClose CommentsPermalink
`(B) LIBERALIZATION OF ASSET REQUIREMENTS- The State meets the requirement specified in either of the following clauses:CommentsClose CommentsPermalink
`(i) ELIMINATION OF ASSET TEST- The State does not apply any asset or resource test for eligibility for children under title XIX or this title.CommentsClose CommentsPermalink
`(ii) ADMINISTRATIVE VERIFICATION OF ASSETS- The State--CommentsClose CommentsPermalink
`(I) permits a parent or caretaker relative who is applying on behalf of a child for medical assistance under title XIX or child health assistance under this title to declare and certify by signature under penalty of perjury information relating to family assets for purposes of determining and redetermining financial eligibility; andCommentsClose CommentsPermalink
`(II) takes steps to verify assets through means other than by requiring documentation from parents and applicants except in individual cases of discrepancies or where otherwise justified.CommentsClose CommentsPermalink
`(C) ELIMINATION OF IN-PERSON INTERVIEW REQUIREMENT- The State does not require an application of a child for medical assistance under title XIX (or for child health assistance under this title), including an application for renewal of such assistance, to be made in person nor does the State require a face-to-face interview, unless there are discrepancies or individual circumstances justifying an in-person application or face-to-face interview.CommentsClose CommentsPermalink
`(D) USE OF JOINT APPLICATION FOR MEDICAID AND CHIP- The application form and supplemental forms (if any) and information verification process is the same for purposes of establishing and renewing eligibility for children for medical assistance under title XIX and child health assistance under this title.CommentsClose CommentsPermalink
`(E) AUTOMATIC RENEWAL (USE OF ADMINISTRATIVE RENEWAL)-CommentsClose CommentsPermalink
`(i) IN GENERAL- The State provides, in the case of renewal of a child's eligibility for medical assistance under title XIX or child health assistance under this title, a pre-printed form completed by the State based on the information available to the State and notice to the parent or caretaker relative of the child that eligibility of the child will be renewed and continued based on such information unless the State is provided other information. Nothing in this clause shall be construed as preventing a State from verifying, through electronic and other means, the information so provided.CommentsClose CommentsPermalink
`(ii) SATISFACTION THROUGH DEMONSTRATED USE OF EX PARTE PROCESS- A State shall be treated as satisfying the requirement of clause (i) if renewal of eligibility of children under title XIX or this title is determined without any requirement for an in-person interview, unless sufficient information is not in the State's possession and cannot be acquired from other sources (including other State agencies) without the participation of the applicant or the applicant's parent or caretaker relative.CommentsClose CommentsPermalink
`(F) PRESUMPTIVE ELIGIBILITY FOR CHILDREN- The State is implementing section 1920A under title XIX as well as, pursuant to section 2107(e)(1), under this title.CommentsClose CommentsPermalink
`(G) EXPRESS LANE- The State is implementing the option described in section 1902(e)(13) under title XIX as well as, pursuant to section 2107(e)(1), under this title.'.CommentsClose CommentsPermalink
(b) GAO Study-CommentsClose CommentsPermalink
(1) IN GENERAL- The Comptroller General of the United States shall conduct a study on the effectiveness of the performance bonus payment program under the amendment made by subsection (a) on the enrollment and retention of eligible children under the Medicaid and CHIP programs and in reducing the rate of uninsurance among such children.CommentsClose CommentsPermalink
(2) REPORT- Not later than January 1, 2013, the Comptroller General shall submit a report to Congress on such study and shall include in such report such recommendations for extending or modifying such program as the Comptroller General determines appropriate.CommentsClose CommentsPermalink
SEC. 112. STATE OPTION TO RELY ON FINDINGS FROM AN EXPRESS LANE AGENCY TO CONDUCT SIMPLIFIED ELIGIBILITY DETERMINATIONS.
(a) Medicaid- Section 1902(e) of the Social Security Act (
`(13) Express Lane Option-CommentsClose CommentsPermalink
`(A) IN GENERAL-CommentsClose CommentsPermalink
`(i) OPTION TO USE A FINDING FROM AN EXPRESS LANE AGENCY- At the option of the State, the State plan may provide that in determining eligibility under this title for a child (as defined in subparagraph (F)), the State may rely on a finding made within a reasonable period (as determined by the State) from an Express Lane agency (as defined in subparagraph (E)) when it determines whether a child satisfies one or more components of eligibility for medical assistance under this title. The State may rely on a finding from an Express Lane agency notwithstanding sections 1902(a)(46)(B), 1903(x), and 1137(d) and any differences in budget unit, disregard, deeming or other methodology, if the following requirements are met:CommentsClose CommentsPermalink
`(I) PROHIBITION ON DETERMINING CHILDREN INELIGIBLE FOR COVERAGE- If a finding from an Express Lane agency would result in a determination that a child does not satisfy an eligibility requirement for medical assistance under this title and for child health assistance under title XXI, the State shall determine eligibility for assistance using its regular procedures.CommentsClose CommentsPermalink
`(II) NOTICE REQUIREMENT- For any child who is found eligible for medical assistance under the State plan under this title or child health assistance under title XXI and who is subject to premiums based on an Express Lane agency's finding of such child's income level, the State shall provide notice that the child may qualify for lower premium payments if evaluated by the State using its regular policies and of the procedures for requesting such an evaluation.CommentsClose CommentsPermalink
`(III) COMPLIANCE WITH SCREEN AND ENROLL REQUIREMENT- The State shall satisfy the requirements under (A) and (B) of section 2102(b)(3) (relating to screen and enroll) before enrolling a child in child health assistance under title XXI. At its option, the State may fulfill such requirements in accordance with either option provided under subparagraph (C) of this paragraph.CommentsClose CommentsPermalink
`(ii) OPTION TO APPLY TO RENEWALS AND REDETERMINATIONS- The State may apply the provisions of this paragraph when conducting initial determinations of eligibility, redeterminations of eligibility, or both, as described in the State plan.CommentsClose CommentsPermalink
`(B) RULES OF CONSTRUCTION- Nothing in this paragraph shall be construed--CommentsClose CommentsPermalink
`(i) to limit or prohibit a State from taking any actions otherwise permitted under this title or title XXI in determining eligibility for or enrolling children into medical assistance under this title or child health assistance under title XXI; orCommentsClose CommentsPermalink
`(ii) to modify the limitations in section 1902(a)(5) concerning the agencies that may make a determination of eligibility for medical assistance under this title.CommentsClose CommentsPermalink
`(C) OPTIONS FOR SATISFYING THE SCREEN AND ENROLL REQUIREMENT-CommentsClose CommentsPermalink
`(i) IN GENERAL- With respect to a child whose eligibility for medical assistance under this title or for child health assistance under title XXI has been evaluated by a State agency using an income finding from an Express Lane agency, a State may carry out its duties under subparagraphs (A) and (B) of section 2102(b)(3) (relating to screen and enroll) in accordance with either clause (ii) or clause (iii).CommentsClose CommentsPermalink
`(ii) ESTABLISHING A SCREENING THRESHOLD-CommentsClose CommentsPermalink
`(I) IN GENERAL- Under this clause, the State establishes a screening threshold set as a percentage of the Federal poverty level that exceeds the highest income threshold applicable under this title to the child by a minimum of 30 percentage points or, at State option, a higher number of percentage points that reflects the value (as determined by the State and described in the State plan) of any differences between income methodologies used by the program administered by the Express Lane agency and the methodologies used by the State in determining eligibility for medical assistance under this title.CommentsClose CommentsPermalink
`(II) CHILDREN WITH INCOME NOT ABOVE THRESHOLD- If the income of a child does not exceed the screening threshold, the child is deemed to satisfy the income eligibility criteria for medical assistance under this title regardless of whether such child would otherwise satisfy such criteria.CommentsClose CommentsPermalink
`(III) CHILDREN WITH INCOME ABOVE THRESHOLD- If the income of a child exceeds the screening threshold, the child shall be considered to have an income above the Medicaid applicable income level described in section 2110(b)(4) and to satisfy the requirement under section 2110(b)(1)(C) (relating to the requirement that CHIP matching funds be used only for children not eligible for Medicaid). If such a child is enrolled in child health assistance under title XXI, the State shall provide the parent, guardian, or custodial relative with the following:CommentsClose CommentsPermalink
`(aa) Notice that the child may be eligible to receive medical assistance under the State plan under this title if evaluated for such assistance under the State's regular procedures and notice of the process through which a parent, guardian, or custodial relative can request that the State evaluate the child's eligibility for medical assistance under this title using such regular procedures.CommentsClose CommentsPermalink
`(bb) A description of differences between the medical assistance provided under this title and child health assistance under title XXI, including differences in cost-sharing requirements and covered benefits.CommentsClose CommentsPermalink
`(iii) TEMPORARY ENROLLMENT IN CHIP PENDING SCREEN AND ENROLL-CommentsClose CommentsPermalink
`(I) IN GENERAL- Under this clause, a State enrolls a child in child health assistance under title XXI for a temporary period if the child appears eligible for such assistance based on an income finding by an Express Lane agency.CommentsClose CommentsPermalink
`(II) DETERMINATION OF ELIGIBILITY- During such temporary enrollment period, the State shall determine the child's eligibility for child health assistance under title XXI or for medical assistance under this title in accordance with this clause.CommentsClose CommentsPermalink
`(III) PROMPT FOLLOW UP- In making such a determination, the State shall take prompt action to determine whether the child should be enrolled in medical assistance under this title or child health assistance under title XXI pursuant to subparagraphs (A) and (B) of section 2102(b)(3) (relating to screen and enroll).CommentsClose CommentsPermalink
`(IV) REQUIREMENT FOR SIMPLIFIED DETERMINATION- In making such a determination, the State shall use procedures that, to the maximum feasible extent, reduce the burden imposed on the individual of such determination. Such procedures may not require the child's parent, guardian, or custodial relative to provide or verify information that already has been provided to the State agency by an Express Lane agency or another source of information unless the State agency has reason to believe the information is erroneous.CommentsClose CommentsPermalink
`(V) AVAILABILITY OF CHIP MATCHING FUNDS DURING TEMPORARY ENROLLMENT PERIOD- Medical assistance for items and services that are provided to a child enrolled in title XXI during a temporary enrollment period under this clause shall be treated as child health assistance under such title.CommentsClose CommentsPermalink
`(D) OPTION FOR AUTOMATIC ENROLLMENT-CommentsClose CommentsPermalink
`(i) IN GENERAL- At its option, a State may initiate an evaluation of an individual's eligibility for medical assistance under this title without an application and determine the individual's eligibility for such assistance using findings from one or more Express Lane agencies and information from sources other than a child, if the requirements of clauses (ii) and (iii) are met.CommentsClose CommentsPermalink
`(ii) INDIVIDUAL CHOICE REQUIREMENT- The requirement of this clause is that the child is enrolled in medical assistance under this title or child health assistance under title XXI only if the child (or a parent, caretaker relative, or guardian on the behalf of the child) has affirmatively assented to such enrollment.CommentsClose CommentsPermalink
`(iii) INFORMATION REQUIREMENT- The requirement of this clause is that the State informs the parent, guardian, or custodial relative of the child of the services that will be covered, appropriate methods for using such services, premium or other cost sharing charges (if any) that apply, medical support obligations (under section 1912(a)) created by enrollment (if applicable), and the actions the parent, guardian, or relative must take to maintain enrollment and renew coverage.CommentsClose CommentsPermalink
`(E) EXPRESS LANE AGENCY DEFINED- In this paragraph, the term `express lane agency' means an agency that meets the following requirements:CommentsClose CommentsPermalink
`(i) The agency determines eligibility for assistance under the Food Stamp Act of 1977, the Richard B. Russell National School Lunch Act, the Child Nutrition Act of 1966, or the Child Care and Development Block Grant Act of 1990.CommentsClose CommentsPermalink
`(ii) The agency notifies the child (or a parent, caretaker relative, or guardian on the behalf of the child)--CommentsClose CommentsPermalink
`(I) of the information which shall be disclosed;CommentsClose CommentsPermalink
`(II) that the information will be used by the State solely for purposes of determining eligibility for and for providing medical assistance under this title or child health assistance under title XXI; andCommentsClose CommentsPermalink
`(III) that the child, or parent, caretaker relative, or guardian, may elect to not have the information disclosed for such purposes.CommentsClose CommentsPermalink
`(iii) The agency and the State agency are subject to an interagency agreement limiting the disclosure and use of such information to such purposes.CommentsClose CommentsPermalink
`(iv) The agency is determined by the State agency to be capable of making the determinations described in this paragraph and is identified in the State plan under this title or title XXI.CommentsClose CommentsPermalink
For purposes of this subparagraph, the term `State agency' refers to the agency determining eligibility for medical assistance under this title or child health assistance under title XXI.CommentsClose CommentsPermalink
`(F) CHILD DEFINED- For purposes of this paragraph, the term `child' means an individual under 19 years of age, or, at the option of a State, such higher age, not to exceed 21 years of age, as the State may elect.'.CommentsClose CommentsPermalink
(b) CHIP- Section 2107(e)(1) of such Act (
`(C) Section 1902(e)(13) (relating to the State option to rely on findings from an Express Lane agency to help evaluate a child's eligibility for medical assistance).'.CommentsClose CommentsPermalink
(c) Electronic Transmission of Information- Section 1902 of such Act (
`(dd) Electronic Transmission of Information- If the State agency determining eligibility for medical assistance under this title or child health assistance under title XXI verifies an element of eligibility based on information from an Express Lane Agency (as defined in subsection (e)(13)(F)), or from another public agency, then the applicant's signature under penalty of perjury shall not be required as to such element. Any signature requirement for an application for medical assistance may be satisfied through an electronic signature, as defined in section 1710(1) of the Government Paperwork Elimination Act (
(d) Authorization of Information Disclosure-CommentsClose CommentsPermalink
(1) IN GENERAL- Title XIX of the Social Security Act is amended--CommentsClose CommentsPermalink
(A) by redesignating section 1939 as section 1940; andCommentsClose CommentsPermalink
(B) by inserting after section 1938 the following new section:CommentsClose CommentsPermalink
`SEC. 1939. AUTHORIZATION TO RECEIVE PERTINENT INFORMATION.
`(a) In General- Notwithstanding any other provision of law, a Federal or State agency or private entity in possession of the sources of data potentially pertinent to eligibility determinations under this title (including eligibility files maintained by Express Lane agencies described in section 1902(e)(13)(F), information described in paragraph (2) or (3) of section 1137(a), vital records information about births in any State, and information described in sections 453(i) and 1902(a)(25)(I)) is authorized to convey such data or information to the State agency administering the State plan under this title, to the extent such conveyance meets the requirements of subsection (b).CommentsClose CommentsPermalink
`(b) Requirements for Conveyance- Data or information may be conveyed pursuant to subsection (a) only if the following requirements are met:CommentsClose CommentsPermalink
`(1) The individual whose circumstances are described in the data or information (or such individual's parent, guardian, caretaker relative, or authorized representative) has either provided advance consent to disclosure or has not objected to disclosure after receiving advance notice of disclosure and a reasonable opportunity to object.CommentsClose CommentsPermalink
`(2) Such data or information are used solely for the purposes of--CommentsClose CommentsPermalink
`(A) identifying individuals who are eligible or potentially eligible for medical assistance under this title and enrolling or attempting to enroll such individuals in the State plan; andCommentsClose CommentsPermalink
`(B) verifying the eligibility of individuals for medical assistance under the State plan.CommentsClose CommentsPermalink
`(3) An interagency or other agreement, consistent with standards developed by the Secretary--CommentsClose CommentsPermalink
`(A) prevents the unauthorized use, disclosure, or modification of such data and otherwise meets applicable Federal requirements safeguarding privacy and data security; andCommentsClose CommentsPermalink
`(B) requires the State agency administering the State plan to use the data and information obtained under this section to seek to enroll individuals in the plan.CommentsClose CommentsPermalink
`(c) Criminal Penalty- A private entity described in the subsection (a) that publishes, discloses, or makes known in any manner, or to any extent not authorized by Federal law, any information obtained under this section shall be fined not more than $1,000 or imprisoned not more than 1 year, or both, for each such unauthorized publication or disclosure.CommentsClose CommentsPermalink
`(d) Rule of Construction- The limitations and requirements that apply to disclosure pursuant to this section shall not be construed to prohibit the conveyance or disclosure of data or information otherwise permitted under Federal law (without regard to this section).'.CommentsClose CommentsPermalink
(2) CONFORMING AMENDMENT TO TITLE XXI- Section 2107(e)(1) of such Act (
`(J) Section 1939 (relating to authorization to receive data potentially pertinent to eligibility determinations).'.CommentsClose CommentsPermalink
(3) CONFORMING AMENDMENT TO PROVIDE ACCESS TO DATA ABOUT ENROLLMENT IN INSURANCE FOR PURPOSES OF EVALUATING APPLICATIONS AND FOR CHIP- Section 1902(a)(25)(I)(i) of such Act (
(A) by inserting `(and, at State option, individuals who are potentially eligible or who apply)' after `with respect to individuals who are eligible'; andCommentsClose CommentsPermalink
(B) by inserting `under this title (and, at State option, child health assistance under title XXI)' after `the State plan'.CommentsClose CommentsPermalink
(e) Effective Date- The amendments made by this section are effective on January 1, 2008.CommentsClose CommentsPermalink
SEC. 113. APPLICATION OF MEDICAID OUTREACH PROCEDURES TO ALL CHILDREN AND PREGNANT WOMEN.
(a) In General- Section 1902(a)(55) of the Social Security Act (
(1) in the matter before subparagraph (A), by striking `individuals for medical assistance under subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or (a)(10)(A)(ii)(IX)' and inserting `children and pregnant women for medical assistance under any provision of this title'; andCommentsClose CommentsPermalink
(2) in subparagraph (B), by inserting before the semicolon at the end the following: `, which need not be the same application form for all such individuals'.CommentsClose CommentsPermalink
(b) Effective Date- The amendments made by subsection (a) take effect on January 1, 2008.CommentsClose CommentsPermalink
SEC. 114. ENCOURAGING CULTURALLY APPROPRIATE ENROLLMENT AND RETENTION PRACTICES.
(a) Use of Medicaid Funds- Section 1903(a)(2) of the Social Security Act (
`(E) an amount equal to 75 percent of so much of the sums expended during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as are attributable to translation or interpretation services in connection with the enrollment and retention under this title of children of families for whom English is not the primary language; plus'.CommentsClose CommentsPermalink
(b) Use of Community Health Workers for Outreach Activities-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 2102(c)(1) of such Act (
(2) IN FEDERAL EVALUATION- Section 2108(c)(3)(B) of such Act (
SEC. 115. CONTINUOUS COVERAGE UNDER CHIP.
(a) In General- Section 2102(b) of the Social Security Act (
`(5) 12-months CONTINUOUS ELIGIBILITY- In the case of a State child health plan that provides child health assistance under this title through a means other than described in section 2101(a)(2), the plan shall provide for implementation under this title of the 12-months continuous eligibility option described in section 1902(e)(12) for targeted low-income children whose family income is below 200 percent of the poverty line.'.CommentsClose CommentsPermalink
(b) Effective Date- The amendment made by subsection (a) shall apply to determinations (and redeterminations) of eligibility made on or after January 1, 2008.CommentsClose CommentsPermalink
Subtitle C--Coverage
SEC. 121. ENSURING CHILD-CENTERED COVERAGE.
(a) Additional Required Services-CommentsClose CommentsPermalink
(1) CHILD-CENTERED COVERAGE- Section 2103 of the Social Security Act (
(A) in subsection (a)--CommentsClose CommentsPermalink
(i) in the matter before paragraph (1), by striking `subsection (c)(5)' and inserting `paragraphs (5) and (6) of subsection (c)'; andCommentsClose CommentsPermalink
(ii) in paragraph (1), by inserting `at least' after `that is'; andCommentsClose CommentsPermalink
(B) in subsection (c)--CommentsClose CommentsPermalink
(i) by redesignating paragraph (5) as paragraph (6); andCommentsClose CommentsPermalink
(ii) by inserting after paragraph (4), the following:CommentsClose CommentsPermalink
`(5) DENTAL, FQHC, AND RHC SERVICES- The child health assistance provided to a targeted low-income child (whether through benchmark coverage or benchmark-equivalent coverage or otherwise) shall include coverage of the following:CommentsClose CommentsPermalink
`(A) Dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.CommentsClose CommentsPermalink
`(B) Federally-qualified health center services (as defined in section 1905(l)(2)) and rural health clinic services (as defined in section 1905(l)(1)).CommentsClose CommentsPermalink
Nothing in this section shall be construed as preventing a State child health plan from providing such services as part of benchmark coverage or in addition to the benefits provided through benchmark coverage.'.CommentsClose CommentsPermalink
(2) REQUIRED PAYMENT FOR FQHC AND RHC SERVICES- Section 2107(e)(1) of such Act (
`(D) Section 1902(bb) (relating to payment for services provided by Federally-qualified health centers and rural health clinics).'.CommentsClose CommentsPermalink
(3) MENTAL HEALTH PARITY- Section 2103(a)(2)(C) of such Act (
(4) EFFECTIVE DATE- The amendments made by this subsection and subsection (d) shall apply to health benefits coverage provided on or after October 1, 2008.CommentsClose CommentsPermalink
(b) Clarification of Requirement to Provide EPSDT Services for All Children in Benchmark Benefit Packages Under Medicaid-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1937(a)(1) of the Social Security Act (
(A) in subparagraph (A)--CommentsClose CommentsPermalink
(i) in the matter before clause (i), by striking `Notwithstanding any other provision of this title' and inserting `Subject to subparagraph (E)'; andCommentsClose CommentsPermalink
(ii) by striking `enrollment in coverage that provides' and all that follows and inserting `benchmark coverage described in subsection (b)(1) or benchmark equivalent coverage described in subsection (b)(2).';CommentsClose CommentsPermalink
(B) by striking subparagraph (C) and inserting the following new subparagraph:CommentsClose CommentsPermalink
`(C) STATE OPTION TO PROVIDE ADDITIONAL BENEFITS- A State, at its option, may provide such additional benefits to benchmark coverage described in subsection (b)(1) or benchmark equivalent coverage described in subsection (b)(2) as the State may specify.'; andCommentsClose CommentsPermalink
(C) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(E) REQUIRING COVERAGE OF EPSDT SERVICES- Nothing in this paragraph shall be construed as affecting a child's entitlement to care and services described in subsections (a)(4)(B) and (r) of section 1905 and provided in accordance with section 1902(a)(43) whether provided through benchmark coverage, benchmark equivalent coverage, or otherwise.'.CommentsClose CommentsPermalink
(2) EFFECTIVE DATE- The amendments made by paragraph (1) shall take effect as if included in the amendment made by section 6044(a) of the Deficit Reduction Act of 2005.CommentsClose CommentsPermalink
(c) Clarification of Coverage of Services in School-Based Health Centers Included as Child Health Assistance-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 2110(a)(5) of such Act (
(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply to child health assistance furnished on or after the date of the enactment of this Act.CommentsClose CommentsPermalink
(d) Assuring Access to Care-CommentsClose CommentsPermalink
(1) STATE CHILD HEALTH PLAN REQUIREMENT- Section 2102(a)(7)(B) of such Act (
(2) REFERENCE TO EFFECTIVE DATE- For the effective date for the amendments made by this subsection, see subsection (a)(5).CommentsClose CommentsPermalink
SEC. 122. IMPROVING BENCHMARK COVERAGE OPTIONS.
(a) Limitation on Secretary-Approved Coverage-CommentsClose CommentsPermalink
(1) UNDER CHIP- Section 2103(a)(4) of the Social Security Act (
(2) UNDER MEDICAID- Section 1937(b)(1)(D) of the Social Security Act (
(b) Requirement for Most Popular Family Coverage for State Employee Coverage Benchmark-CommentsClose CommentsPermalink
(1) CHIP- Section 2103(b)(2) of such Act (
(2) MEDICAID- Section 1937(b)(1)(B) of such Act is amended by inserting `and that has been selected most frequently, by employees seeking dependent coverage, among such plans that provide such dependent coverage, in either of the previous 2 plan years' before the period at the end.CommentsClose CommentsPermalink
(c) Effective Date- The amendments made by this section shall apply to health benefits coverage provided on or after October 1, 2008.CommentsClose CommentsPermalink
SEC. 123. PREMIUM GRACE PERIOD.
(a) In General- Section 2103(e)(3) of the Social Security Act (
`(C) PREMIUM GRACE PERIOD- The State child health plan--CommentsClose CommentsPermalink
`(i) shall afford individuals enrolled under the plan a grace period of at least 30 days from the beginning of a new coverage period to make premium payments before the individual's coverage under the plan may be terminated; andCommentsClose CommentsPermalink
`(ii) shall provide to such an individual, not later than 7 days after the first day of such grace period, notice--CommentsClose CommentsPermalink
`(I) that failure to make a premium payment within the grace period will result in termination of coverage under the State child health plan; andCommentsClose CommentsPermalink
`(II) of the individual's right to challenge the proposed termination pursuant to the applicable Federal regulations.CommentsClose CommentsPermalink
For purposes of clause (i), the term `new coverage period' means the month immediately following the last month for which the premium has been paid.'.CommentsClose CommentsPermalink
(b) Effective Date- The amendment made by subsection (a) shall apply to new coverage periods beginning on or after January 1, 2009.CommentsClose CommentsPermalink
Subtitle D--Populations
SEC. 131. OPTIONAL COVERAGE OF CHILDREN UP TO AGE 21 UNDER CHIP.
(a) In General- Section 2110(c)(1) of the Social Security Act (
(b) Effective Date- The amendment made by subsection (a) shall take effect on January 1, 2008.CommentsClose CommentsPermalink
SEC. 132. OPTIONAL COVERAGE OF LEGAL IMMIGRANTS UNDER THE MEDICAID PROGRAM AND CHIP.
(a) Medicaid Program- Section 1903(v) of the Social Security Act (
(1) in paragraph (1), by striking `paragraph (2)' and inserting `paragraphs (2) and (4)'; andCommentsClose CommentsPermalink
(2) by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(4)(A) A State may elect (in a plan amendment under this title) to provide medical assistance under this title, notwithstanding sections 401(a), 402(b), 403, and 421 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, for aliens who are lawfully residing in the United States (including battered aliens described in section 431(c) of such Act) and who are otherwise eligible for such assistance, within either or both of the following eligibility categories:CommentsClose CommentsPermalink
`(i) PREGNANT WOMEN- Women during pregnancy (and during the 60-day period beginning on the last day of the pregnancy).CommentsClose CommentsPermalink
`(ii) CHILDREN- Individuals under age 19 (or such higher age as the State has elected under section 1902(l)(1)(D)), including optional targeted low-income children described in section 1905(u)(2)(B).CommentsClose CommentsPermalink
`(B) In the case of a State that has elected to provide medical assistance to a category of aliens under subparagraph (A), no debt shall accrue under an affidavit of support against any sponsor of such an alien on the basis of provision of medical assistance to such category and the cost of such assistance shall not be considered as an unreimbursed cost.'.CommentsClose CommentsPermalink
(b) CHIP- Section 2107(e)(1) of such Act (
`(F) Section 1903(v)(4)(A) (relating to optional coverage of certain categories of lawfully residing immigrants), insofar as it relates to the category of pregnant women described in clause (i) of such section, but only if the State has elected to apply such section with respect to such women under title XIX and the State has elected the option under section 2111 to provide assistance for pregnant women under this title.CommentsClose CommentsPermalink
`(G) Section 1903(v)(4)(A) (relating to optional coverage of categories of lawfully residing immigrants), insofar as it relates to the category of children described in clause (ii) of such section, but only if the State has elected to apply such section with respect to such children under title XIX.'.CommentsClose CommentsPermalink
(c) Effective Date- The amendments made by this section take effect on the date of the enactment of this Act.CommentsClose CommentsPermalink
SEC. 133. STATE OPTION TO EXPAND OR ADD COVERAGE OF CERTAIN PREGNANT WOMEN UNDER CHIP.
(a) CHIP-CommentsClose CommentsPermalink
(1) COVERAGE- Title XXI (
`SEC. 2111. OPTIONAL COVERAGE OF TARGETED LOW-INCOME PREGNANT WOMEN.
`(a) Optional Coverage- Notwithstanding any other provision of this title, a State may provide for coverage, through an amendment to its State child health plan under section 2102, of assistance for pregnant women for targeted low-income pregnant women in accordance with this section, but only if--CommentsClose CommentsPermalink
`(1) the State has established an income eligibility level--CommentsClose CommentsPermalink
`(A) for pregnant women, under any of clauses (i)(III), (i)(IV), or (ii)(IX) of section 1902(a)(10)(A), that is at least 185 percent (or such higher percent as the State has in effect for pregnant women under this title) of the poverty line applicable to a family of the size involved, but in no case a percent lower than the percent in effect under any such clause as of July 1, 2007; andCommentsClose CommentsPermalink
`(B) for children under 19 years of age under this title (or title XIX) that is at least 200 percent of the poverty line applicable to a family of the size involved; andCommentsClose CommentsPermalink
`(2) the State does not impose, with respect to the enrollment under the State child health plan of targeted low-income children during the quarter, any enrollment cap or other numerical limitation on enrollment, any waiting list, any procedures designed to delay the consideration of applications for enrollment, or similar limitation with respect to enrollment.CommentsClose CommentsPermalink
`(b) Definitions- For purposes of this title:CommentsClose CommentsPermalink
`(1) ASSISTANCE FOR PREGNANT WOMEN- The term `assistance for pregnant women' has the meaning given the term child health assistance in section 2110(a) as if any reference to targeted low-income children were a reference to targeted low-income pregnant women.CommentsClose CommentsPermalink
`(2) TARGETED LOW-INCOME PREGNANT WOMAN- The term `targeted low-income pregnant woman' means a woman--CommentsClose CommentsPermalink
`(A) during pregnancy and through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends;CommentsClose CommentsPermalink
`(B) whose family income exceeds 185 percent (or, if higher, the percent applied under subsection (a)(1)(A)) of the poverty level applicable to a family of the size involved, but does not exceed the income eligibility level established under the State child health plan under this title for a targeted low-income child; andCommentsClose CommentsPermalink
`(C) who satisfies the requirements of paragraphs (1)(A), (1)(C), (2), and (3) of section 2110(b), applied as if any reference to a child was a reference to a pregnant woman.CommentsClose CommentsPermalink
`(c) References to Terms and Special Rules- In the case of, and with respect to, a State providing for coverage of assistance for pregnant women to targeted low-income pregnant women under subsection (a), the following special rules apply:CommentsClose CommentsPermalink
`(1) Any reference in this title (other than in subsection (b)) to a targeted low-income child is deemed to include a reference to a targeted low-income pregnant woman.CommentsClose CommentsPermalink
`(2) Any reference in this title to child health assistance (other than with respect to the provision of early and periodic screening, diagnostic, and treatment services) with respect to such women is deemed a reference to assistance for pregnant women.CommentsClose CommentsPermalink
`(3) Any such reference (other than in section 2105(d)) to a child is deemed a reference to a woman during pregnancy and the period described in subsection (b)(2)(A).CommentsClose CommentsPermalink
`(4) In applying section 2102(b)(3)(B), any reference to children found through screening to be eligible for medical assistance under the State medicaid plan under title XIX is deemed a reference to pregnant women.CommentsClose CommentsPermalink
`(5) There shall be no exclusion of benefits for services described in subsection (b)(1) based on any preexisting condition and no waiting period (including any waiting period imposed to carry out section 2102(b)(3)(C)) shall apply.CommentsClose CommentsPermalink
`(6) In applying section 2103(e)(3)(B) in the case of a pregnant woman provided coverage under this section, the limitation on total annual aggregate cost-sharing shall be applied to such pregnant woman.CommentsClose CommentsPermalink
`(7) In applying section 2104(i)--CommentsClose CommentsPermalink
`(A) in the case of a State which did not provide for coverage for pregnant women under this title (under a waiver or otherwise) during fiscal year 2007, the allotment amount otherwise computed for the first fiscal year in which the State elects to provide coverage under this section shall be increased by an amount (determined by the Secretary) equal to the enhanced FMAP of the expenditures under this title for such coverage, based upon projected enrollment and per capita costs of such enrollment; andCommentsClose CommentsPermalink
`(B) in the case of a State which provided for coverage of pregnant women under this title for the previous fiscal year--CommentsClose CommentsPermalink
`(i) in applying paragraph (2)(B) of such section, there shall also be taken into account (in an appropriate proportion) the percentage increase in births in the State for the relevant period; andCommentsClose CommentsPermalink
`(ii) in applying paragraph (3), pregnant women (and per capita expenditures for such women) shall be accounted for separately from children, but shall be included in the total amount of any allotment adjustment under such paragraph.CommentsClose CommentsPermalink
`(d) Automatic Enrollment for Children Born to Women Receiving Assistance for Pregnant Women- If a child is born to a targeted low-income pregnant woman who was receiving assistance for pregnant women under this section on the date of the child's birth, the child shall be deemed to have applied for child health assistance under the State child health plan and to have been found eligible for such assistance under such plan or to have applied for medical assistance under title XIX and to have been found eligible for such assistance under such title on the date of such birth, based on the mother's reported income as of the time of her enrollment under this section and applicable income eligibility levels under this title and title XIX, and to remain eligible for such assistance until the child attains 1 year of age. During the period in which a child is deemed under the preceding sentence to be eligible for child health or medical assistance, the assistance for pregnant women or medical assistance eligibility identification number of the mother shall also serve as the identification number of the child, and all claims shall be submitted and paid under such number (unless the State issues a separate identification number for the child before such period expires).'.CommentsClose CommentsPermalink
(2) ADDITIONAL AMENDMENT- Section 2107(e)(1)(I) of such Act (
`(I) Sections 1920 and 1920A (relating to presumptive eligibility for pregnant women and children).'.CommentsClose CommentsPermalink
(b) Amendments to Medicaid-CommentsClose CommentsPermalink
(1) ELIGIBILITY OF A NEWBORN- Section 1902(e)(4) of the Social Security Act (
(2) APPLICATION OF QUALIFIED ENTITIES TO PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN UNDER MEDICAID- Section 1920(b) of the Social Security Act (
`The term `qualified provider' also includes a qualified entity, as defined in section 1920A(b)(3).'.CommentsClose CommentsPermalink
SEC. 134. LIMITATION ON WAIVER AUTHORITY TO COVER ADULTS.
Section 2102 of the Social Security Act (
`(d) Limitation on Coverage of Adults- Notwithstanding any other provision of this title, the Secretary may not, through the exercise of any waiver authority on or after January 1, 2008, provide for Federal financial participation to a State under this title for health care services for individuals who are not targeted low-income children or pregnant women unless the Secretary determines that no eligible targeted low-income child in the State would be denied coverage under this title for health care services because of such eligibility. In making such determination, the Secretary must receive assurances that--CommentsClose CommentsPermalink
`(1) there is no waiting list under this title in the State for targeted low-income children to receive child health assistance under this title; andCommentsClose CommentsPermalink
`(2) the State has in place an outreach program to reach all targeted low-income children in families with incomes less than 200 percent of the poverty line.'.CommentsClose CommentsPermalink
SEC. 135. NO FEDERAL FUNDING FOR ILLEGAL ALIENS.
Nothing in this Act allows Federal payment for individuals who are not legal residents.CommentsClose CommentsPermalink
SEC. 136. AUDITING REQUIREMENT TO ENFORCE CITIZENSHIP RESTRICTIONS ON ELIGIBILITY FOR MEDICAID AND CHIP BENEFITS.
Section 1903(x) of the Social Security Act (as amended by section 405(c)(1)(A) of division B of the Tax Relief and Health Care Act of 2006 (
`(4)(A) Each State shall audit a statistically-based sample of cases of individuals whose eligibility for medical assistance (or child health assistance) is determined under section 1902(a)(46)(B) or under subsection (v)(4)(A) in order to demonstrate to the satisfaction of the Secretary that Federal funds under this title or title XXI are not unlawfully spent for benefits for individuals who are not legal residents. In conducting such audits, a State may rely on case reviews regularly conducted pursuant to its Medicaid Quality Control or Payment Error Rate Measurement (PERM) eligibility reviews under subsection (u) and the provisions of subsection (e) of section 1137 shall apply under this paragraph in the same manner as they apply under subsection (b) of such section.CommentsClose CommentsPermalink
`(B) The State shall remit to the Secretary the Federal share of any unlawful expenditures for benefits, for aliens who are not legal residents, which are identified under an audit conducted under subparagraph (A).'.CommentsClose CommentsPermalink
Subtitle E--Access
SEC. 141. CHILDREN'S ACCESS, PAYMENT, AND EQUALITY COMMISSION.
Title XIX of the Social Security Act is amended by inserting before section 1901 the following new section:CommentsClose CommentsPermalink
`CHILDREN'S ACCESS, PAYMENT, AND EQUALITY COMMISSION
`Sec. 1900. (a) Establishment- There is hereby established as an agency of Congress the Children's Access, Payment, and Equality Commission (in this section referred to as the `Commission').CommentsClose CommentsPermalink
`(b) Duties-CommentsClose CommentsPermalink
`(1) REVIEW OF PAYMENT POLICIES AND ANNUAL REPORTS- The Commission shall--CommentsClose CommentsPermalink
`(A) review Federal and State payment policies of the Medicaid program established under this title (in this section referred to as `Medicaid') and the State Children's Health Insurance Program established under title XXI (in this section referred to as `CHIP'), including topics described in paragraph (2);CommentsClose CommentsPermalink
`(B) review access to, and affordability of, coverage and services for enrollees under Medicaid and CHIP;CommentsClose CommentsPermalink
`(C) make recommendations to Congress concerning such policies;CommentsClose CommentsPermalink
`(D) by not later than March 1 of each year, submit to Congress a report containing the results of such reviews and its recommendations concerning such policies; andCommentsClose CommentsPermalink
`(E) by not later than June 1 of each year, submit to Congress a report containing an examination of issues affecting Medicaid and CHIP, including the implications of changes in health care delivery in the United States and in the market for health care services on such programs.CommentsClose CommentsPermalink
`(2) SPECIFIC TOPICS TO BE REVIEWED- Specifically, the Commission shall review the following:CommentsClose CommentsPermalink
`(A) The factors affecting expenditures for services in different sectors (such as physician, hospital and other sectors), payment methodologies, and their relationship to access and quality of care for Medicaid and CHIP beneficiaries.CommentsClose CommentsPermalink
`(B) The impact of Federal and State Medicaid and CHIP payment policies on access to services (including dental services) for children (including children with disabilities) and other Medicaid and CHIP populations.CommentsClose CommentsPermalink
`(C) The impact of Federal and State Medicaid and CHIP policies on reducing health disparities, including geographic disparities and disparities among minority populations.CommentsClose CommentsPermalink
`(D) The overall financial stability of the health care safety net, including Federally-qualified health centers, rural health centers, school-based clinics, disproportionate share hospitals, public hospitals, providers and grantees under section 2612(a)(5) of the Public Health Service Act (popularly known as the Ryan White CARE Act), and other providers that have a patient base which includes a disproportionate number of uninsured or low-income individuals and the impact of CHIP and Medicaid policies on such stability.CommentsClose CommentsPermalink
`(E) The relation (if any) between payment rates for providers and improvement in care for children as measured under the children's health quality measurement program established under section 151 of the Children's Health and Medicare Protection Act of 2007.CommentsClose CommentsPermalink
`(F) The affordability, cost effectiveness, and accessibility of services needed by special populations under Medicaid and CHIP as compared with private-sector coverage.CommentsClose CommentsPermalink
`(G) The extent to which the operation of Medicaid and CHIP ensures access, comparable to access under employer-sponsored or other private health insurance coverage (or in the case of federally-qualified health center services (as defined in section 1905(l)(2)) and rural health clinic services (as defined in section 1905(l)(1)), access comparable to the access to such services under title XIX), for targeted low-income children.CommentsClose CommentsPermalink
`(H) The effect of demonstrations under section 1115, benchmark coverage under section 1937, and other coverage under section 1938, on access to care, affordability of coverage, provider ability to achieve children's health quality performance measures, and access to safety net services.CommentsClose CommentsPermalink
`(3) COMMENTS ON CERTAIN SECRETARIAL REPORTS- If the Secretary submits to Congress (or a committee of Congress) a report that is required by law and that relates to payment policies under Medicaid or CHIP, the Secretary shall transmit a copy of the report to the Commission. The Commission shall review the report and, not later than 6 months after the date of submittal of the Secretary's report to Congress, shall submit to the appropriate committees of Congress written comments on such report. Such comments may include such recommendations as the Commission deems appropriate.CommentsClose CommentsPermalink
`(4) AGENDA AND ADDITIONAL REVIEWS- The Commission shall consult periodically with the Chairmen and Ranking Minority Members of the appropriate committees of Congress regarding the Commission's agenda and progress towards achieving the agenda. The Commission may conduct additional reviews, and submit additional reports to the appropriate committees of Congress, from time to time on such topics relating to the program under this title or title XXI as may be requested by such Chairmen and Members and as the Commission deems appropriate.CommentsClose CommentsPermalink
`(5) AVAILABILITY OF REPORTS- The Commission shall transmit to the Secretary a copy of each report submitted under this subsection and shall make such reports available to the public.CommentsClose CommentsPermalink
`(6) APPROPRIATE COMMITTEE OF CONGRESS- For purposes of this section, the term `appropriate committees of Congress' means the Committees on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate.CommentsClose CommentsPermalink
`(7) VOTING AND REPORTING REQUIREMENTS- With respect to each recommendation contained in a report submitted under paragraph (1), each member of the Commission shall vote on the recommendation, and the Commission shall include, by member, the results of that vote in the report containing the recommendation.CommentsClose CommentsPermalink
`(8) EXAMINATION OF BUDGET CONSEQUENCES- Before making any recommendations, the Commission shall examine the budget consequences of such recommendations, directly or through consultation with appropriate expert entities.CommentsClose CommentsPermalink
`(c) Application of Provisions- The following provisions of section 1805 shall apply to the Commission in the same manner as they apply to the Medicare Payment Advisory Commission:CommentsClose CommentsPermalink
`(1) Subsection (c) (relating to membership), except that the membership of the Commission shall also include representatives of children, pregnant women, individuals with disabilities, seniors, low-income families, and other groups of CHIP and Medicaid beneficiaries.CommentsClose CommentsPermalink
`(2) Subsection (d) (relating to staff and consultants).CommentsClose CommentsPermalink
`(3) Subsection (e) (relating to powers).CommentsClose CommentsPermalink
`(d) Authorization of Appropriations-CommentsClose CommentsPermalink
`(1) REQUEST FOR APPROPRIATIONS- The Commission shall submit requests for appropriations in the same manner as the Comptroller General submits requests for appropriations, but amounts appropriated for the Commission shall be separate from amounts appropriated for the Comptroller General.CommentsClose CommentsPermalink
`(2) AUTHORIZATION- There are authorized to be appropriated such sums as may be necessary to carry out the provisions of this section.'.CommentsClose CommentsPermalink
SEC. 142. MODEL OF INTERSTATE COORDINATED ENROLLMENT AND COVERAGE PROCESS.
(a) In General- In order to assure continuity of coverage of low-income children under the Medicaid program and the State Children's Health Insurance Program (CHIP), not later than 18 months after the date of the enactment of this Act, the Comptroller General of the United States, in consultation with State Medicaid and CHIP directors and organizations representing program beneficiaries, shall develop a model process for the coordination of the enrollment, retention, and coverage under such programs of children who, because of migration of families, emergency evacuations, educational needs, or otherwise, frequently change their State of residency or otherwise are temporarily located outside of the State of their residency.CommentsClose CommentsPermalink
(b) Report to Congress- After development of such model process, the Comptroller General shall submit to Congress a report describing additional steps or authority needed to make further improvements to coordinate the enrollment, retention, and coverage under CHIP and Medicaid of children described in subsection (a).CommentsClose CommentsPermalink
SEC. 143. MEDICAID CITIZENSHIP DOCUMENTATION REQUIREMENTS.
(a) State Option to Require Children to Present Satisfactory Documentary Evidence of Proof of Citizenship or Nationality for Purposes of Eligibility for Medicaid; Requirement for Auditing-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1902 of the Social Security Act (
(A) in subsection (a)(46)--CommentsClose CommentsPermalink
(i) by inserting `(A)' after `(46)'; andCommentsClose CommentsPermalink
(ii) by adding at the end the following new subparagraphs:CommentsClose CommentsPermalink
`(B) at the option of the State, require that, with respect to a child under 21 years of age (other than an individual described in section 1903(x)(2)) who declares to be a citizen or national of the United States for purposes of establishing initial eligibility for medical assistance under this title (or, at State option, for purposes of renewing or redetermining such eligibility to the extent that such satisfactory documentary evidence of citizenship or nationality has not yet been presented), there is presented satisfactory documentary evidence of citizenship or nationality of the individual (using criteria determined by the State, which shall be no more restrictive than the documentation specified in section 1903(x)(3)); andCommentsClose CommentsPermalink
`(C) comply with the auditing requirements of section 1903(x)(4);'; andCommentsClose CommentsPermalink
(B) in subsection (b)(3), by inserting `or any citizenship documentation requirement for a child under 21 years of age that is more restrictive than what a State may provide under section 1903(x)' before the period at the end.CommentsClose CommentsPermalink
(2) ELIMINATION OF DENIAL OF PAYMENTS FOR CHILDREN- Section 1903(i)(22) of such Act (
(b) Clarification of Rules for Children Born in the United States to Mothers Eligible for Medicaid- Section 1903(x)(2) of such Act (
(1) in subparagraph (C), by striking `or' at the end;CommentsClose CommentsPermalink
(2) by redesignating subparagraph (D) as subparagraph (E); andCommentsClose CommentsPermalink
(3) by inserting after subparagraph (C) the following new subparagraph:CommentsClose CommentsPermalink
`(D) pursuant to the application of section 1902(e)(4) (and, in the case of an individual who is eligible for medical assistance on such basis, the individual shall be deemed to have provided satisfactory documentary evidence of citizenship or nationality and shall not be required to provide further documentary evidence on any date that occurs during or after the period in which the individual is eligible for medical assistance on such basis; or'.CommentsClose CommentsPermalink
(c) Documentation for Native Americans - Section 1903(x)(3)(B) of such Act is amended--CommentsClose CommentsPermalink
(1) by redesignating clause (v) as clause (vi); andCommentsClose CommentsPermalink
(2) by inserting after clause (iv) the following new clause:CommentsClose CommentsPermalink
`(v) For an individual who is a member of, or enrolled in or affiliated with, a federally-recognized Indian tribe, a document issued by such tribe evidencing such membership, enrollment, or affiliation with the tribe (such as a tribal enrollment card or certificate of degree of Indian blood), and, only with respect to those federally-recognized Indian tribes located within States having an international border whose membership includes individuals who are not citizens of the United States, such other forms of documentation (including tribal documentation, if appropriate) as the Secretary, after consulting with such tribes, determines to be satisfactory documentary evidence of citizenship or nationality for purposes of satisfying the requirement of this subparagraph.'.CommentsClose CommentsPermalink
(d) Reasonable Opportunity- Section 1903(x) of such Act, as amended by subsection (a)(2), is further amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(5) In the case of an individual declaring to be a citizen or national of the United States with respect to whom a State requires the presentation of satisfactory documentary evidence of citizenship or nationality under section 1902(a)(46)(B), the individual shall be provided at least the reasonable opportunity to present satisfactory documentary evidence of citizenship or nationality under this subsection as is provided under clauses (i) and (ii) of section 1137(d)(4)(A) to an individual for the submittal to the State of evidence indicating a satisfactory immigration status and shall not be denied medical assistance on the basis of failure to provide such documentation until the individual has had such an opportunity.'.CommentsClose CommentsPermalink
(e) Effective Date-CommentsClose CommentsPermalink
(1) RETROACTIVE APPLICATION- The amendments made by this section shall take effect as if included in the enactment of the Deficit Reduction Act of 2005 (
(2) RESTORATION OF ELIGIBILITY- In the case of an individual who, during the period that began on July 1, 2006, and ends on the date of the enactment of this Act, was determined to be ineligible for medical assistance under a State Medicaid program solely as a result of the application of subsections (i)(22) and (x) of section 1903 of the Social Security Act (as in effect during such period), but who would have been determined eligible for such assistance if such subsections, as amended by this section, had applied to the individual, a State may deem the individual to be eligible for such assistance as of the date that the individual was determined to be ineligible for such medical assistance on such basis.CommentsClose CommentsPermalink
SEC. 144. ACCESS TO DENTAL CARE FOR CHILDREN.
(a) Dental Education for Parents of Newborns- The Secretary of Health and Human Services shall develop and implement, through entities that fund or provide perinatal care services to targeted low-income children under a State child health plan under title XXI of the Social Security Act, a program to deliver oral health educational materials that inform new parents about risks for, and prevention of, early childhood caries and the need for a dental visit within their newborn's first year of life.CommentsClose CommentsPermalink
(b) Provision of Dental Services Through FQHCs-CommentsClose CommentsPermalink
(1) MEDICAID- Section 1902(a) of the Social Security Act (
(A) by striking `and' at the end of paragraph (69);CommentsClose CommentsPermalink
(B) by striking the period at the end of paragraph (70) and inserting `; and'; andCommentsClose CommentsPermalink
(C) by inserting after paragraph (70) the following new paragraph:CommentsClose CommentsPermalink
`(71) provide that the State will not prevent a Federally-qualified health center from entering into contractual relationships with private practice dental providers in the provision of Federally-qualified health center services.'.CommentsClose CommentsPermalink
(2) CHIP- Section 2107(e)(1) of such Act (
`(B) Section 1902(a)(71) (relating to limiting FQHC contracting for provision of dental services).'.CommentsClose CommentsPermalink
(3) EFFECTIVE DATE- The amendments made by this subsection shall take effect on January 1, 2008.CommentsClose CommentsPermalink
(c) Reporting Information on Dental Health-CommentsClose CommentsPermalink
(1) MEDICAID- Section 1902(a)(43)(D)(iii) of such Act (
(2) CHIP- Section 2108 of such Act (
`(e) Information on Dental Care for Children-CommentsClose CommentsPermalink
`(1) IN GENERAL- Each annual report under subsection (a) shall include the following information with respect to care and services described in section 1905(r)(3) provided to targeted low-income children enrolled in the State child health plan under this title at any time during the year involved:CommentsClose CommentsPermalink
`(A) The number of enrolled children by age grouping used for reporting purposes under section 1902(a)(43).CommentsClose CommentsPermalink
`(B) For children within each such age grouping, information of the type contained in questions 12(a)-(c) of CMS Form 416 (that consists of the number of enrolled targeted low income children who receive any, preventive, or restorative dental care under the State plan).CommentsClose CommentsPermalink
`(C) For the age grouping that includes children 8 years of age, the number of such children who have received a protective sealant on at least one permanent molar tooth.CommentsClose CommentsPermalink
`(2) INCLUSION OF INFORMATION ON ENROLLEES IN MANAGED CARE PLANS- The information under paragraph (1) shall include information on children who are enrolled in managed care plans and other private health plans and contracts with such plans under this title shall provide for the reporting of such information by such plans to the State.'.CommentsClose CommentsPermalink
(3) EFFECTIVE DATE- The amendments made by this subsection shall be effective for annual reports submitted for years beginning after date of enactment.CommentsClose CommentsPermalink
(d) GAO Study and Report-CommentsClose CommentsPermalink
(1) STUDY- The Comptroller General of the United States shall provide for a study that examines--CommentsClose CommentsPermalink
(A) access to dental services by children in underserved areas; andCommentsClose CommentsPermalink
(B) the feasibility and appropriateness of using qualified mid-level dental health providers, in coordination with dentists, to improve access for children to oral health services and public health overall.CommentsClose CommentsPermalink
(2) REPORT- Not later than 1 year after the date of the enactment of this Act, the Comptroller General shall submit to Congress a report on the study conducted under paragraph (1).CommentsClose CommentsPermalink
SEC. 145. PROHIBITING INITIATION OF NEW HEALTH OPPORTUNITY ACCOUNT DEMONSTRATION PROGRAMS.
After the date of the enactment of this Act, the Secretary of Health and Human Services may not approve any new demonstration programs under section 1938 of the Social Security Act (
Subtitle F--Quality and Program Integrity
SEC. 151. PEDIATRIC HEALTH QUALITY MEASUREMENT PROGRAM.
(a) Quality Measurement of Children's Health-CommentsClose CommentsPermalink
(1) ESTABLISHMENT OF PROGRAM TO DEVELOP QUALITY MEASURES FOR CHILDREN'S HEALTH- The Secretary of Health and Human Services (in this section referred to as the `Secretary') shall establish a child health care quality measurement program (in this subsection referred to as the `children's health quality measurement program') to develop and implement--CommentsClose CommentsPermalink
(A) pediatric quality measures on children's health care that may be used by public and private health care purchasers (and a system for reporting such measures); andCommentsClose CommentsPermalink
(B) measures of overall program performance that may be used by public and private health care purchasers.CommentsClose CommentsPermalink
The Secretary shall publish, not later than September 30, 2009, the recommended measures under the program for application under the amendments made by subsection (b) for years beginning with 2010.CommentsClose CommentsPermalink
(2) MEASURES-CommentsClose CommentsPermalink
(A) SCOPE- The measures developed under the children's health quality measurement program shall--CommentsClose CommentsPermalink
(i) provide comprehensive information with respect to the provision and outcomes of health care for young children, school age children, and older children;CommentsClose CommentsPermalink
(ii) be designed to identify disparities by pediatric characteristics (including, at a minimum, those specified in subparagraph (C)) in child health and the provision of health care;CommentsClose CommentsPermalink
(iii) be designed to ensure that the data required for such measures is collected and reported in a standard format that permits comparison at a State, plan, and provider level, and between insured and uninsured children;CommentsClose CommentsPermalink
(iv) take into account existing measures of child health quality and be periodically updated;CommentsClose CommentsPermalink
(v) include measures of clinical health care quality which meet the requirements for pediatric quality measures in paragraph (1);CommentsClose CommentsPermalink
(vi) improve and augment existing measures of clinical health care quality for children's health care and develop new and emerging measures; andCommentsClose CommentsPermalink
(vii) increase the portfolio of evidence-based pediatric quality measures available to public and private purchasers, providers, and consumers.CommentsClose CommentsPermalink
(B) SPECIFIC MEASURES- Such measures shall include measures relating to at least the following aspects of health care for children:CommentsClose CommentsPermalink
(i) The proportion of insured (and uninsured) children who receive age-appropriate preventive health and dental care (including age appropriate immunizations) at each stage of child health development.CommentsClose CommentsPermalink
(ii) The proportion of insured (and uninsured) children who receive dental care for restoration of teeth, relief of pain and infection, and maintenance of dental health.CommentsClose CommentsPermalink
(iii) The effectiveness of early health care interventions for children whose assessments indicate the presence or risk of physical or mental conditions that could adversely affect growth and development.CommentsClose CommentsPermalink
(iv) The effectiveness of treatment to ameliorate the effects of diagnosed physical and mental health conditions, including chronic conditions.CommentsClose CommentsPermalink
(v) The proportion of children under age 21 who are continuously insured for a period of 12 months or longer.CommentsClose CommentsPermalink
(vi) The effectiveness of health care for children with disabilities.CommentsClose CommentsPermalink
(vii) Data on State efforts to reduce hospitalization rate of premature infants under the age of 12 months who were born prior to 35 weeks.CommentsClose CommentsPermalink
In carrying out clause (vi), the Secretary shall develop quality measures and best practices relating to cystic fibrosis.CommentsClose CommentsPermalink
(C) REPORTING METHODOLOGY FOR ANALYSIS BY PEDIATRIC CHARACTERISTICS- The children's health quality measurement program shall describe with specificity such measures and the process by which such measures will be reported in a manner that permits analysis based on each of the following pediatric characteristics:CommentsClose CommentsPermalink
(i) Age.CommentsClose CommentsPermalink
(ii) Gender.CommentsClose CommentsPermalink
(iii) Race.CommentsClose CommentsPermalink
(iv) Ethnicity.CommentsClose CommentsPermalink
(v) Primary language of the child's parents (or caretaker relative).CommentsClose CommentsPermalink
(vi) Disability or chronic condition (including cystic fibrosis).CommentsClose CommentsPermalink
(vii) Geographic location.CommentsClose CommentsPermalink
(viii) Coverage status under public and private health insurance programs.CommentsClose CommentsPermalink
(D) PEDIATRIC QUALITY MEASURE- In this subsection, the term `pediatric quality measure' means a measurement of clinical care that assesses one or more aspects of pediatric health care quality (in various settings) including the structure of the clinical care system, the process and outcome of care, or patient experience in such care.CommentsClose CommentsPermalink
(3) CONSULTATION IN DEVELOPING QUALITY MEASURES FOR CHILDREN'S HEALTH SERVICES- In developing and implementing the children's health quality measurement program, the Secretary shall consult with--CommentsClose CommentsPermalink
(A) States;CommentsClose CommentsPermalink
(B) pediatric hospitals, pediatricians, and other primary and specialized pediatric health care professionals (including members of the allied health professions) who specialize in the care and treatment of children, particularly children with special physical, mental, and developmental health care needs;CommentsClose CommentsPermalink
(C) dental professionals;CommentsClose CommentsPermalink
(D) health care providers that furnish primary health care to children and families who live in urban and rural medically underserved communities or who are members of distinct population sub-groups at heightened risk for poor health outcomes;CommentsClose CommentsPermalink
(E) national organizations representing children, including children with disabilities and children with chronic conditions;CommentsClose CommentsPermalink
(F) national organizations and individuals with expertise in pediatric health quality performance measurement; andCommentsClose CommentsPermalink
(G) voluntary consensus standards setting organizations and other organizations involved in the advancement of evidence based measures of health care.CommentsClose CommentsPermalink
(4) USE OF GRANTS AND CONTRACTS- In carrying out the children's health quality measurement program, the Secretary may award grants and contracts to develop, test, validate, update, and disseminate quality measures under the program.CommentsClose CommentsPermalink
(5) TECHNICAL ASSISTANCE- The Secretary shall provide technical assistance to States to establish for the reporting of quality measures under titles XIX and XXI of the Social Security Act in accordance with the children's health quality measurement program.CommentsClose CommentsPermalink
(b) Dissemination of Information on the Quality of Program Performance- Not later than January 1, 2009, and annually thereafter, the Secretary shall collect, analyze, and make publicly available on a public website of the Department of Health and Human Services in an online format--CommentsClose CommentsPermalink
(1) a complete list of all measures in use by States as of such date and used to measure the quality of medical and dental health services furnished to children enrolled under title XIX of XXI of the Social Security Act by participating providers, managed care entities, and plan issuers; andCommentsClose CommentsPermalink
(2) information on health care quality for children contained in external quality review reports required under section 1932(c)(2) of such Act (
(c) Reports to Congress on Program Performance- Not later than January 1, 2010, and every 2 years thereafter, the Secretary shall report to Congress on--CommentsClose CommentsPermalink
(1) the quality of health care for children enrolled under titles XIX and XXI of the Social Security Act under the children's health quality measurement program; andCommentsClose CommentsPermalink
(2) patterns of health care utilization with respect to the measures specified in subsection (a)(2)(B) among children by the pediatric characteristics listed in subsection (a)(2)(C).CommentsClose CommentsPermalink
SEC. 152. APPLICATION OF CERTAIN MANAGED CARE QUALITY SAFEGUARDS TO CHIP.
(a) In General- Section 2103(f) of Social Security Act (
`(3) COMPLIANCE WITH MANAGED CARE REQUIREMENTS- The State child health plan shall provide for the application of subsections (a)(4), (a)(5), (b), (c), (d), and (e) of section 1932 (relating to requirements for managed care) to coverage, State agencies, enrollment brokers, managed care entities, and managed care organizations under this title in the same manner as such subsections apply to coverage and such entities and organizations under title XIX.'.CommentsClose CommentsPermalink
(b) Effective Date- The amendment made by subsection (a) shall apply to contract years for health plans beginning on or after July 1, 2008.CommentsClose CommentsPermalink
SEC. 153. UPDATED FEDERAL EVALUATION OF CHIP.
Section 2108(c) of the Social Security Act (
`(5) SUBSEQUENT EVALUATION USING UPDATED INFORMATION-CommentsClose CommentsPermalink
`(A) IN GENERAL- The Secretary, directly or through contracts or interagency agreements, shall conduct an independent subsequent evaluation of 10 States with approved child health plans.CommentsClose CommentsPermalink
`(B) SELECTION OF STATES AND MATTERS INCLUDED- Paragraphs (2) and (3) shall apply to such subsequent evaluation in the same manner as such provisions apply to the evaluation conducted under paragraph (1).CommentsClose CommentsPermalink
`(C) SUBMISSION TO CONGRESS- Not later than December 31, 2010, the Secretary shall submit to Congress the results of the evaluation conducted under this paragraph.CommentsClose CommentsPermalink
`(D) FUNDING- Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated $10,000,000 for fiscal year 2009 for the purpose of conducting the evaluation authorized under this paragraph. Amounts appropriated under this subparagraph shall remain available for expenditure through fiscal year 2011.'.CommentsClose CommentsPermalink
SEC. 154. ACCESS TO RECORDS FOR IG AND GAO AUDITS AND EVALUATIONS.
Section 2108(d) of the Social Security Act (
`(d) Access to Records for IG and GAO Audits and Evaluations- For the purpose of evaluating and auditing the program established under this title, the Secretary, the Office of Inspector General, and the Comptroller General shall have access to any books, accounts, records, correspondence, and other documents that are related to the expenditure of Federal funds under this title and that are in the possession, custody, or control of States receiving Federal funds under this title or political subdivisions thereof, or any grantee or contractor of such States or political subdivisions.'.CommentsClose CommentsPermalink
SEC. 155. REFERENCES TO TITLE XXI.
Section 704 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (Appendix F, 113 Stat. 1501A-321), as enacted into law by section 1000(a)(6) of
SEC. 156. RELIANCE ON LAW; EXCEPTION FOR STATE LEGISLATION.
(a) Reliance on Law- With respect to amendments made by this title or title VIII that become effective as of a date--CommentsClose CommentsPermalink
(1) such amendments are effective as of such date whether or not regulations implementing such amendments have been issued; andCommentsClose CommentsPermalink
(2) Federal financial participation for medical assistance or child health assistance furnished under title XIX or XXI, respectively, of the Social Security Act on or after such date by a State in good faith reliance on such amendments before the date of promulgation of final regulations, if any, to carry out such amendments (or before the date of guidance, if any, regarding the implementation of such amendments) shall not be denied on the basis of the State's failure to comply with such regulations or guidance.CommentsClose CommentsPermalink
(b) Exception for State Legislation- In the case of a State plan under title XIX or State child health plan under XXI of the Social Security Act, which the Secretary of Health and Human Services determines requires State legislation in order for respective plan to meet one or more additional requirements imposed by amendments made by this title or title VIII, the respective State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such an additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of the session shall be considered to be a separate regular session of the State legislature.CommentsClose CommentsPermalink
TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A--Improvements in Benefits
SEC. 201. COVERAGE AND WAIVER OF COST-SHARING FOR PREVENTIVE SERVICES.
(a) Preventive Services Defined; Coverage of Additional Preventive Services- Section 1861 of the Social Security Act (
(1) in subsection (s)(2)--CommentsClose CommentsPermalink
(A) in subparagraph (Z), by striking `and' after the semicolon at the end;CommentsClose CommentsPermalink
(B) in subparagraph (AA), by adding `and' after the semicolon at the end; andCommentsClose CommentsPermalink
(C) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(BB) additional preventive services (described in subsection (ccc)(1)(M));'; andCommentsClose CommentsPermalink
(2) by adding at the end the following new subsection:CommentsClose CommentsPermalink
`Preventive Services
`(ccc)(1) The term `preventive services' means the following:CommentsClose CommentsPermalink
`(A) Prostate cancer screening tests (as defined in subsection (oo)).CommentsClose CommentsPermalink
`(B) Colorectal cancer screening tests (as defined in subsection (pp)).CommentsClose CommentsPermalink
`(C) Diabetes outpatient self-management training services (as defined in subsection (qq)).CommentsClose CommentsPermalink
`(D) Screening for glaucoma for certain individuals (as described in subsection (s)(2)(U)).CommentsClose CommentsPermalink
`(E) Medical nutrition therapy services for certain individuals (as described in subsection (s)(2)(V)).CommentsClose CommentsPermalink
`(F) An initial preventive physical examination (as defined in subsection (ww)).CommentsClose CommentsPermalink
`(G) Cardiovascular screening blood tests (as defined in subsection (xx)(1)).CommentsClose CommentsPermalink
`(H) Diabetes screening tests (as defined in subsection described in subsection (s)(2)(Y)).CommentsClose CommentsPermalink
`(I) Ultrasound screening for abdominal aortic aneurysm for certain individuals (as described in described in subsection (s)(2)(AA)).CommentsClose CommentsPermalink
`(J) Pneumococcal and influenza vaccine and their administration (as described in subsection (s)(10)(A)).CommentsClose CommentsPermalink
`(K) Hepatitis B vaccine and its administration for certain individuals (as described in subsection (s)(10)(B)).CommentsClose CommentsPermalink
`(L) Screening mammography (as defined in subsection (jj)).CommentsClose CommentsPermalink
`(M) Screening pap smear and screening pelvic exam (as described in subsection (s)(14)).CommentsClose CommentsPermalink
`(N) Bone mass measurement (as defined in subsection (rr)).CommentsClose CommentsPermalink
`(O) Additional preventive services (as determined under paragraph (2)).CommentsClose CommentsPermalink
`(2)(A) The term `additional preventive services' means items and services, including mental health services, not described in subparagraphs (A) through (N) of paragraph (1) that the Secretary determines to be reasonable and necessary for the prevention or early detection of an illness or disability.CommentsClose CommentsPermalink
`(B) In making determinations under subparagraph (1), the Secretary shall--CommentsClose CommentsPermalink
`(i) take into account evidence-based recommendations by the United States Preventive Services Task Force and other appropriate organizations; andCommentsClose CommentsPermalink
`(ii) use the process for making national coverage determinations (as defined in section 1869(f)(1)(B)) under this title.'.CommentsClose CommentsPermalink
(b) Payment and Elimination of Cost-Sharing-CommentsClose CommentsPermalink
(1) IN GENERAL-CommentsClose CommentsPermalink
(A) IN GENERAL- Section 1833(a)(1) of the Social Security Act (
(i) in clause (T), by striking `80 percent' and inserting `100 percent';CommentsClose CommentsPermalink
(ii) by striking `and' before `(V)'; andCommentsClose CommentsPermalink
(iii) by inserting before the semicolon at the end the following: `, and (W) with respect to additional preventive services (as defined in section 1861(ccc)(2)) and other preventive services for which a payment rate is not otherwise established under this section, the amount paid shall be 100 percent of the lesser of the actual charge for the services or the amount determined under a fee schedule established by the Secretary for purposes of this clause'.CommentsClose CommentsPermalink
(B) APPLICATION TO SIGMOIDOSCOPIES AND COLONOSCOPIES- Section 1834(d) of such Act (
(i) in paragraph (2)(C), by amending clause (ii) to read as follows:CommentsClose CommentsPermalink
`(ii) NO COINSURANCE- In the case of a beneficiary who receives services described in clause (i), there shall be no coinsurance applied.'; andCommentsClose CommentsPermalink
(ii) in paragraph (3)(C), by amending clause (ii) to read as follows:CommentsClose CommentsPermalink
`(ii) NO COINSURANCE- In the case of a beneficiary who receives services described in clause (i), there shall be no coinsurance applied.'.CommentsClose CommentsPermalink
(2) ELIMINATION OF COINSURANCE IN OUTPATIENT HOSPITAL SETTINGS-CommentsClose CommentsPermalink
(A) EXCLUSION FROM OPD FEE SCHEDULE- Section 1833(t)(1)(B)(iv) of the Social Security Act (
(B) CONFORMING AMENDMENTS- Section 1833(a)(2) of the Social Security Act (
(i) in subparagraph (F), by striking `and' after the semicolon at the end;CommentsClose CommentsPermalink
(ii) in subparagraph (G)(ii), by adding `and'at the end; andCommentsClose CommentsPermalink
(iii) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(H) with respect to additional preventive services (as defined in section 1861(ccc)(2)) furnished by an outpatient department of a hospital, the amount determined under paragraph (1)(W);'.CommentsClose CommentsPermalink
(3) WAIVER OF APPLICATION OF DEDUCTIBLE FOR ALL PREVENTIVE SERVICES- The first sentence of section 1833(b) of the Social Security Act (
(A) in clause (1), by striking `items and services described in section 1861(s)(10)(A)' and inserting `preventive services (as defined in section 1861(ccc)(1))';CommentsClose CommentsPermalink
(B) by inserting `and' before `(4)'; andCommentsClose CommentsPermalink
(C) by striking clauses (5) through (8).CommentsClose CommentsPermalink
(c) Inclusion as Part of Initial Preventive Physical Examination- Section 1861(ww)(2) of the Social Security Act (
`(M) Additional preventive services (as defined in subsection (ccc)(2)).'.CommentsClose CommentsPermalink
(d) Effective Date- The amendments made by this section shall apply to services furnished on or after January 1, 2008.CommentsClose CommentsPermalink
SEC. 202. WAIVER OF DEDUCTIBLE FOR COLORECTAL CANCER SCREENING TESTS REGARDLESS OF CODING, SUBSEQUENT DIAGNOSIS, OR ANCILLARY TISSUE REMOVAL.
(a) In General- Section 1833(b) of the Social Security Act (
(b) Effective Date- The amendment made by subsection (a) shall apply to items and services furnished on or after January 1, 2008.CommentsClose CommentsPermalink
SEC. 203. PARITY FOR MENTAL HEALTH COINSURANCE.
Section 1833(c) of the Social Security Act (
Subtitle B--Improving, Clarifying, and Simplifying Financial Assistance for Low Income Medicare Beneficiaries
SEC. 211. IMPROVING ASSETS TESTS FOR MEDICARE SAVINGS PROGRAM AND LOW-INCOME SUBSIDY PROGRAM.
(a) Application of Highest Level Permitted Under LIS-CommentsClose CommentsPermalink
(1) TO FULL-PREMIUM SUBSIDY ELIGIBLE INDIVIDUALS- Section 1860D-14(a) of the Social Security Act (
(A) in paragraph (1), in the matter before subparagraph (A), by inserting `(or, beginning with 2009, paragraph (3)(E))' after `paragraph (3)(D)'; andCommentsClose CommentsPermalink
(B) in paragraph (3)(A)(iii), by striking `(D) or'.CommentsClose CommentsPermalink
(2) ANNUAL INCREASE IN LIS RESOURCE TEST- Section 1860D-14(a)(3)(E)(i) of such Act (
(A) by striking `and' at the end of subclause (I);CommentsClose CommentsPermalink
(B) in subclause (II), by inserting `(before 2009)' after `subsequent year';CommentsClose CommentsPermalink
(C) by striking the period at the end of subclause (II) and inserting a semicolon;CommentsClose CommentsPermalink
(D) by inserting after subclause (II) the following new subclauses:CommentsClose CommentsPermalink
`(III) for 2009, $17,000 (or $34,000 in the case of the combined value of the individual's assets or resources and the assets or resources of the individual's spouse); andCommentsClose CommentsPermalink
`(IV) for a subsequent year, the dollar amounts specified in this subclause (or subclause (III)) for the previous year increased by the annual percentage increase in the consumer price index (all items; U.S. city average) as of September of such previous year.'; andCommentsClose CommentsPermalink
(E) in the last sentence, by inserting `or (IV)' after `subclause (II)'.CommentsClose CommentsPermalink
(3) APPLICATION OF LIS TEST UNDER MEDICARE SAVINGS PROGRAM- Section 1905(p)(1)(C) of such Act (
(b) Effective Date- The amendments made by subsection (a) shall apply to eligibility determinations for income-related subsidies and medicare cost-sharing furnished for periods beginning on or after January 1, 2009.CommentsClose CommentsPermalink
SEC. 212. MAKING QI PROGRAM PERMANENT AND EXPANDING ELIGIBILITY.
(a) Making Program Permanent-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1902(a)(10)(E)(iv) of the Social Security Act (
(A) by striking `sections 1933 and' and by inserting `section'; andCommentsClose CommentsPermalink
(B) by striking `(but only for' and all that follows through `September 2007)'.CommentsClose CommentsPermalink
(2) ELIMINATION OF FUNDING LIMITATION-CommentsClose CommentsPermalink
(A) IN GENERAL- Section 1933 of such Act (
(i) in subsection (a), by striking `who are selected to receive such assistance under subsection (b)';CommentsClose CommentsPermalink
(ii) by striking subsections (b), (c), (e), and (g);CommentsClose CommentsPermalink
(iii) in subsection (d), by striking `furnished in a State' and all that follows and inserting `the Federal medical assistance percentage shall be equal to 100 percent.'; andCommentsClose CommentsPermalink
(iv) by redesignating subsections (d) and (f) as subsections (b) and (c), respectively.CommentsClose CommentsPermalink
(B) CONFORMING AMENDMENT- Section 1905(b) of such Act (
(C) EFFECTIVE DATE- The amendments made by subparagraph (A) shall take effect on October 1, 2007.CommentsClose CommentsPermalink
(b) Increase in Eligibility to 150 Percent of the Federal Poverty Level- Section 1902(a)(10)(E)(iv) of such Act is further amended by inserting `(or, effective January 1, 2008, 150 percent)' after `135 percent'.CommentsClose CommentsPermalink
SEC. 213. ELIMINATING BARRIERS TO ENROLLMENT.
(a) Administrative Verification of Income and Resources Under the Low-Income Subsidy Program- Clause (iii) of section 1860D-14(a)(3)(E) of the Social Security Act (
`(iii) CERTIFICATION OF INCOME AND RESOURCES- For purposes of applying this section--CommentsClose CommentsPermalink
`(I) an individual shall be permitted to apply on the basis of self-certification of income and resources; andCommentsClose CommentsPermalink
`(II) matters attested to in the application shall be subject to appropriate methods of verification without the need of the individual to provide additional documentation, except in extraordinary situations as determined by the Commissioner.'.CommentsClose CommentsPermalink
(b) Automatic Reenrollment Without Need to Reapply Under Low-Income Subsidy Program- Section 1860D-14(a)(3) of such Act (
`(G) AUTOMATIC REENROLLMENT- For purposes of applying this section, in the case of an individual who has been determined to be a subsidy eligible individual (and within a particular class of such individuals, such as a full-subsidy eligible individual or a partial subsidy eligible individual), the individual shall be deemed to continue to be so determined without the need for any annual or periodic application unless and until the individual notifies a Federal or State official responsible for such determinations that the individual's eligibility conditions have changed so that the individual is no longer a subsidy eligible individual (or is no longer within such class of such individuals).'.CommentsClose CommentsPermalink
(c) Encouraging Application of Procedures Under Medicare Savings Program- Section 1905(p) of such Act (
`(7) The Secretary shall take all reasonable steps to encourage States to provide for administrative verification of income and automatic reenrollment (as provided under subparagraphs (C)(iii) and (G) of section 1860D-14(a)(3) in the case of the low-income subsidy program).'.CommentsClose CommentsPermalink
(d) SSA Assistance With Medicare Savings Program and Low-Income Subsidy Program Applications- Section 1144 of such Act (
`(c) Assistance With Medicare Savings Program and Low-Income Subsidy Program Applications-CommentsClose CommentsPermalink
`(1) DISTRIBUTION OF APPLICATIONS TO APPLICANTS FOR MEDICARE- In the case of each individual applying for hospital insurance benefits under section 226 or 226A, the Commissioner shall provide the following:CommentsClose CommentsPermalink
`(A) Information describing the low-income subsidy program under section 1860D-14 and the medicare savings program under title XIX.CommentsClose CommentsPermalink
`(B) An application for enrollment under such low-income subsidy program as well as a simplified application form (developed under section 1905(p)(5)) for medical assistance for medicare cost-sharing under title XIX.CommentsClose CommentsPermalink
`(C) Information on how the individual may obtain assistance in completing such applications, including information on how the individual may contact the State health insurance assistance program (SHIP) for the State in which the individual is located.CommentsClose CommentsPermalink
The Commissioner shall make such application forms available at local offices of the Social Security Administration.CommentsClose CommentsPermalink
`(2) TRAINING PERSONNEL IN ASSISTING IN COMPLETING APPLICATIONS- The Commissioner shall provide training to those employees of the Social Security Administration who are involved in receiving applications for benefits described in paragraph (1) in assisting applicants in completing a medicare savings program application described in paragraph (1). Such employees who are so trained shall provide such assistance upon request.CommentsClose CommentsPermalink
`(3) TRANSMITTAL OF APPLICATION- If such an employee assists in completing such an application, the employee, with the consent of the applicant, shall transmit the application to the appropriate State medicaid agency for processing.CommentsClose CommentsPermalink
`(4) COORDINATION WITH OUTREACH- The Commissioner shall coordinate outreach activities under this subsection with outreach activities conducted by States in connection with the low-income subsidy program and the medicare savings program.'.CommentsClose CommentsPermalink
(e) Medicaid Agency Consideration of Applications- Section 1935(a) of such Act (
`(4) CONSIDERATION OF MSP APPLICATIONS- The State shall accept medicare savings program applications transmitted under section 1144(c)(3) and act on such applications in the same manner and deadlines as if they had been submitted directly by the applicant.'.CommentsClose CommentsPermalink
(f) Translation of Model Form- Section 1905(p)(5)(A) of the Social Security Act (
(g) Disclosure of Tax Return Information for Purposes of Providing Low-Income Subsidies Under Medicare-CommentsClose CommentsPermalink
(1) IN GENERAL- Subsection (l) of section 6103 of the Internal Revenue Code of 1986 is amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(21) DISCLOSURE OF RETURN INFORMATION FOR PURPOSES OF PROVIDING LOW-INCOME SUBSIDIES UNDER MEDICARE-CommentsClose CommentsPermalink
`(A) RETURN INFORMATION FROM INTERNAL REVENUE SERVICE TO SOCIAL SECURITY ADMINISTRATION- The Secretary, upon written request from the Commissioner of Social Security, shall disclose to the officers and employees of the Social Security Administration with respect to any individual identified by the Commissioner as potentially eligible (based on information other than return information) for low-income subsidies under section 1860D-14 of the Social Security Act--CommentsClose CommentsPermalink
`(i) whether the adjusted gross income for the applicable year is less than 135 percent of the poverty line (as specified by the Commissioner in such request),CommentsClose CommentsPermalink
`(ii) whether such adjusted gross income is between 135 percent and 150 percent of the poverty line (as so specified),CommentsClose CommentsPermalink
`(iii) whether any designated distributions (as defined in section 3405(e)(1)) were reported with respect to such individual under section 6047(d) for the applicable year, and the amount (if any) of the distributions so reported,CommentsClose CommentsPermalink
`(iv) whether the return was a joint return for the applicable year, andCommentsClose CommentsPermalink
`(v) the applicable year.CommentsClose CommentsPermalink
`(B) APPLICABLE YEAR-CommentsClose CommentsPermalink
`(i) IN GENERAL- For the purposes of this paragraph, the term `applicable year' means the most recent taxable year for which information is available in the Internal Revenue Service's taxpayer data information systems, or, if there is no return filed for the individual for such year, the prior taxable year.CommentsClose CommentsPermalink
`(ii) NO RETURN- If no return is filed for such individual for both taxable years referred to in clause (i), the Secretary shall disclose the fact that there is no return filed for such individual for the applicable year in lieu of the information described in subparagraph (A).CommentsClose CommentsPermalink
`(C) RESTRICTION ON USE OF DISCLOSED INFORMATION- Return information disclosed under this paragraph may be used only for the purpose of improving the efforts of the Social Security Administration to contact and assist eligible individuals for, and administering, low-income subsidies under section 1860D-14 of the Social Security Act.CommentsClose CommentsPermalink
`(D) TERMINATION- No disclosure shall be made under this paragraph after the 2-year period beginning on the date of the enactment of this paragraph.'.CommentsClose CommentsPermalink
(2) PROCEDURES AND RECORDKEEPING RELATED TO DISCLOSURES- Paragraph (4) of section 6103(p) of such Code is amended by striking `or (17)' each place it appears and inserting `(17), or (21)'.CommentsClose CommentsPermalink
(3) REPORT- Not later than 18 months after the date of the enactment of this Act, the Secretary of the Treasury, after consultation with the Commissioner of Social Security, shall submit a written report to Congress regarding the use of disclosures made under section 6103(l)(21) of the Internal Revenue Code of 1986, as added by this subsection, in identifying individuals eligible for the low-income subsidies under section 1860D-14 of the Social Security Act.CommentsClose CommentsPermalink
(4) EFFECTIVE DATE- The amendment made by this subsection shall apply to disclosures made after the date of the enactment of this Act.CommentsClose CommentsPermalink
(h) Effective Date- Except as otherwise provided, the amendments made by this section shall take effect on January 1, 2009.CommentsClose CommentsPermalink
SEC. 214. ELIMINATING APPLICATION OF ESTATE RECOVERY.
(a) In General- Section 1917(b)(1)(B)(ii) of the Social Security Act (
(b) Effective Date- The amendment made by subsection (a) shall take effect as of January 1, 2008.CommentsClose CommentsPermalink
SEC. 215. ELIMINATION OF PART D COST-SHARING FOR CERTAIN NON-INSTITUTIONALIZED FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS.
(a) In General- Section 1860D-14(a)(1)(D)(i) of the Social Security Act (
(1) by striking `INSTITUTIONALIZED INDIVIDUALS- In' and inserting `ELIMINATION OF COST-SHARING FOR CERTAIN FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS-CommentsClose CommentsPermalink
`(I) INSTITUTIONALIZED INDIVIDUALS- In'; andCommentsClose CommentsPermalink
(2) by adding at the end the following new subclause:CommentsClose CommentsPermalink
`(II) CERTAIN OTHER INDIVIDUALS- In the case of an individual who is a full-benefit dual eligible individual and with respect to whom there has been a determination that but for the provision of home and community based care (whether under section 1915 or under a waiver under section 1115) the individual would require the level of care provided in a hospital or a nursing facility or intermediate care facility for the mentally retarded the cost of which could be reimbursed under the State plan under title XIX, the elimination of any beneficiary coinsurance described in section 1860D-2(b)(2) (for all amounts through the total amount of expenditures at which benefits are available under section 1860D-2(b)(4)).'.CommentsClose CommentsPermalink
(b) Effective Date- The amendments made by subsection (a) shall apply to drugs dispensed on or after January 1, 2009.CommentsClose CommentsPermalink
SEC. 216. EXEMPTIONS FROM INCOME AND RESOURCES FOR DETERMINATION OF ELIGIBILITY FOR LOW-INCOME SUBSIDY.
(a) In General- Section 1860D-14(a)(3) of the Social Security Act (
(1) in subparagraph (C)(i), by inserting `and except that support and maintenance furnished in kind shall not be counted as income' after `section 1902(r)(2)';CommentsClose CommentsPermalink
(2) in subparagraph (D), in the matter before clause (i), by inserting `subject to the additional exclusions provided under subparagraph (G)' before `)';CommentsClose CommentsPermalink
(3) in subparagraph (E)(i), in the matter before subclause (I), by inserting `subject to the additional exclusions provided under subparagraph (G)' before `)'; andCommentsClose CommentsPermalink
(4) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(I) ADDITIONAL EXCLUSIONS- In determining the resources of an individual (and the eligible spouse of the individual, if any) under section 1613 for purposes of subparagraphs (D) and (E) the following additional exclusions shall apply:CommentsClose CommentsPermalink
`(i) LIFE INSURANCE POLICY- No part of the value of any life insurance policy shall be taken into account.CommentsClose CommentsPermalink
`(ii) PENSION OR RETIREMENT PLAN- No balance in any pension or retirement plan shall be taken into account.'.CommentsClose CommentsPermalink
(b) Effective Date- The amendments made by this section shall take effect on January 1, 2009, and shall apply to determinations of eligibility for months beginning with January 2009.CommentsClose CommentsPermalink
SEC. 217. COST-SHARING PROTECTIONS FOR LOW-INCOME SUBSIDY-ELIGIBLE INDIVIDUALS.
(a) In General- Section 1860D-14(a) of the Social Security Act (
(1) in paragraph (1)(D), by adding at the end the following new clause:CommentsClose CommentsPermalink
`(iv) OVERALL LIMITATION ON COST-SHARING- In the case of all such individuals, a limitation on aggregate cost-sharing under this part for a year not to exceed 5 percent of income.'; andCommentsClose CommentsPermalink
(2) in paragraph (2), by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(F) OVERALL LIMITATION ON COST-SHARING- A limitation on aggregate cost-sharing under this part for a year not to exceed 5 percent of income.'.CommentsClose CommentsPermalink
(b) Effective Date- The amendments made by subsection (a) shall apply as of January 1, 2009.CommentsClose CommentsPermalink
SEC. 218. INTELLIGENT ASSIGNMENT IN ENROLLMENT.
(a) In General- Section 1860D-1(b)(1) of the Social Security Act (
(1) in the second sentence of subparagraph (C), by inserting `, subject to subparagraph (D),' before `on a random basis'; andCommentsClose CommentsPermalink
(2) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(D) INTELLIGENT ASSIGNMENT- In the case of any auto-enrollment under subparagraph (C), no part D eligible individual described in such subparagraph shall be enrolled in a prescription drug plan which does not meet the following requirements:CommentsClose CommentsPermalink
`(i) FORMULARY- The plan has a formulary that covers at least--CommentsClose CommentsPermalink
`(I) 95 percent of the 100 most commonly prescribed non-duplicative generic covered part D drugs for the population of individuals entitled to benefits under part A or enrolled under part B; andCommentsClose CommentsPermalink
`(II) 95 percent of the 100 most commonly prescribed non-duplicative brand name covered part D drugs for such population.CommentsClose CommentsPermalink
`(ii) PHARMACY NETWORK- The plan has a network of pharmacies that substantially exceeds the minimum requirements for prescription drug plans in the State and that provides access in areas where lower income individuals reside.CommentsClose CommentsPermalink
`(iii) QUALITY-CommentsClose CommentsPermalink
`(I) IN GENERAL- Subject to subclause (I), the plan has an above average score on quality ratings of the Secretary of prescription drug plans under this part.CommentsClose CommentsPermalink
`(II) EXCEPTION- Subclause (I) shall not apply to a plan that is a new plan (as defined by the Secretary), with respect to the plan year involved.CommentsClose CommentsPermalink
`(iv) LOW COST- The total cost under this title of providing prescription drug coverage under the plan consistent with the previous clauses of this subparagraph is among the lowest 25th percentile of prescription drug plans under this part in the State.CommentsClose CommentsPermalink
In the case that no plan meets the requirements under clauses (i) through (iv), the Secretary shall implement this subparagraph to the greatest extent possible with the goal of protecting beneficiary access to drugs without increasing the cost relative to the enrollment process under subparagraph (C) as in existence before the date of the enactment of this subparagraph.'.CommentsClose CommentsPermalink
(b) Effective Date- The amendment made by subsection (a) shall take effect for enrollments effected on or after November 15, 2009.CommentsClose CommentsPermalink
Subtitle C--Part D Beneficiary Improvements
SEC. 221. INCLUDING COSTS INCURRED BY AIDS DRUG ASSISTANCE PROGRAMS AND INDIAN HEALTH SERVICE IN PROVIDING PRESCRIPTION DRUGS TOWARD THE ANNUAL OUT OF POCKET THRESHOLD UNDER PART D.
(a) In General- Section 1860D-2(b)(4)(C) of the Social Security Act (
(1) in clause (i), by striking `and' at the end;CommentsClose CommentsPermalink
(2) in clause (ii)--CommentsClose CommentsPermalink
(A) by striking `such costs shall be treated as incurred only if' and inserting `subject to clause (iii), such costs shall be treated as incurred only if';CommentsClose CommentsPermalink
(B) by striking `, under section 1860D-14, or under a State Pharmaceutical Assistance Program'; andCommentsClose CommentsPermalink
(C) by striking the period at the end and inserting `; and'; andCommentsClose CommentsPermalink
(3) by inserting after clause (ii) the following new clause:CommentsClose CommentsPermalink
`(iii) such costs shall be treated as incurred and shall not be considered to be reimbursed under clause (ii) if such costs are borne or paid--CommentsClose CommentsPermalink
`(I) under section 1860D-14;CommentsClose CommentsPermalink
`(II) under a State Pharmaceutical Assistance Program;CommentsClose CommentsPermalink
`(III) by the Indian Health Service, an Indian tribe or tribal organization, or an urban Indian organization (as defined in section 4 of the Indian Health Care Improvement Act); orCommentsClose CommentsPermalink
`(IV) under an AIDS Drug Assistance Program under part B of title XXVI of the Public Health Service Act.'.CommentsClose CommentsPermalink
(b) Effective Date- The amendments made by subsection (a) shall apply to costs incurred on or after January 1, 2009.CommentsClose CommentsPermalink
SEC. 222. PERMITTING MID-YEAR CHANGES IN ENROLLMENT FOR FORMULARY CHANGES ADVERSELY IMPACT AN ENROLLEE.
(a) In General- Section 1860D-1(b)(3) of the Social Security Act (
`(F) CHANGE IN FORMULARY RESULTING IN INCREASE IN COST-SHARING-CommentsClose CommentsPermalink
`(i) IN GENERAL- Except as provided in clause (ii), in the case of an individual enrolled in a prescription drug plan (or MA-PD plan) who has been prescribed a covered part D drug while so enrolled, if the formulary of the plan is materially changed (other than at the end of a contract year) so to reduce the coverage (or increase the cost-sharing) of the drug under the plan.CommentsClose CommentsPermalink
`(ii) EXCEPTION- Clause (i) shall not apply in the case that a drug is removed from the formulary of a plan because of a recall or withdrawal of the drug issued by the Food and Drug Administration.'.CommentsClose CommentsPermalink
(b) Effective Date- The amendment made by subsection (a) shall apply to contract years beginning on or after January 1, 2009.CommentsClose CommentsPermalink
SEC. 223. REMOVAL OF EXCLUSION OF BENZODIAZEPINES FROM REQUIRED COVERAGE UNDER THE MEDICARE PRESCRIPTION DRUG PROGRAM.
(a) In General- Section 1860D-2(e)(2)(A) of the Social Security Act (
(1) by striking `subparagraph (E)' and inserting `subparagraphs (E) and (J)'; andCommentsClose CommentsPermalink
(2) by inserting `and benzodiazepines, respectively' after `smoking cessation agents'.CommentsClose CommentsPermalink
(b) Effective Date- The amendments made by subsection (a) shall apply to prescriptions dispensed on or after January 1, 2013.CommentsClose CommentsPermalink
SEC. 224. PERMITTING UPDATING DRUG COMPENDIA UNDER PART D USING PART B UPDATE PROCESS.
Section 1860D-4(b)(3)(C) of the Social Security Act (
`(iv) UPDATING DRUG COMPENDIA USING PART B PROCESS- The Secretary may apply under this subparagraph the same process for updating drug compendia that is used for purposes of section 1861(t)(2)(B)(ii).'.CommentsClose CommentsPermalink
SEC. 225. CODIFICATION OF SPECIAL PROTECTIONS FOR SIX PROTECTED DRUG CLASSIFICATIONS.
(a) In General- Section 1860D-4(b)(3) of the Social Security Act (
(1) in subparagraph (C)(i), by inserting `, except as provided in subparagraph (G),' after `although'; andCommentsClose CommentsPermalink
(2) by inserting after subparagraph (F) the following new subparagraph:CommentsClose CommentsPermalink
`(G) REQUIRED INCLUSION OF DRUGS IN CERTAIN THERAPEUTIC CLASSES-CommentsClose CommentsPermalink
`(i) IN GENERAL- The formulary must include all or substantially all covered part D drugs in each of the following therapeutic classes of covered part D drugs:CommentsClose CommentsPermalink
`(I) Anticonvulsants.CommentsClose CommentsPermalink
`(II) Antineoplastics.CommentsClose CommentsPermalink
`(III) Antiretrovirals.CommentsClose CommentsPermalink
`(IV) Antidepressants.CommentsClose CommentsPermalink
`(V) Antipsychotics.CommentsClose CommentsPermalink
`(VI) Immunosuppresessants.CommentsClose CommentsPermalink
`(ii) USE OF UTILIZATION MANAGEMENT TOOLS- A PDP sponsor of a prescription drug plan may use prior authorization or step therapy for the initiation of medications within one of the classifications specified in clause (i) but only when approved by the Secretary, except that such prior authorization or step therapy may not be used in the case of antiretrovirals and in the case of individuals who already are stabilized on a drug treatment regimen.'.CommentsClose CommentsPermalink
(b) Effective Date- The amendment made by subsection (a) shall apply for plan years beginning on or after January 1, 2009.CommentsClose CommentsPermalink
SEC. 226. ELIMINATION OF MEDICARE PART D LATE ENROLLMENT PENALTIES PAID BY LOW-INCOME SUBSIDY-ELIGIBLE INDIVIDUALS.
(a) Individuals With Income Below 135 Percent of Poverty Line- Paragraph (1)(A)(ii) of section 1860D-14(a) of the Social Security Act (
`(ii) 100 percent of any late enrollment penalties imposed under section 1860D-13(b) for such individual.'.CommentsClose CommentsPermalink
(b) Individuals With Income Between 135 and 150 Percent of Poverty Line- Paragraph (2)(A) of such section is amended--CommentsClose CommentsPermalink
(1) by inserting `equal to (i) an amount' after `premium subsidy';CommentsClose CommentsPermalink
(2) by striking `paragraph (1)(A)' and inserting `clause (i) of paragraph (1)(A)'; andCommentsClose CommentsPermalink
(3) by adding at the end before the period the following: `, plus (ii) 100 percent of the amount described in clause (ii) of such paragraph for such individual'.CommentsClose CommentsPermalink
(c) Effective Date- The amendments made by this section shall apply to subsidies for months beginning with January 2008.CommentsClose CommentsPermalink
SEC. 227. SPECIAL ENROLLMENT PERIOD FOR SUBSIDY ELIGIBLE INDIVIDUALS.
(a) In General- Section 1860D-1(b)(3) of the Social Security Act (
`(G) ELIGIBILITY FOR LOW-INCOME SUBSIDY-CommentsClose CommentsPermalink
`(i) IN GENERAL- In the case of an applicable subsidy eligible individual (as defined in clause (ii)), the special enrollment period described in clause (iii).CommentsClose CommentsPermalink
`(ii) APPLICABLE SUBSIDY ELIGIBLE INDIVIDUAL DEFINED- For purposes of this subparagraph, the term `applicable subsidy eligible individual' means a part D eligible individual who is determined under subparagraph (B) of section 1860D-14(a)(3) to be a subsidy eligible individual (as defined in subparagraph (A) of such section), and includes such an individual who was enrolled in a prescription drug plan or an MA-PD plan on the date of such determination.CommentsClose CommentsPermalink
`(iii) SPECIAL ENROLLMENT PERIOD DESCRIBED- The special enrollment period described in this clause, with respect to an applicable subsidy eligible individual, is the 90-day period beginning on the date the individual receives notification that such individual has been determined under section 1860D-14(a)(3)(B) to be a subsidy eligible individual (as so defined).'.CommentsClose CommentsPermalink
(b) Automatic Enrollment Process for Certain Subsidy Eligible Individuals- Section 1860D-1(b)(1) of the Social Security Act (
`(E) SPECIAL RULE FOR SUBSIDY ELIGIBLE INDIVIDUALS- The process established under subparagraph (A) shall include, in the case of an applicable subsidy eligible individual (as defined in clause (ii) of paragraph (3)(F)) who fails to enroll in a prescription drug plan or an MA-PD plan during the special enrollment period described in clause (iii) of such paragraph applicable to such individual, a process for the facilitated enrollment of the individual in the prescription drug plan or MA-PD plan that is most appropriate for such individual (as determined by the Secretary). Nothing in the previous sentence shall prevent an individual described in such sentence from declining enrollment in a plan determined appropriate by the Secretary (or in the program under this part) or from changing such enrollment.'.CommentsClose CommentsPermalink
(c) Effective Date- The amendments made by this section shall apply to subsidy determinations made for months beginning with January 2008.CommentsClose CommentsPermalink
Subtitle D--Reducing Health Disparities
SEC. 231. MEDICARE DATA ON RACE, ETHNICITY, AND PRIMARY LANGUAGE.
(a) Requirements-CommentsClose CommentsPermalink
(1) IN GENERAL- The Secretary of Health and Human Services (in this subtitle referred to as the `Secretary') shall--CommentsClose CommentsPermalink
(A) collect data on the race, ethnicity, and primary language of each applicant for and recipient of benefits under title XVIII of the Social Security Act--CommentsClose CommentsPermalink
(i) using, at a minimum, the categories for race and ethnicity described in the 1997 Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity;CommentsClose CommentsPermalink
(ii) using the standards developed under subsection (e) for the collection of language data;CommentsClose CommentsPermalink
(iii) where practicable, collecting data for additional population groups if such groups can be aggregated into the minimum race and ethnicity categories; andCommentsClose CommentsPermalink
(iv) where practicable, through self-reporting;CommentsClose CommentsPermalink
(B) with respect to the collection of the data described in subparagraph (A) for applicants and recipients who are minors or otherwise legally incapacitated, require that--CommentsClose CommentsPermalink
(i) such data be collected from the parent or legal guardian of such an applicant or recipient; andCommentsClose CommentsPermalink
(ii) the preferred language of the parent or legal guardian of such an applicant or recipient be collected;CommentsClose CommentsPermalink
(C) systematically analyze at least annually such data using the smallest appropriate units of analysis feasible to detect racial and ethnic disparities in health and health care and when appropriate, for men and women separately;CommentsClose CommentsPermalink
(D) report the results of analysis annually to the Director of the Office for Civil Rights, the Committee on Health, Education, Labor, and Pensions and the Committee on Finance of the Senate, and the Committee on Energy and Commerce and the Committee on Ways and Means of the House of Representatives; andCommentsClose CommentsPermalink
(E) ensure that the provision of assistance to an applicant or recipient of assistance is not denied or otherwise adversely affected because of the failure of the applicant or recipient to provide race, ethnicity, and primary language data.CommentsClose CommentsPermalink
(2) RULES OF CONSTRUCTION- Nothing in this subsection shall be construed--CommentsClose CommentsPermalink
(A) to permit the use of information collected under this subsection in a manner that would adversely affect any individual providing any such information; andCommentsClose CommentsPermalink
(B) to require health care providers to collect data.CommentsClose CommentsPermalink
(b) Protection of Data- The Secretary shall ensure (through the promulgation of regulations or otherwise) that all data collected pursuant to subsection (a) is protected--CommentsClose CommentsPermalink
(1) under the same privacy protections as the Secretary applies to other health data under the regulations promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (
(2) from all inappropriate internal use by any entity that collects, stores, or receives the data, including use of such data in determinations of eligibility (or continued eligibility) in health plans, and from other inappropriate uses, as defined by the Secretary.CommentsClose CommentsPermalink
(c) Collection Plan- In carrying out the duties specified in subsection (a), the Secretary shall develop and implement a plan to improve the collection, analysis, and reporting of racial, ethnic, and primary language data within the programs administered under title XVIII of the Social Security Act, and, in consultation with the National Committee on Vital Health Statistics, the Office of Minority Health, and other appropriate public and private entities, shall make recommendations on how to--CommentsClose CommentsPermalink
(1) implement subsection (a) while minimizing the cost and administrative burdens of data collection and reporting;CommentsClose CommentsPermalink
(2) expand awareness that data collection, analysis, and reporting by race, ethnicity, and primary language is legal and necessary to assure equity and non-discrimination in the quality of health care services;CommentsClose CommentsPermalink
(3) ensure that future patient record systems, including electronic health records, electronic medical records and patient health records, have data code sets for racial, ethnic, and primary language identifiers and that such identifiers can be retrieved from clinical records, including records transmitted electronically;CommentsClose CommentsPermalink
(4) improve health and health care data collection and analysis for more population groups if such groups can be aggregated into the minimum race and ethnicity categories;CommentsClose CommentsPermalink
(5) provide researchers with greater access to racial, ethnic, and primary language data, subject to privacy and confidentiality regulations; andCommentsClose CommentsPermalink
(6) safeguard and prevent the misuse of data collected under subsection (a).CommentsClose CommentsPermalink
(d) Compliance With Standards- Data collected under subsection (a) shall be obtained, maintained, and presented (including for reporting purposes and at a minimum) in accordance with the 1997 Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity.CommentsClose CommentsPermalink
(e) Language Collection Standards- Not later than 1 year after the date of enactment of this Act, the Director of the Office of Minority Health, in consultation with the Office for Civil Rights of the Department of Health and Human Services, shall develop and disseminate Standards for the Classification of Federal Data on Preferred Written and Spoken Language.CommentsClose CommentsPermalink
(f) Technical Assistance for the Collection and Reporting of Data-CommentsClose CommentsPermalink
(1) IN GENERAL- The Secretary may, either directly or through grant or contract, provide technical assistance to enable a health care provider or plan operating under the Medicare program to comply with the requirements of this section.CommentsClose CommentsPermalink
(2) TYPES OF ASSISTANCE- Assistance provided under this subsection may include assistance to--CommentsClose CommentsPermalink
(A) enhance or upgrade computer technology that will facilitate racial, ethnic, and primary language data collection and analysis;CommentsClose CommentsPermalink
(B) improve methods for health data collection and analysis including additional population groups beyond the Office of Management and Budget categories if such groups can be aggregated into the minimum race and ethnicity categories;CommentsClose CommentsPermalink
(C) develop mechanisms for submitting collected data subject to existing privacy and confidentiality regulations;CommentsClose CommentsPermalink
(D) develop educational programs to raise awareness that data collection and reporting by race, ethnicity, and preferred language are legal and essential for eliminating health and health care disparities; andCommentsClose CommentsPermalink
(E) provide for the revision of existing HIPAA claims-related code sets to mandate the collection of racial and ethnicity data, and to provide a code set for primary language.CommentsClose CommentsPermalink
(g) Analysis of Racial and Ethnic Data- The Secretary, acting through the Director of the Agency for Health Care Research and Quality and in coordination with the Administrator of the Centers for Medicare & Medicaid Services, shall--CommentsClose CommentsPermalink
(1) identify appropriate quality assurance mechanisms to monitor for health disparities under the Medicare program;CommentsClose CommentsPermalink
(2) specify the clinical, diagnostic, or therapeutic measures which should be monitored;CommentsClose CommentsPermalink
(3) develop new quality measures relating to racial and ethnic disparities in health and health care;CommentsClose CommentsPermalink
(4) identify the level at which data analysis should be conducted; andCommentsClose CommentsPermalink
(5) share data with external organizations for research and quality improvement purposes, in compliance with applicable Federal privacy laws.CommentsClose CommentsPermalink
(h) Report- Not later than 2 years after the date of enactment of this Act, and biennially thereafter, the Secretary shall submit to the appropriate committees of Congress a report on the effectiveness of data collection, analysis, and reporting on race, ethnicity, and primary language under the programs administered through title XVIII of the Social Security Act. The report shall evaluate the progress made with respect to the plan under subsection (c) or subsequent revisions thereto.CommentsClose CommentsPermalink
(i) Authorization of Appropriations- There is authorized to be appropriated to carry out this section, such sums as may be necessary for each of fiscal years 2008 through 2012.CommentsClose CommentsPermalink
SEC. 232. ENSURING EFFECTIVE COMMUNICATION IN MEDICARE.
(a) Ensuring Effective Communication by the Centers for Medicare & Medicaid Services-CommentsClose CommentsPermalink
(1) STUDY ON MEDICARE PAYMENTS FOR LANGUAGE SERVICES- The Secretary of Health and Human Services shall conduct a study that examines ways that Medicare should develop payment systems for language services using the results of the demonstration program conducted under section 233.CommentsClose CommentsPermalink
(2) ANALYSES- The study shall include an analysis of each of the following:CommentsClose CommentsPermalink
(A) How to develop and structure appropriate payment systems for language services for all Medicare service providers.CommentsClose CommentsPermalink
(B) The feasibility of adopting a payment methodology for on-site interpreters, including interpreters who work as independent contractors and interpreters who work for agencies that provide on-site interpretation, pursuant to which such interpreters could directly bill Medicare for services provided in support of physician office services for an LEP Medicare patient.CommentsClose CommentsPermalink
(C) The feasibility of Medicare contracting directly with agencies that provide off-site interpretation including telephonic and video interpretation pursuant to which such contractors could directly bill Medicare for the services provided in support of physician office services for an LEP Medicare patient.CommentsClose CommentsPermalink
(D) The feasibility of modifying the existing Medicare resource-based relative value scale (RBRVS) by using adjustments (such as multipliers or add-ons) when a patient is LEP.CommentsClose CommentsPermalink
(E) How each of options described in a previous paragraph would be funded and how such funding would affect physician payments, a physician's practice, and beneficiary cost-sharing.CommentsClose CommentsPermalink
(3) VARIATION IN PAYMENT SYSTEM DESCRIBED- The payment systems described in subsection (b) may allow variations based upon types of service providers, available delivery methods, and costs for providing language services including such factors as--CommentsClose CommentsPermalink
(A) the type of language services provided (such as provision of health care or health care related services directly in a non-English language by a bilingual provider or use of an interpreter);CommentsClose CommentsPermalink
(B) type of interpretation services provided (such as in-person, telephonic, video interpretation);CommentsClose CommentsPermalink
(C) the methods and costs of providing language services (including the costs of providing language services with internal staff or through contract with external independent contractors and/or agencies);CommentsClose CommentsPermalink
(D) providing services for languages not frequently encountered in the United States; andCommentsClose CommentsPermalink
(E) providing services in rural areas.CommentsClose CommentsPermalink
(4) REPORT- The Secretary shall submit a report on the study conducted under subsection (a) to appropriate committees of Congress not later than 1 year after the expiration of the demonstration program conducted under section 3.CommentsClose CommentsPermalink
(b) Health Plans- Section 1857(g)(1) of the Social Security Act (
(1) by striking `or' at the end of subparagraph (F);CommentsClose CommentsPermalink
(2) by adding `or' at the end of subparagraph (G); andCommentsClose CommentsPermalink
(3) by inserting after subparagraph (G) the following new subparagraph:CommentsClose CommentsPermalink
`(H) fails substantially to provide language services to limited English proficient beneficiaries enrolled in the plan that are required under law;'.CommentsClose CommentsPermalink
SEC. 233. DEMONSTRATION TO PROMOTE ACCESS FOR MEDICARE BENEFICIARIES WITH LIMITED ENGLISH PROFICIENCY BY PROVIDING REIMBURSEMENT FOR CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES.
(a) In General- Within one year after the date of the enactment of this Act the Secretary, acting through the Centers for Medicare & Medicaid Services, shall award 24 3-year demonstration grants to eligible Medicare service providers to improve effective communication between such providers and Medicare beneficiaries who are living in communities where racial and ethnic minorities, including populations that face language barriers, are underserved with respect to such services. The Secretary shall not authorize a grant larger than $500,000 over three years for any grantee.CommentsClose CommentsPermalink
(b) Eligibility; Priority-CommentsClose CommentsPermalink
(1) ELIGIBILITY- To be eligible to receive a grant under subsection (1) an entity shall--CommentsClose CommentsPermalink
(A) be--CommentsClose CommentsPermalink
(i) a provider of services under part A of title XVIII of the Social Security Act;CommentsClose CommentsPermalink
(ii) a service provider under part B of such title;CommentsClose CommentsPermalink
(iii) a part C organization offering a Medicare part C plan under part C of such title; orCommentsClose CommentsPermalink
(iv) a PDP sponsor of a prescription drug plan under part D of such title; andCommentsClose CommentsPermalink
(B) prepare and submit to the Secretary an application, at such time, in such manner, and accompanied by such additional information as the Secretary may require.CommentsClose CommentsPermalink
(2) PRIORITY-CommentsClose CommentsPermalink
(A) DISTRIBUTION- To the extent feasible, in awarding grants under this section, the Secretary shall award--CommentsClose CommentsPermalink
(i) 6 grants to providers of services described in paragraph (1)(A)(i);CommentsClose CommentsPermalink
(ii) 6 grants to service providers described in paragraph (1)(A)(ii);CommentsClose CommentsPermalink
(iii) 6 grants to organizations described in paragraph (1)(A)(iii); andCommentsClose CommentsPermalink
(iv) 6 grants to sponsors described in paragraph (1)(A)(iv).CommentsClose CommentsPermalink
(B) FOR COMMUNITY ORGANIZATIONS- The Secretary shall give priority to applicants that have developed partnerships with community organizations or with agencies with experience in language access.CommentsClose CommentsPermalink
(C) VARIATION IN GRANTEES- The Secretary shall also ensure that the grantees under this section represent, among other factors, variations in--CommentsClose CommentsPermalink
(i) different types of service providers and organizations under parts A through D of title XVIII of the Social Security Act;CommentsClose CommentsPermalink
(ii) languages needed and their frequency of use;CommentsClose CommentsPermalink
(iii) urban and rural settings;CommentsClose CommentsPermalink
(iv) at least two geographic regions; andCommentsClose CommentsPermalink
(v) at least two large metropolitan statistical areas with diverse populations.CommentsClose CommentsPermalink
(c) Use of Funds-CommentsClose CommentsPermalink
(1) IN GENERAL- A grantee shall use grant funds received under this section to pay for the provision of competent language services to Medicare beneficiaries who are limited English proficient. Competent interpreter services may be provided through on-site interpretation, telephonic interpretation, or video interpretation or direct provision of health care or health care related services by a bilingual health care provider. A grantee may use bilingual providers, staff, or contract interpreters. A grantee may use grant funds to pay for competent translation services. A grantee may use up to 10 percent of the grant funds to pay for administrative costs associated with the provision of competent language services and for reporting required under subsection (E).CommentsClose CommentsPermalink
(2) ORGANIZATIONS- Grantees that are part C organizations or PDP sponsors must ensure that their network providers receive at least 50 percent of the grant funds to pay for the provision of competent language services to Medicare beneficiaries who are limited English proficient, including physicians and pharmacies.CommentsClose CommentsPermalink
(3) DETERMINATION OF PAYMENTS FOR LANGUAGE SERVICES- Payments to grantees shall be calculated based on the estimated numbers of LEP Medicare beneficiaries in a grantee's service area utilizing--CommentsClose CommentsPermalink
(A) data on the numbers of limited English proficient individuals who speak English less than `very well' from the most recently available data from the Bureau of the Census or other State-based study the Secretary determines likely to yield accurate data regarding the number of LEP individuals served by the grantee; orCommentsClose CommentsPermalink
(B) the grantee's own data if the grantee routinely collects data on Medicare beneficiaries' primary language in a manner determined by the Secretary to yield accurate data and such data shows greater numbers of LEP individuals than the data listed in subparagraph (A).CommentsClose CommentsPermalink
(4) LIMITATIONS-CommentsClose CommentsPermalink
(A) REPORTING- Payments shall only be provided under this section to grantees that report their costs of providing language services as required under subsection (e). If a grantee fails to provide the reports under such section for the first year of a grant, the Secretary may terminate the grant and solicit applications from new grantees to participate in the subsequent two years of the demonstration program.CommentsClose CommentsPermalink
(B) TYPE OF SERVICES-CommentsClose CommentsPermalink
(i) IN GENERAL- Subject to clause (ii), payments shall be provided under this section only to grantees that utilize competent bilingual staff or competent interpreter or translation services which--CommentsClose CommentsPermalink
(I) if the grantee operates in a State that has statewide health care interpreter standards, meet the State standards currently in effect; orCommentsClose CommentsPermalink
(II) if the grantee operates in a State that does not have statewide health care interpreter standards, utilizes competent interpreters who follow the National Council on Interpreting in Health Care's Code of Ethics and Standards of Practice.CommentsClose CommentsPermalink
(ii) EXEMPTIONS- The requirements of clause (i) shall not apply--CommentsClose CommentsPermalink
(I) in the case of a Medicare beneficiary who is limited English proficient (who has been informed in the beneficiary's primary language of the availability of free interpreter and translation services) and who requests the use of family, friends, or other persons untrained in interpretation or translation and the grantee documents the request in the beneficiary's record; andCommentsClose CommentsPermalink
(II) in the case of a medical emergency where the delay directly associated with obtaining a competent interpreter or translation services would jeopardize the health of the patient.CommentsClose CommentsPermalink
Nothing in clause (ii)(II) shall be construed to exempt an emergency rooms or similar entities that regularly provide health care services in medical emergencies from having in place systems to provide competent interpreter and translation services without undue delay.CommentsClose CommentsPermalink
(d) Assurances- Grantees under this section shall--CommentsClose CommentsPermalink
(1) ensure that appropriate clinical and support staff receive ongoing education and training in linguistically appropriate service delivery; ensure the linguistic competence of bilingual providers;CommentsClose CommentsPermalink
(2) offer and provide appropriate language services at no additional charge to each patient with limited English proficiency at all points of contact, in a timely manner during all hours of operation;CommentsClose CommentsPermalink
(3) notify Medicare beneficiaries of their right to receive language services in their primary language;CommentsClose CommentsPermalink
(4) post signage in the languages of the commonly encountered group or groups present in the service area of the organization; andCommentsClose CommentsPermalink
(5) ensure that--CommentsClose CommentsPermalink
(A) primary language data are collected for recipients of language services; andCommentsClose CommentsPermalink
(B) consistent with the privacy protections provided under the regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (
(e) Reporting Requirements- Grantees under this section shall provide the Secretary with reports at the conclusion of the each year of a grant under this section. each report shall include at least the following information:CommentsClose CommentsPermalink
(1) The number of Medicare beneficiaries to whom language services are provided.CommentsClose CommentsPermalink
(2) The languages of those Medicare beneficiaries.CommentsClose CommentsPermalink
(3) The types of language services provided (such as provision of services directly in non-English language by a bilingual health care provider or use of an interpreter).CommentsClose CommentsPermalink
(4) Type of interpretation (such as in-person, telephonic, or video interpretation).CommentsClose CommentsPermalink
(5) The methods of providing language services (such as staff or contract with external independent contractors or agencies).CommentsClose CommentsPermalink
(6) The length of time for each interpretation encounter.CommentsClose CommentsPermalink
(7) The costs of providing language services (which may be actual or estimated, as determined by the Secretary).CommentsClose CommentsPermalink
(f) No Cost Sharing- LEP Beneficiaries shall not have to pay cost-sharing or co-pays for language services provided through this demonstration program.CommentsClose CommentsPermalink
(g) Evaluation and Report- The Secretary shall conduct an evaluation of the demonstration program under this section and shall submit to the appropriate committees of Congress a report not later than 1 year after the completion of the program. The report shall include the following:CommentsClose CommentsPermalink
(1) An analysis of the patient outcomes and costs of furnishing care to the LEP Medicare beneficiaries participating in the project as compared to such outcomes and costs for limited English proficient Medicare beneficiaries not participating.CommentsClose CommentsPermalink
(2) The effect of delivering culturally and linguistically appropriate services on beneficiary access to care, utilization of services, efficiency and cost-effectiveness of health care delivery, patient satisfaction, and select health outcomes.CommentsClose CommentsPermalink
(3) Recommendations regarding the extension of such project to the entire Medicare program.CommentsClose CommentsPermalink
(h) General Provisions- Nothing in this section shall be construed to limit otherwise existing obligations of recipients of Federal financial assistance under title VI of the Civil Rights Act of 1964 (
(i) Authorization of Appropriations- There are authorized to be appropriated to carry out this section $10,000,000 for each fiscal year of the demonstration.CommentsClose CommentsPermalink
SEC. 234. DEMONSTRATION TO IMPROVE CARE TO PREVIOUSLY UNINSURED.
(a) Establishment- Within one year after the date of enactment of this Act, the Secretary shall establish a demonstration project to determine the greatest needs and most effective methods of outreach to medicare beneficiaries who were previously uninsured.CommentsClose CommentsPermalink
(b) Scope- The demonstration shall be in no fewer than 10 sites, and shall include state health insurance assistance programs, community health centers, community-based organizations, community health workers, and other service providers under parts A, B, and C of title XVIII of the Social Security Act. Grantees that are plans operating under part C shall document that enrollees who were previously uninsured receive the `Welcome to Medicare' physical exam.CommentsClose CommentsPermalink
(c) Duration- The Secretary shall conduct the demonstration project for a period of 2 years.CommentsClose CommentsPermalink
(d) Report and Evaluation- The Secretary shall conduct an evaluation of the demonstration and not later than 1 year after the completion of the project shall submit to Congress a report including the following:CommentsClose CommentsPermalink
(1) An analysis of the effectiveness of outreach activities targeting beneficiaries who were previously uninsured, such as revising outreach and enrollment materials (including the potential for use of video information), providing one-on-one counseling, working with community health workers, and amending the Medicare and You handbook.CommentsClose CommentsPermalink
(2) The effect of such outreach on beneficiary access to care, utilization of services, efficiency and cost-effectiveness of health care delivery, patient satisfaction, and select health outcomes.CommentsClose CommentsPermalink
SEC. 235. OFFICE OF THE INSPECTOR GENERAL REPORT ON COMPLIANCE WITH AND ENFORCEMENT OF NATIONAL STANDARDS ON CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES (CLAS) IN MEDICARE.
(a) Report- Not later than two years after the date of the enactment of this Act, the Inspector General of the Department of Health and Human Services shall prepare and publish a report on--CommentsClose CommentsPermalink
(1) the extent to which Medicare providers and plans are complying with the Office for Civil Rights' Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons and the Office of Minority Health's Culturally and Linguistically Appropriate Services Standards in health care; andCommentsClose CommentsPermalink
(2) a description of the costs associated with or savings related to the provision of language services.CommentsClose CommentsPermalink
Such report shall include recommendations on improving compliance with CLAS Standards and recommendations on improving enforcement of CLAS Standards.CommentsClose CommentsPermalink
(b) Implementation- Not later than one year after the date of publication of the report under subsection (a), the Department of Health and Human Services shall implement changes responsive to any deficiencies identified in the report.CommentsClose CommentsPermalink
SEC. 236. IOM REPORT ON IMPACT OF LANGUAGE ACCESS SERVICES.
(a) In General- The Secretary of Health and Human Services shall seek to enter into an arrangement with the Institute of Medicine under which the Institute will prepare and publish, not later than 3 years after the date of the enactment of this Act, a report on the impact of language access services on the health and health care of limited English proficient populations.CommentsClose CommentsPermalink
(b) Contents- Such report shall include--CommentsClose CommentsPermalink
(1) recommendations on the development and implementation of policies and practices by health care organizations and providers for limited English proficient patient populations;CommentsClose CommentsPermalink
(2) a description of the effect of providing language access services on quality of health care and access to care and reduced medical error; andCommentsClose CommentsPermalink
(3) a description of the costs associated with or savings related to provision of language access services.CommentsClose CommentsPermalink
SEC. 237. DEFINITIONS.
In this subtitle:CommentsClose CommentsPermalink
(1) BILINGUAL- The term `bilingual' with respect to an individual means a person who has sufficient degree of proficiency in two languages and can ensure effective communication can occur in both languages.CommentsClose CommentsPermalink
(2) COMPETENT INTERPRETER SERVICES- The term `competent interpreter services' means a trans-language rendition of a spoken message in which the interpreter comprehends the source language and can speak comprehensively in the target language to convey the meaning intended in the source language. The interpreter knows health and health-related terminology and provides accurate interpretations by choosing equivalent expressions that convey the best matching and meaning to the source language and captures, to the greatest possible extent, all nuances intended in the source message.CommentsClose CommentsPermalink
(3) COMPETENT TRANSLATION SERVICES- The term `competent translation services' means a trans-language rendition of a written document in which the translator comprehends the source language and can write comprehensively in the target language to convey the meaning intended in the source language. The translator knows health and health-related terminology and provides accurate translations by choosing equivalent expressions that convey the best matching and meaning to the source language and captures, to the greatest possible extent, all nuances intended in the source document.CommentsClose CommentsPermalink
(4) EFFECTIVE COMMUNICATION- The term `effective communication' means an exchange of information between the provider of health care or health care-related services and the limited English proficient recipient of such services that enables limited English proficient individuals to access, understand, and benefit from health care or health care-related services.CommentsClose CommentsPermalink
(5) INTERPRETING/INTERPRETATION- The terms `interpreting' and `interpretation' mean the transmission of a spoken message from one language into another, faithfully, accurately, and objectively.CommentsClose CommentsPermalink
(6) HEALTH CARE SERVICES- The term `health care services' means services that address physical as well as mental health conditions in all care settings.CommentsClose CommentsPermalink
(7) HEALTH CARE-RELATED SERVICES- The term `health care-related services' means human or social services programs or activities that provide access, referrals or links to health care.CommentsClose CommentsPermalink
(8) LANGUAGE ACCESS- The term `language access' means the provision of language services to an LEP individual designed to enhance that individual's access to, understanding of or benefit from health care or health care-related services.CommentsClose CommentsPermalink
(9) LANGUAGE SERVICES- The term `language services' means provision of health care services directly in a non-English language, interpretation, translation, and non-English signage.CommentsClose CommentsPermalink
(10) LIMITED ENGLISH PROFICIENT- The term `limited English proficient' or `LEP' with respect to an individual means an individual who speaks a primary language other than English and who cannot speak, read, write or understand the English language at a level that permits the individual to effectively communicate with clinical or nonclinical staff at an entity providing health care or health care related services.CommentsClose CommentsPermalink
(11) MEDICARE PROGRAM- The term `Medicare program' means the programs under parts A through D of title XVIII of the Social Security Act.CommentsClose CommentsPermalink
(12) SERVICE PROVIDER- The term `service provider' includes all suppliers, providers of services, or entities under contract to provide coverage, items or services under any part of title XVIII of the Social Security Act.CommentsClose CommentsPermalink
TITLE III--PHYSICIANS' SERVICE PAYMENT REFORM
SEC. 301. ESTABLISHMENT OF SEPARATE TARGET GROWTH RATES FOR SERVICE CATEGORIES.
(a) Establishment of Service Categories- Subsection (j) of section 1848 of the Social Security Act (
`(5) SERVICE CATEGORIES- For services furnished on or after January 1, 2008, each of the following categories of physicians' services shall be treated as a separate `service category':CommentsClose CommentsPermalink
`(A) Evaluation and management services for primary care (including new and established patient office visits delivered by physicians who the Secretary determines provide accessible, continuous, coordinated, and comprehensive care for Medicare beneficiaries, emergency department visits, and home visits), and for preventive services (including screening mammography, colorectal cancer screening, and other services as defined by the Secretary, limited to the recommendations of the United States Preventive Services Task Force).CommentsClose CommentsPermalink
`(B) Evaluation and management services not described in subparagraph (A).CommentsClose CommentsPermalink
`(C) Imaging services (as defined in subsection (b)(4)(B)) and diagnostic tests (other than clinical diagnostic laboratory tests) not described in subparagraph (A).CommentsClose CommentsPermalink
`(D) Procedures that are subject (under regulations promulgated to carry out this section) to a 10-day or 90-day global period (in this paragraph referred to as `major procedures'), except that the Secretary may reclassify as minor procedures under subparagraph (F) any procedures that would otherwise be included in this category if the Secretary determines that such procedures are not major procedures.CommentsClose CommentsPermalink
`(E) Anesthesia services that are paid on the basis of the separate conversion factor for anesthesia services determined under subsection (d)(1)(D).CommentsClose CommentsPermalink
`(F) Minor procedures and any other physicians' services that are not described in a preceding subparagraph.'.CommentsClose CommentsPermalink
(b) Establishment of Separate Conversion Factors for Each Service Category- Subsection (d)(1) of section 1848 of the Social Security Act (
(1) in subparagraph (A)--CommentsClose CommentsPermalink
(A) by designating the sentence beginning `The conversion factor' as clause (i) with the heading `APPLICATION OF SINGLE CONVERSION FACTOR- ' and with appropriate indentation;CommentsClose CommentsPermalink
(B) by striking `The conversion factor' and inserting `Subject to clause (ii), the conversion factor'; andCommentsClose CommentsPermalink
(C) by adding at the end the following new clause:CommentsClose CommentsPermalink
`(ii) APPLICATION OF MULTIPLE CONVERSION FACTORS BEGINNING WITH 2008-CommentsClose CommentsPermalink
`(I) IN GENERAL- In applying clause (i) for years beginning with 2008, separate conversion factors shall be established for each service category of physicians' services (as defined in subsection (j)(5)) and any reference in this section to a conversion factor for such years shall be deemed to be a reference to the conversion factor for each of such categories.CommentsClose CommentsPermalink
`(II) INITIAL CONVERSION FACTORS; SPECIAL RULE FOR ANESTHESIA SERVICES- Such factors for 2008 shall be based upon the single conversion factor for 2007 multiplied by the update established under paragraph (8) for such category for 2008. In the case of the service category described in subsection (j)(5)(F) (relating to anesthesia services), the conversion factor for 2008 shall be based on the separate conversion factor specified in subparagraph (D) for 2007 multiplied by the update established under paragraph (8) for such category for 2008.CommentsClose CommentsPermalink
`(III) UPDATING OF CONVERSION FACTORS- Such factor for a service category for a subsequent year shall be based upon the conversion factor for such category for the previous year and adjusted by the update established for such category under paragraph (8) for the year involved.'; andCommentsClose CommentsPermalink
(2) in subparagraph (D), by inserting `(before 2008)' after `for a year'.CommentsClose CommentsPermalink
(c) Establishing Updates for Conversion Factors for Service Categories- Section 1848(d) of the Social Security Act (
(1) in paragraph (4)(B), by striking `and (6)' and inserting `, (6), (8), and (9)';CommentsClose CommentsPermalink
(2) in paragraph (4)(C)(iii), by striking `The allowed' and inserting `Subject to paragraph (8)(B), the allowed';CommentsClose CommentsPermalink
(3) in paragraph (4)(D), by striking `The update' and inserting `Subject to paragraph (8)(E), the update'; andCommentsClose CommentsPermalink
(4) by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(8) UPDATES FOR SERVICE CATEGORIES BEGINNING WITH 2008 AND ENDING WITH 2012-CommentsClose CommentsPermalink
`(A) IN GENERAL- In applying paragraph (4) for a year beginning with 2008 and ending with 2012, the following rules apply:CommentsClose CommentsPermalink
`(i) APPLICATION OF SEPARATE UPDATE ADJUSTMENTS FOR EACH SERVICE CATEGORY- Pursuant to paragraph (1)(A)(ii)(I), the update shall be made to the conversion factor for each service category (as defined in subsection (j)(5)) based upon an update adjustment factor for the respective category and year and the update adjustment factor shall be computed, for a year, separately for each service category.CommentsClose CommentsPermalink
`(ii) COMPUTATION OF ALLOWED AND ACTUAL EXPENDITURES BASED ON SERVICE CATEGORIES- In computing the prior year adjustment component and the cumulative adjustment component under clauses (i) and (ii) of paragraph (4)(B), the following rules apply:CommentsClose CommentsPermalink
`(I) APPLICATION BASED ON SERVICE CATEGORIES- The allowed expenditures and actual expenditures shall be the allowed and actual expenditures for the service category, as determined under subparagraph (B).CommentsClose CommentsPermalink
`(II) LIMITATION TO PHYSICIAN FEE-SCHEDULE SERVICES- Actual expenditures shall only take into account expenditures for services furnished under the physician fee schedule.CommentsClose CommentsPermalink
`(III) APPLICATION OF CATEGORY SPECIFIC TARGET GROWTH RATE- The growth rate applied under clause (ii)(II) of such paragraph shall be the target growth rate for the service category involved under subsection (f)(5).CommentsClose CommentsPermalink
`(IV) ALLOCATION OF CUMULATIVE OVERHANG- There shall be substituted for the difference described in subparagraph (B)(ii)(I) of such paragraph the amount described in subparagraph (C)(i) for the service category involved.CommentsClose CommentsPermalink
`(B) DETERMINATION OF ALLOWED EXPENDITURES- In applying paragraph (4) for a year beginning with 2008, notwithstanding subparagraph (C)(iii) of such paragraph, the allowed expenditures for a service category for a year is an amount computed by the Secretary as follows:CommentsClose CommentsPermalink
`(i) FOR 2008- For 2008:CommentsClose CommentsPermalink
`(I) TOTAL 2007 ALLOWED EXPENDITURES FOR ALL SERVICES INCLUDED IN SGR COMPUTATION- Compute total allowed expenditures for physicians' services (as defined in subsection (f)(4)(A)) for 2007 that would otherwise be calculated under subsection (d) but for this paragraph.CommentsClose CommentsPermalink
`(II) TOTAL 2007 ALLOWED EXPENDITURES FOR PHYSICIAN FEE SCHEDULE SERVICES- Compute total allowed expenditures for services furnished under the physician fee schedule for 2007 by subtracting, from the total allowed expenditures computed under subclause (I), the Secretary's estimate of the amount of the actual expenditures for 2007 for services included in such subclause for which payment is not made under the fee schedule established pursuant to this section.CommentsClose CommentsPermalink
`(III) ALLOCATION OF 2007 ALLOWED EXPENDITURES TO SERVICE CATEGORY- Compute allowed expenditures for the service category involved for 2007 by multiplying the total allowed expenditures computed under subclause (II) by the overhang allocation factor for the service category (as defined in subparagraph (C)(iii)).CommentsClose CommentsPermalink
`(IV) INCREASE BY GROWTH RATE TO OBTAIN 2008 ALLOWED EXPENDITURES FOR SERVICE CATEGORY- Compute allowed expenditures for the service category for 2008 by increasing the allowed expenditures for the service category for 2007 computed under subclause (III) by the target growth rate for such service category under subsection (f) for 2008.CommentsClose CommentsPermalink
`(ii) FOR SUBSEQUENT YEARS- For a subsequent year, take the amount of allowed expenditures for such category for the preceding year (under clause (i) or this clause) and increase it by the target growth rate determined under subsection (f) for such category and year.CommentsClose CommentsPermalink
`(C) COMPUTATION AND APPLICATION OF CUMULATIVE OVERHANG AMONG CATEGORIES-CommentsClose CommentsPermalink
`(i) IN GENERAL- For purposes of applying paragraph (4)(B)(ii)(II) under clause (ii)(IV), the amount described in this clause for a year (beginning with 2008) is the sum of the following:CommentsClose CommentsPermalink
`(I) Pre-2008 CUMULATIVE OVERHANG- The amount of the pre-2008 cumulative excess spending (as defined in clause (ii)) multiplied by the overhang allocation factor for the service category (under clause (iii)).CommentsClose CommentsPermalink
`(II) Post-2007 CUMULATIVE AMOUNTS- For a year beginning with 2009, the difference (which may be positive or negative) between the amount of the allowed expenditures for physicians' services (as determined under paragraph (4)(C)) in the service category from January 1, 2008, through the end of the prior year and the amount of the actual expenditures for such services in such category during that period.CommentsClose CommentsPermalink
`(ii) Pre-2008 CUMULATIVE EXCESS SPENDING DEFINED- For purposes of clause (i)(I), the term `pre-2008 cumulative excess spending' means the difference described in paragraph (4)(B)(ii)(I) as determined for the year 2008, taking into account expenditures through December 31, 2007. Such difference takes into account expenditures included in subsection (f)(4)(A).CommentsClose CommentsPermalink
`(iii) OVERHANG ALLOCATION FACTOR- For purposes of this paragraph, the term `overhang allocation factor' means, for a service category, the proportion, as determined by the Secretary of total actual expenditures under this part for items and services in such category during 2007 to the total of such actual expenditures for all the service categories. In calculating such proportion, the Secretary shall only take into account services furnished under the physician fee schedule.CommentsClose CommentsPermalink
`(D) UPDATES FOR 2008 AND 2009- The update to the conversion factors for each service category for each of 2008 and 2009 shall be equal to 0.5 percent.CommentsClose CommentsPermalink
`(E) CHANGE IN RESTRICTION ON UPDATE ADJUSTMENT FACTOR FOR 2010 AND 2011- The update adjustment factor determined under subparagraph (4)(B), as modified by this paragraph, for a service category for a year (beginning with 2010 and ending with 2011) may be less than -0.07, but may not be less than -0.14.CommentsClose CommentsPermalink
`(9) NO UPDATE FOR SERVICE CATEGORIES BEGINNING WITH 2013- The update to the conversion factor for each of the service categories established under paragraph (8) for 2013 and each succeeding year shall be 0 percent.'.CommentsClose CommentsPermalink
(d) Application of Separate Target Growth Rates for Each Category-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1848(f) of the Social Security Act (
`(5) APPLICATION OF SEPARATE TARGET GROWTH RATES FOR EACH SERVICE CATEGORY BEGINNING WITH 2008- The target growth rate for a year beginning with 2008 shall be computed and applied separately under this subsection for each service category (as defined in subsection (j)(5)) and shall be computed using the same method for computing the sustainable growth rate except for the following:CommentsClose CommentsPermalink
`(A) The reference in paragraphs (2)(A) and (2)(D) to `all physicians' services' is deemed a reference to the physicians' services included in such category but shall not take into account items and services included in physicians' services through the operation of paragraph (4)(A).CommentsClose CommentsPermalink
`(B) The factor described in paragraph (2)(C) for the service category described in subsection (j)(5)(A) shall be increased by 0.025.CommentsClose CommentsPermalink
`(C) A national coverage determination (as defined in section 1869(f)(1)(B)) shall be treated as a change in regulation described in paragraph (2)(D).'.CommentsClose CommentsPermalink
(2) USE OF TARGET GROWTH RATES- Section 1848 of such Act is further amended--CommentsClose CommentsPermalink
(A) in subsection (d)--CommentsClose CommentsPermalink
(i) in paragraph (1)(E)(ii), by inserting `or target' after `sustainable'; andCommentsClose CommentsPermalink
(ii) in paragraph (4)(B)(ii)(II), by inserting `or target' after `sustainable'; andCommentsClose CommentsPermalink
(B) in subsection (f)--CommentsClose CommentsPermalink
(i) in the heading by inserting `; Target Growth Rate' after `Sustainable Growth Rate';CommentsClose CommentsPermalink
(ii) in paragraph (1)--CommentsClose CommentsPermalink
(I) by striking `and' at the end of subparagraph (A);CommentsClose CommentsPermalink
(II) in subparagraph (B), by inserting `before 2008' after `each succeeding year' and by striking the period at the end and inserting `; and'; andCommentsClose CommentsPermalink
(III) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(C) November 1 of each succeeding year the target growth rate for such succeeding year and each of the 2 preceding years.'; andCommentsClose CommentsPermalink
(iii) in paragraph (2), in the matter before subparagraph (A), by inserting after `beginning with 2000' the following: `and ending with 2007'.CommentsClose CommentsPermalink
(e) Reports on Expenditures for Part B Drugs and Clinical Diagnostic Laboratory Tests-CommentsClose CommentsPermalink
(1) REPORTING REQUIREMENT- The Secretary of Health and Human Services shall include information in the annual physician fee schedule proposed rule on the change in the annual rate of growth of actual expenditures for clinical diagnostic laboratory tests or drugs, biologicals, and radiopharmaceuticals for which payment is made under part B of title XVIII of the Social Security Act.CommentsClose CommentsPermalink
(2) RECOMMENDATIONS- The report submitted under paragraph (1) shall include an analysis of the reasons for such excess expenditures and recommendations for addressing them in the future.CommentsClose CommentsPermalink
SEC. 302. IMPROVING ACCURACY OF RELATIVE VALUES UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE.
(a) Use of Expert Panel to Identify Misvalued Physicians' Services- Section 1848(c) of the Social Security Act (
`(7) USE OF EXPERT PANEL TO IDENTIFY MISVALUED PHYSICIANS' SERVICES-CommentsClose CommentsPermalink
`(A) IN GENERAL- The Secretary shall establish an expert panel (in this paragraph referred to as the `expert panel')--CommentsClose CommentsPermalink
`(i) to identify, through data analysis, physicians' services for which the relative value under this subsection is potentially misvalued, particularly those services for which such relative value may be overvalued;CommentsClose CommentsPermalink
`(ii) to assess whether those misvalued services warrant review using existing processes (referred to in paragraph (2)(J)(ii)) for the consideration of coding changes; andCommentsClose CommentsPermalink
`(iii) to advise the Secretary concerning the exercise of authority under clauses (ii)(III) and (vi) of paragraph (2)(B).CommentsClose CommentsPermalink
`(B) COMPOSITION OF PANEL- The expert panel shall be appointed by the Secretary and composed of--CommentsClose CommentsPermalink
`(i) members with expertise in medical economics and technology diffusion;CommentsClose CommentsPermalink
`(ii) members with clinical expertise;CommentsClose CommentsPermalink
`(iii) physicians, particularly physicians (such as a physician employed by the Veterans Administration or a physician who has a full time faculty appointment at a medical school) who are not directly affected by changes in the physician fee schedule under this section;CommentsClose CommentsPermalink
`(iv) carrier medical directors; andCommentsClose CommentsPermalink
`(v) representatives of private payor health plans.CommentsClose CommentsPermalink
`(C) APPOINTMENT CONSIDERATIONS- In appointing members to the expert panel, the Secretary shall assure racial and ethnic diversity on the panel and may consider appointing a liaison from organizations with experience in the consideration of coding changes to the panel.'.CommentsClose CommentsPermalink
(b) Examination of Services With Substantial Changes- Such section is further amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(8) EXAMINATION OF SERVICES WITH SUBSTANTIAL CHANGES- The Secretary, in consultation with the expert panel under paragraph (7), shall--CommentsClose CommentsPermalink
`(A) conduct a five-year review of physicians' services in conjunction with the RUC 5-year review, particularly for services that have experienced substantial changes in length of stay, site of service, volume, practice expense, or other factors that may indicate changes in physician work;CommentsClose CommentsPermalink
`(B) identify new services to determine if they are likely to experience a reduction in relative value over time and forward a list of the services so identified for such five-year review; andCommentsClose CommentsPermalink
`(C) for physicians' services that are otherwise unreviewed under the process the Secretary has established, periodically review a sample of relative value units within different types of services to assess the accuracy of the relative values contained in the Medicare physician fee schedule.'.CommentsClose CommentsPermalink
(c) Authority to Reduce Work Component for Services With Accelerated Volume Growth-CommentsClose CommentsPermalink
(1) IN GENERAL- Paragraph (2)(B) of such section is amended--CommentsClose CommentsPermalink
(A) in clause (v), by adding at the end the following new subclause:CommentsClose CommentsPermalink
`(III) REDUCTIONS IN WORK VALUE UNITS FOR SERVICES WITH ACCELERATED VOLUME GROWTH- Effective January 1, 2009, reduced expenditures attributable to clause (vi).'; andCommentsClose CommentsPermalink
(B) by adding at the end the following new clauses:CommentsClose CommentsPermalink
`(vi) AUTHORIZING REDUCTION IN WORK VALUE UNITS FOR SERVICES WITH ACCELERATED VOLUME GROWTH- The Secretary may provide (without using existing processes the Secretary has established for review of relative value) for a reduction in the work value units for a particular physician's service if the annual rate of growth in the expenditures for such service for which payment is made under this part for individuals for 2006 or a subsequent year exceeds the average annual rate of growth in expenditures of all physicians' services for which payment is made under this part by more than 10 percentage points for such year.CommentsClose CommentsPermalink
`(vii) CONSULTATION WITH EXPERT PANEL AND BASED ON CLINICAL EVIDENCE- The Secretary shall exercise authority under clauses (ii)(III) and (vi) in consultation with the expert panel established under paragraph (7) and shall take into account clinical evidence supporting or refuting the merits of such accelerated growth.'.CommentsClose CommentsPermalink
(2) EFFECTIVE DATE- The amendments made by paragraph (1) shall apply with respect to payment for services furnished on or after January 1, 2009.CommentsClose CommentsPermalink
(d) Adjustment Authority for Efficiency Gains for New Procedures- Paragraph (2)(B)(ii) of such section is amended by adding at the end the following new subclause:CommentsClose CommentsPermalink
`(III) ADJUSTMENT AUTHORITY FOR EFFICIENCY GAINS FOR NEW PROCEDURES- In carrying out subclauses (I) and (II), the Secretary may apply a methodology, based on supporting evidence, under which there is imposed a reduction over a period of years in specified relative value units in the case of a new (or newer) procedure to take into account inherent efficiencies that are typically or likely to be gained during the period of initial increased application of the procedure.'.CommentsClose CommentsPermalink
SEC. 303. FEEDBACK MECHANISM ON PRACTICE PATTERNS.
By not later than July 1, 2008, the Secretary of Health and Human Services shall develop and implement a mechanism to measure resource use on a per capita and an episode basis in order to provide confidential feedback to physicians in the Medicare program on how their practice patterns compare to physicians generally, both in the same locality as well as nationally. Such feedback shall not be subject to disclosure under
SEC. 304. PAYMENTS FOR EFFICIENT AREAS.
Section 1833 of the Social Security Act (
`(v) Incentive Payments for Efficient Areas-CommentsClose CommentsPermalink
`(1) IN GENERAL- In the case of services furnished under the physician fee schedule under section 1848 on or after January 1, 2009, and before January 1, 2011, by a supplier that is paid under such fee schedule in an efficient area (as identified under paragraph (2)), in addition to the amount of payment that would otherwise be made for such services under this part, there also shall be paid an amount equal to 5 percent of the payment amount for the services under this part.CommentsClose CommentsPermalink
`(2) IDENTIFICATION OF EFFICIENT AREAS-CommentsClose CommentsPermalink
`(A) IN GENERAL- Based upon available data, the Secretary shall identify those counties or equivalent areas in the United States in the lowest fifth percentile of utilization based on per capita spending for services provided in 2007 under this part and part A as standardized to eliminate the effect of geographic adjustments in payment rates.CommentsClose CommentsPermalink
`(B) IDENTIFICATION OF COUNTIES WHERE SERVICE IS FURNISHED.- For purposes of paying the additional amount specified in paragraph (1), if the Secretary uses the 5-digit postal ZIP Code where the service is furnished, the dominant county of the postal ZIP Code (as determined by the United States Postal Service, or otherwise) shall be used to determine whether the postal ZIP Code is in a county described in subparagraph (A).CommentsClose CommentsPermalink
`(C) JUDICIAL REVIEW- There shall be no administrative or judicial review under section 1869, 1878, or otherwise, respecting--CommentsClose CommentsPermalink
`(i) the identification of a county or other area under subparagraph (A); orCommentsClose CommentsPermalink
`(ii) the assignment of a postal ZIP Code to a county or other area under subparagraph (B).CommentsClose CommentsPermalink
`(D) PUBLICATION OF LIST OF COUNTIES; POSTING ON WEBSITE- With respect to a year for which a county or area is identified under this paragraph, the Secretary shall identify such counties or areas as part of the proposed and final rule to implement the physician fee schedule under section 1848 for the applicable year. The Secretary shall post the list of counties identified under this paragraph on the Internet website of the Centers for Medicare & Medicaid Services.'.CommentsClose CommentsPermalink
SEC. 305. RECOMMENDATIONS ON REFINING THE PHYSICIAN FEE SCHEDULE.
(a) Recommendations on Consolidated Coding for Services Commonly Performed Together- Not later than December 31, 2008, the Comptroller General of the United States shall--CommentsClose CommentsPermalink
(1) complete an analysis of codes paid under the Medicare physician fee schedule to determine whether the codes for procedures that are commonly furnished together should be combined; andCommentsClose CommentsPermalink
(2) submit to Congress a report on such analysis and include in the report recommendations on whether an adjustment should be made to the relative value units for such combined code.CommentsClose CommentsPermalink
(b) Recommendations on Increased Use of Bundled Payments- Not later than December 31, 2008, the Comptroller General of the United States shall--CommentsClose CommentsPermalink
(1) complete an analysis of those procedures under the Medicare physician fee schedule for which no global payment methodology is applied but for which a `bundled' payment methodology would be appropriate; andCommentsClose CommentsPermalink
(2) submit to Congress a report on such analysis and include in the report recommendations on increasing the use of `bundled' payment methodology under such schedule.CommentsClose CommentsPermalink
(c) Medicare Physician Fee Schedule- In this section, the term `Medicare physician fee schedule' means the fee schedule established under section 1848 of the Social Security Act (
SEC. 306. IMPROVED AND EXPANDED MEDICAL HOME DEMONSTRATION PROJECT.
(a) In General- The Secretary of Health and Human Services (in this section referred to as the `Secretary') shall establish under title XVIII of the Social Security Act an expanded medical home demonstration project (in this section referred to as the `expanded project') under this section. The expanded project supersedes the project that was initiated under section 204 of the Medicare Improvement and Extension Act of 2006 (division B of
(1) to guide the redesign of the health care delivery system to provide accessible, continuous, comprehensive, and coordinated, care to Medicare beneficiaries; andCommentsClose CommentsPermalink
(2) to provide care management fees to personal physicians delivering continuous and comprehensive care in qualified medical homes.CommentsClose CommentsPermalink
(b) Nature and Scope of Project-CommentsClose CommentsPermalink
(1) DURATION; SCOPE- The expanded project shall operate during a period of three years, beginning not later than October 1, 2009, and shall include a nationally representative sample of physicians serving urban, rural, and underserved areas throughout the United States.CommentsClose CommentsPermalink
(2) ENCOURAGING PARTICIPATION OF SMALL PHYSICIAN PRACTICES-CommentsClose CommentsPermalink
(A) IN GENERAL- The expanded project shall be designed to include the participation of physicians in practices with fewer than four full-time equivalent physicians, as well as physicians in larger practices particularly in rural and underserved areas.CommentsClose CommentsPermalink
(B) TECHNICAL ASSISTANCE- In order to facilitate the participation under the expanded project of physicians in such practices, the Secretary shall make available additional technical assistance to such practices during the first year of the expanded project.CommentsClose CommentsPermalink
(3) SELECTION OF HOMES TO PARTICIPATE- The Secretary shall select up to 500 medical homes to participate in the expanded project and shall give priority to--CommentsClose CommentsPermalink
(A) the selection of up to 100 HIT-enhanced medical homes; andCommentsClose CommentsPermalink
(B) the selection of other medical homes that serve communities whose populations are at higher risk for health disparities.CommentsClose CommentsPermalink
(4) BENEFICIARY PARTICIPATION- The Secretary shall establish a process for any Medicare beneficiary who is served by a medical home participating in the expanded project to elect to participate in the project. Each beneficiary who elects to so participate shall be eligible--CommentsClose CommentsPermalink
(A) for enhanced medical home services under the project with no cost sharing for the additional services; andCommentsClose CommentsPermalink
(B) for a reduction of up to 50 percent in the coinsurance for services furnished under the physician fee schedule under section 1848 of the Social Security Act by the medical home.CommentsClose CommentsPermalink
The Secretary shall develop standard recruitment materials and election processes for Medicare beneficiaries who are electing to participate in the expanded project.CommentsClose CommentsPermalink
(c) Standards for Medical Homes, HIT-Enhanced Medical Homes-CommentsClose CommentsPermalink
(1) STANDARD SETTING AND CERTIFICATION PROCESS- The Secretary shall establish a process for selection of a qualified standard setting and certification organization--CommentsClose CommentsPermalink
(A) to establish standards, consistent with this section, for medical practices to qualify as medical homes or as HIT-enhanced medical homes; andCommentsClose CommentsPermalink
(B) to provide for the review and certification of medical practices as meeting such standards.CommentsClose CommentsPermalink
(2) BASIC STANDARDS FOR MEDICAL HOMES- For purposes of this subsection, the term `medical home' means a physician-directed practice that has been certified, under paragraph (1), as meeting the following standards:CommentsClose CommentsPermalink
(A) ACCESS AND COMMUNICATION WITH PATIENTS- The practice applies standards for access to care and communication with participating beneficiaries.CommentsClose CommentsPermalink
(B) MANAGING PATIENT INFORMATION AND USING INFORMATION IN MANAGEMENT TO SUPPORT PATIENT CARE- The practice has readily accessible, clinically useful information on participating beneficiaries that enables the practice to treat such beneficiaries comprehensively and systematically.CommentsClose CommentsPermalink
(C) MANAGING AND COORDINATING CARE ACCORDING TO INDIVIDUAL NEEDS- The practice maintains continuous relationships with participating beneficiaries by implementing evidence-based guidelines and applying them to the identified needs of individual beneficiaries over time and with the intensity needed by such beneficiaries.CommentsClose CommentsPermalink
(D) PROVIDING ONGOING ASSISTANCE AND ENCOURAGEMENT IN PATIENT SELF-MANAGEMENT- The practice--CommentsClose CommentsPermalink
(i) collaborates with participating beneficiaries to pursue their goals for optimal achievable health; andCommentsClose CommentsPermalink
(ii) assesses patient-specific barriers to communication and conducts activities to support patient self-management.CommentsClose CommentsPermalink
(E) RESOURCES TO MANAGE CARE- The practice has in place the resources and processes necessary to achieve improvements in the management and coordination of care for participating beneficiaries.CommentsClose CommentsPermalink
(F) MONITORING PERFORMANCE- The practice monitors its clinical process and performance (including outcome measures) in meeting the applicable standards under this subsection and provides information in a form and manner specified by the Secretary with respect to such process and performance.CommentsClose CommentsPermalink
(3) ADDITIONAL STANDARDS FOR HIT-ENHANCED MEDICAL HOME- For purposes of this subsection, the term `HIT-enhanced medical home' means a medical home that has been certified, under paragraph (1), as using a health information technology system that includes at least the following elements:CommentsClose CommentsPermalink
(A) ELECTRONIC HEALTH RECORD (EHR)- The system uses, for participating beneficiaries, an electronic health record that meets the following standards:CommentsClose CommentsPermalink
(i) The record--CommentsClose CommentsPermalink
(I) has the capability of interoperability with secure data acquisition from health information technology systems of other health care providers in the area served by the home; orCommentsClose CommentsPermalink
(II) the capability to securely acquire clinical data delivered by such other health care providers to a secure common data source.CommentsClose CommentsPermalink
(ii) The record protects the privacy and security of health information.CommentsClose CommentsPermalink
(iii) The record has the capability to acquire, manage, and display all the types of clinical information commonly relevant to services furnished by the medical home, such as complete medical records, radiographic image retrieval, and clinical laboratory information.CommentsClose CommentsPermalink
(iv) The record is integrated with decision support capacities that facilitate the use of evidence-based medicine and clinical decision support tools to guide decision-making at the point-of-care based on patient-specific factors.CommentsClose CommentsPermalink
(B) E-PRESCRIBING- The system supports e-prescribing and computerized physician order entry.CommentsClose CommentsPermalink
(C) OUTCOME MEASUREMENT- The system supports the secure, confidential provision of clinical process and outcome measures approved by the National Quality Forum to the Secretary for use in confidential manner for provider feedback and peer review and for outcomes and clinical effectiveness research.CommentsClose CommentsPermalink
(D) PATIENT EDUCATION CAPABILITY- The system actively facilitates participating beneficiaries engaging in the management of their own health through education and support systems and tools for shared decision-making.CommentsClose CommentsPermalink
(E) SUPPORT OF BASIC STANDARDS- The elements of such system, such as the electronic health record, email communications, patient registries, and clinical-decision support tools, are integrated in a manner to better achieve the basic standards specified in paragraph (2) for a medical home.CommentsClose CommentsPermalink
(4) USE OF DATA- The Secretary shall use the data submitted under paragraph (1)(F) in a confidential manner for feedback and peer review for medical homes and for outcomes and clinical effectiveness research. After the first two years of the expanded project, these data may be used for adjustment in the monthly medical home care management fee under subsection (d)(2)(E).CommentsClose CommentsPermalink
(d) Monthly Medical Home Care Management Fee-CommentsClose CommentsPermalink
(1) IN GENERAL- Under the expanded project, the Secretary shall provide for payment to the personal physician of each participating beneficiary of a monthly medical home care management fee.CommentsClose CommentsPermalink
(2) AMOUNT OF PAYMENT- In determining the amount of such fee, the Secretary shall consider the following:CommentsClose CommentsPermalink
(A) OPERATING EXPENSES- The additional practice expenses for the delivery of services through a medical home, taking into account the additional expenses for an HIT-enhanced medical home. Such expenses include costs associated with--CommentsClose CommentsPermalink
(i) structural expenses, such as equipment, maintenance, and training costs;CommentsClose CommentsPermalink
(ii) enhanced access and communication functions;CommentsClose CommentsPermalink
(iii) population management and registry functions;CommentsClose CommentsPermalink
(iv) patient medical data and referral tracking functions;CommentsClose CommentsPermalink
(v) provision of evidence-based care;CommentsClose CommentsPermalink
(vi) implementation and maintenance of health information technology;CommentsClose CommentsPermalink
(vii) reporting on performance and improvement conditions; andCommentsClose CommentsPermalink
(viii) patient education and patient decision support, including print and electronic patient education materials.CommentsClose CommentsPermalink
(B) ADDED VALUE SERVICES- The value of additional physician work, such as augmented care plan oversight, expanded e-mail and telephonic consultations, extended patient medical data review (including data stored and transmitted electronically), and physician supervision of enhanced self management education, and expanded follow-up accomplished by non-physician personnel, in a medical home that is not adequately taken into account in the establishment of the physician fee schedule under section 1848 of the Social Security Act.CommentsClose CommentsPermalink
(C) RISK ADJUSTMENT- The development of an appropriate risk adjustment mechanism to account for the varying costs of medical homes based upon characteristics of participating beneficiaries.CommentsClose CommentsPermalink
(D) HIT ADJUSTMENT- Variation of the fee based on the extensiveness of use of the health information technology in the medical home.CommentsClose CommentsPermalink
(E) PERFORMANCE-BASED- After the first two years of the expanded project, an adjustment of the fee based on performance of the medical home in achieving quality or outcomes standards.CommentsClose CommentsPermalink
(3) PERSONAL PHYSICIAN DEFINED- For purposes of this subsection, the term `personal physician' means, with respect to a participating Medicare beneficiary, a physician (as defined in section 1861(r)(1) of the Social Security Act (
(e) Funding-CommentsClose CommentsPermalink
(1) USE OF CURRENT PROJECT FUNDING- Funds otherwise applied to the demonstration under section 204 of the Medicare Improvement and Extension Act of 2006 (division B of
(2) ADDITIONAL FUNDING FROM SMI TRUST FUND-CommentsClose CommentsPermalink
(A) IN GENERAL- In addition to the funds provided under paragraph (1), there shall be available, from the Federal Supplementary Medical Insurance Trust Fund (under section 1841 of the Social Security Act), the amount of $500,000,000 to carry out the expanded project, including payments to of monthly medical home care management fees under subsection (d), reductions in coinsurance for participating beneficiaries under subsection (b)(4)(B), and funds for the design, implementation, and evaluation of the expanded project.CommentsClose CommentsPermalink
(B) MONITORING EXPENDITURES; EARLY TERMINATION- The Secretary shall monitor the expenditures under the expanded project and may terminate the project early in order that expenditures not exceed the amount of funding provided for the project under subparagraph (A).CommentsClose CommentsPermalink
(f) Evaluations and Reports-CommentsClose CommentsPermalink
(1) ANNUAL INTERIM EVALUATIONS AND REPORTS- For each year of the expanded project, the Secretary shall provide for an evaluation of the project and shall submit to Congress, by a date specified by the Secretary, a report on the project and on the evaluation of the project for each such year.CommentsClose CommentsPermalink
(2) FINAL EVALUATION AND REPORT- The Secretary shall provide for an evaluation of the expanded project and shall submit to Congress, not later than 18 months after the date of completion of the project, a report on the project and on the evaluation of the project.CommentsClose CommentsPermalink
SEC. 307. REPEAL OF PHYSICIAN ASSISTANCE AND QUALITY INITIATIVE FUND.
Subsection (l) of section 1848 of the Social Security Act (
SEC. 308. ADJUSTMENT TO MEDICARE PAYMENT LOCALITIES.
Section 1848(e) of the Social Security Act (42 U.S.C.1395w-4(e)) is amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(6) FEE SCHEDULE GEOGRAPHIC AREAS-CommentsClose CommentsPermalink
`(A) IN GENERAL-CommentsClose CommentsPermalink
`(i) REVISION- Subject to clause (ii), for services furnished on or after January 1, 2008, the Secretary shall revise the fee schedule areas used for payment under this section applicable to the State of California using the county-based geographic adjustment factor as specified in option 3 (table 9) in the proposed rule for the 2008 physician fee schedule published at 72 Fed. Reg. 38,122 (July 12, 2007).CommentsClose CommentsPermalink
`(ii) TRANSITION- For services furnished during the period beginning January 1, 2008, and ending December 31, 2010, after calculating the work, practice expense, and malpractice geographic indices described in clauses (i), (ii), and (iii) of paragraph (1)(A) that would otherwise apply, the Secretary shall increase any such geographic index for any county in California that is lower than the geographic index used for payment for services under this section as of December 31, 2007, in such county to such geographic index level.CommentsClose CommentsPermalink
`(B) SUBSEQUENT REVISIONS-CommentsClose CommentsPermalink
`(i) TIMING- Not later than January 1, 2011, the Secretary shall review and make revisions to fee schedule areas in all States for which more than one fee schedule area is used for payment of services under this section. The Secretary may revise fee schedule areas in States in which a single fee schedule area is used for payment for services under this section using the same methodology applied in the previous sentence.CommentsClose CommentsPermalink
`(ii) LINK WITH GEOGRAPHIC INDEX DATA REVISION- The revision described in clause (i) shall be made effective concurrently with the application of the periodic review of geographic adjustment factors required under paragraph (1)(C) for 2011 and subsequent periods.'.CommentsClose CommentsPermalink
SEC. 309. PAYMENT FOR IMAGING SERVICES.
(a) Payment Under Part B of the Medicare Program for Diagnostic Imaging Services Furnished in Facilities Conditioned on Accreditation of Facilities-CommentsClose CommentsPermalink
(1) SPECIAL PAYMENT RULE-CommentsClose CommentsPermalink
(A) IN GENERAL- Section 1848(b)(4) of the Social Security Act (
(i) in the heading, by striking `RULE' and inserting `RULES';CommentsClose CommentsPermalink
(ii) in subparagraph (A), by striking `IN GENERAL' and inserting `LIMITATION'; andCommentsClose CommentsPermalink
(iii) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(C) PAYMENT ONLY FOR SERVICES PROVIDED IN ACCREDITED FACILITIES-CommentsClose CommentsPermalink
`(i) IN GENERAL- In the case of imaging services that are diagnostic imaging services described in clause (ii), the payment amount for the technical component and the professional component of the services established for a year under the fee schedule described in paragraph (1) shall each be zero, unless the services are furnished at a diagnostic imaging services facility that meets the certificate requirement described in section 354(b)(1) of the Public Health Service Act, as applied under subsection (m). The previous sentence shall not apply with respect to the technical component if the imaging equipment meets certification standards and the professional component of a diagnostic imaging service that is furnished by a physician.CommentsClose CommentsPermalink
`(ii) DIAGNOSTIC IMAGING SERVICES- For purposes of clause (i) and subsection (m), the term `diagnostic imaging services' means all imaging modalities, including diagnostic magnetic resonance imaging (`MRI'), computed tomography (`CT'), positron emission tomography (`PET'), nuclear medicine procedures, x-rays, sonograms, ultrasounds, echocardiograms, and such emerging diagnostic imaging technologies as specified by the Secretary.'.CommentsClose CommentsPermalink
(B) EFFECTIVE DATE-CommentsClose CommentsPermalink
(i) IN GENERAL- Subject to clause (ii), the amendments made by subparagraph (A) shall apply to diagnostic imaging services furnished on or after January 1, 2010.CommentsClose CommentsPermalink
(ii) EXTENSION FOR ULTRASOUND SERVICES- The amendments made by subparagraph (A) shall apply to diagnostic imaging services that are ultrasound services on or after January 1, 2012.CommentsClose CommentsPermalink
(2) CERTIFICATION OF FACILITIES THAT FURNISH DIAGNOSTIC IMAGING SERVICES- Section 1848 of the Social Security Act (
`(m) Certification of Facilities That Furnish Diagnostic Imaging Services-CommentsClose CommentsPermalink
`(1) IN GENERAL- For purposes of subsection (b)(4)(C)(i), except as provided under paragraphs (2) through (8), the provisions of section 354 of the Public Health Service Act (as in effect as of June 1, 2007), relating to the certification of mammography facilities, shall apply, with respect to the provision of diagnostic imaging services (as defined in subsection (b)(4)(C)(ii)) and to a diagnostic imaging services facility defined in paragraph (8) (and to the process of accrediting such facilities) in the same manner that such provisions apply, with respect to the provision of mammograms and to a facility defined in subsection (a)(3) of such section (and to the process of accrediting such mammography facilities).CommentsClose CommentsPermalink
`(2) TERMINOLOGY AND REFERENCES- For purposes of applying section 354 of the Public Health Service Act under paragraph (1)--CommentsClose CommentsPermalink
`(A) any reference to `mammography', or `breast imaging' is deemed a reference to `diagnostic imaging services (as defined in section 1848(b)(4)(C)(ii) of the Social Security Act)';CommentsClose CommentsPermalink
`(B) any reference to a mammogram or film is deemed a reference to an image, as defined in paragraph (8);CommentsClose CommentsPermalink
`(C) any reference to `mammography facility' or to a `facility' under such section 354 is deemed a reference to a diagnostic imaging services facility, as defined in paragraph (8);CommentsClose CommentsPermalink
`(D) any reference to radiological equipment used to image the breast is deemed a reference to medical imaging equipment used to provide diagnostic imaging services;CommentsClose CommentsPermalink
`(E) any reference to radiological procedures or radiological is deemed a reference to medical imaging services, as defined in paragraph (8) or medical imaging, respectively;CommentsClose CommentsPermalink
`(F) any reference to an inspection (as defined in subsection (a)(4) of such section) or inspector is deemed a reference to an audit (as defined in paragraph (8)) or auditor, respectively;CommentsClose CommentsPermalink
`(G) any reference to a medical physicist (as described in subsection (f)(1)(E) of such section) is deemed to include a reference to a magnetic resonance scientist or the appropriate qualified expert as determined by the accrediting body;CommentsClose CommentsPermalink
`(H) in applying subsection (d)(1)(A)(i) of such section, the reference to `type of each x-ray machine, image receptor, and processor' is deemed a reference to `type of imaging equipment';CommentsClose CommentsPermalink
`(I) in applying subsection (d)(1)(B) of such section, the reference that `the person or agent submits to the Secretary' is deemed a reference that `the person or agent submits to the Secretary, through the appropriate accreditation body';CommentsClose CommentsPermalink
`(J) in applying subsection (d)(1)(B)(i) of such section, the reference to standards established by the Secretary is deemed a reference to standards established by an accreditation body and approved by the Secretary;CommentsClose CommentsPermalink
`(K) in applying subsection (e) of such section, relating to an accreditation body--CommentsClose CommentsPermalink
`(i) in paragraph (1)(A), the reference to `may' is deemed a reference to `shall';CommentsClose CommentsPermalink
`(ii) in paragraph (1)(B)(i)(II), the reference to `a random sample of clinical images from such facilities' is deemed a reference to `a statistically significant random sample of clinical images from a statistically significant random sample of facilities';CommentsClose CommentsPermalink
`(iii) in paragraph (3)(A) of such section--CommentsClose CommentsPermalink
`(I) the reference to `paragraph (1)(B)' in such subsection is deemed to be a reference to `paragraph (1)(B) and subsection (f)'; andCommentsClose CommentsPermalink
`(II) the reference to the `Secretary' is deemed a reference to `an accreditation body, with the approval of the Secretary'; andCommentsClose CommentsPermalink
`(iv) in paragraph (6)(B), the reference to the Committee on Labor and Human Resources of the Senate is deemed to be the Committee on Finance of the Senate and the reference to the Committee on Energy and Commerce of the House of Representatives is deemed to include a reference to the Committee on Ways and Means of the House of Representatives;CommentsClose CommentsPermalink
`(L) in applying subsection (f), relating to quality standards--CommentsClose CommentsPermalink
`(i) each reference to standards established by the Secretary is deemed a reference to standards established by an accreditation body involved and approved by the Secretary under subsection (d)(1)(B)(i) of such section;CommentsClose CommentsPermalink
`(ii) in paragraph (1)(A), the reference to `radiation dose' is deemed a reference to `radiation dose, as appropriate';CommentsClose CommentsPermalink
`(iii) in paragraph (1)(B), the reference to `radiological standards' is deemed a reference to `medical imaging standards, as appropriate';CommentsClose CommentsPermalink
`(iv) in paragraphs (1)(D)(ii) and (1)(E)(iii), the reference to `the Secretary' is deemed a reference to `an accreditation body with the approval of the Secretary';CommentsClose CommentsPermalink
`(v) in each of subclauses (III) and (IV) of paragraph (1)(G)(ii), each reference to `patient' is deemed a reference to `patient, if requested by the patient'; andCommentsClose CommentsPermalink
`(M) in applying subsection (g), relating to inspections--CommentsClose CommentsPermalink
`(i) each reference to the `Secretary or State or local agency acting on behalf of the Secretary' is deemed to include a reference to an accreditation body involved;CommentsClose CommentsPermalink
`(ii) in the first sentence of paragraph (1)(F), the reference to `annual inspections required under this paragraph' is deemed a reference to `the audits carried out in facilities at least every three years from the date of initial accreditation under this paragraph'; andCommentsClose CommentsPermalink
`(iii) in the second sentence of paragraph (1)(F), the reference to `inspections carried out under this paragraph' is deemed a reference to `audits conducted under this paragraph during the previous year'.CommentsClose CommentsPermalink
`(3) DATES AND PERIODS- For purposes of paragraph (1), in applying section 354 of the Public Health Service Act, the following applies:CommentsClose CommentsPermalink
`(A) IN GENERAL- Except as provided in subparagraph (B)--CommentsClose CommentsPermalink
`(i) any reference to `October 1, 1994' shall be deemed a reference to `January 1, 2010';CommentsClose CommentsPermalink
`(ii) the reference to `the date of the enactment of this section' in each of subsections (e)(1)(D) and (f)(1)(E)(iii) is deemed to be a reference to `the date of the enactment of the Children's Health and Medicare Protection Act of 2007';CommentsClose CommentsPermalink
`(iii) the reference to `annually' in subsection (g)(1)(E) is deemed a reference to `every three years';CommentsClose CommentsPermalink
`(iv) the reference to `October 1, 1996' in subsection (l) is deemed to be a reference to `January 1, 2011';CommentsClose CommentsPermalink
`(v) the reference to `October 1, 1999' in subsection (n)(3)(H) is deemed to be a reference to `January 1, 2012'; andCommentsClose CommentsPermalink
`(vi) the reference to `October 1, 1993' in the matter following paragraph (3)(J) of subsection (n) is deemed to be a reference `January 1, 2010'.CommentsClose CommentsPermalink
`(B) ULTRASOUND SERVICES- With respect to diagnostic imaging services that are ultrasounds--CommentsClose CommentsPermalink
`(i) any reference to `October 1, 1994' shall be deemed a reference to `January 1, 2012';CommentsClose CommentsPermalink
`(ii) the reference to `the date of the enactment of this section' in subsection (f)(1)(E)(iii) is deemed to be a reference to `7 years after the date of the enactment of the Children's Health and Medicare Protection Act of 2007';CommentsClose CommentsPermalink
`(iii) the reference to `October 1, 1996' in subsection (l) is deemed to be a reference to `January 1, 2013';CommentsClose CommentsPermalink
`(4) PROVISIONS NOT APPLICABLE- For purposes of paragraph (1), in applying section 354 of the Public Health Service Act, the following provision shall not apply:CommentsClose CommentsPermalink
`(A) Subsections (e) and (f) of such section, in so far as the respective subsection imposes any requirement for a physician to be certified, accredited, or otherwise meet requirements, with respect to the provision of any diagnostic imaging services, as a condition of payment under subsection (b)(4)(C)(i), with respect to the professional or technical component, for such service.CommentsClose CommentsPermalink
`(B) Subsection (e)(1)(B)(v).CommentsClose CommentsPermalink
`(C) Subsection (f)(1)(H) of such section, relating to standards for special techniques for mammograms of patients with breast implants.CommentsClose CommentsPermalink
`(D) Subsection (g)(6) of such section, relating to an inspection demonstration program.CommentsClose CommentsPermalink
`(E) Subsection (n) of such section, relating to the national advisory committee.CommentsClose CommentsPermalink
`(F) Subsection (p) of such section, relating to breast cancer screening surveillance research grants.CommentsClose CommentsPermalink
`(G) Paragraphs (1)(B) and (2) of subsection (r) of such section, related to funding.CommentsClose CommentsPermalink
`(5) ACCREDITATION BODIES- For purposes of paragraph (1), in applying section 354(e)(1) of the Public Health Service, the following shall apply:CommentsClose CommentsPermalink
`(A) APPROVAL OF TWO ACCREDITATION BODIES FOR EACH TREATMENT MODALITY- In the case that there is more than one accreditation body for a treatment modality that qualifies for approval under this subsection, the Secretary shall approve at least two accreditation bodies for such treatment modality.CommentsClose CommentsPermalink
`(B) ADDITIONAL ACCREDITATION BODY STANDARDS- In addition to the standards described in subparagraph (B) of such section for accreditation bodies, the Secretary shall establish standards that require--CommentsClose CommentsPermalink
`(i) the timely integration of new technology by accreditation bodies for purposes of accrediting facilities under this subsection; andCommentsClose CommentsPermalink
`(ii) the accreditation body involved to evaluate the annual medical physicist survey (or annual medical survey of another appropriate qualified expert chosen by the accreditation body) of a facility upon onsite review of such facility.CommentsClose CommentsPermalink
`(6) ADDITIONAL QUALITY STANDARDS- For purposes of paragraph (1), in applying subsection (f)(1) of section 354 of the Public Health Service--CommentsClose CommentsPermalink
`(A) the quality standards under such subsection shall, with respect to a facility include--CommentsClose CommentsPermalink
`(i) standards for qualifications of medical personnel who are not physicians and who perform diagnostic imaging services at the facility that require such personnel to ensure that individuals, prior to performing medical imaging, demonstrate compliance with the standards established under subsection (a) through successful completion of certification by a nationally recognized professional organization, licensure, completion of an examination, pertinent coursework or degree program, verified pertinent experience, or through other ways determined appropriate by an accreditation body (with the approval of the Secretary, or through some combination thereof);CommentsClose CommentsPermalink
`(ii) standards requiring the facility to maintain records of the credentials of physicians and other medical personnel described in clause (i);CommentsClose CommentsPermalink
`(iii) standards for qualifications and responsibilities of medical directors and other personnel with supervising roles at the facility;CommentsClose CommentsPermalink
`(iv) standards that require the facility has procedures to ensure the safety of patients of the facility; andCommentsClose CommentsPermalink
`(v) standards for the establishment of a quality control program at the facility to be implemented as described in subparagraph (E) of such subsection;CommentsClose CommentsPermalink
`(B) the quality standards described in subparagraph (B) of such subsection shall be deemed to include standards that require the establishment and maintenance of a quality assurance and quality control program at each facility that is adequate and appropriate to ensure the reliability, clarity, and accuracy of the technical quality of diagnostic images produced at such facilities; andCommentsClose CommentsPermalink
`(C) the quality standard described in subparagraph (C) of such subsection, relating to a requirement for personnel who perform specified services, shall include in such requirement that such personnel must meet continuing medical education standards as specified by an accreditation body (with the approval of the Secretary) and update such standards at least once every three years.CommentsClose CommentsPermalink
`(7) ADDITIONAL REQUIREMENTS- Notwithstanding any provision of section 354 of the Public Health Service Act, the following shall apply to the accreditation process under this subsection for purposes of subsection (b)(4)(C)(i):CommentsClose CommentsPermalink
`(A) Any diagnostic imaging services facility accredited before January 1, 2010 (or January 1, 2012, in the case of ultrasounds), by an accrediting body approved by the Secretary shall be deemed a facility accredited by an approved accreditation body for purposes of such subsection as of such date if the facility submits to the Secretary proof of such accreditation by transmittal of the certificate of accreditation, including by electronic means.CommentsClose CommentsPermalink
`(B) The Secretary may require the accreditation under this subsection of an emerging technology used in the provision of a diagnostic imaging service as a condition of payment under subsection (b)(4)(C)(i) for such service at such time as the Secretary determines there is sufficient empirical and scientific information to properly carry out the accreditation process for such technology.CommentsClose CommentsPermalink
`(8) DEFINITIONS- For purposes of this subsection:CommentsClose CommentsPermalink
`(A) AUDIT- The term `audit' means an onsite evaluation, with respect to a diagnostic imaging services facility, by the Secretary, State or local agency on behalf of the Secretary, or accreditation body approved under this subsection that includes the following:CommentsClose CommentsPermalink
`(i) Equipment verification.CommentsClose CommentsPermalink
`(ii) Evaluation of policies and procedures for compliance with accreditation requirements.CommentsClose CommentsPermalink
`(iii) Evaluation of personnel qualifications and credentialing.CommentsClose CommentsPermalink
`(iv) Evaluation of the technical quality of images.CommentsClose CommentsPermalink
`(v) Evaluation of patient reports.CommentsClose CommentsPermalink
`(vi) Evaluation of peer-review mechanisms and other quality assurance activities.CommentsClose CommentsPermalink
`(vii) Evaluation of quality control procedures, results, and follow-up actions.CommentsClose CommentsPermalink
`(viii) Evaluation of medical physicists (or other appropriate professionals chosen by the accreditation body) and magnetic resonance scientist surveys.CommentsClose CommentsPermalink
`(ix) Evaluation of consumer complaint mechanisms.CommentsClose CommentsPermalink
`(x) Provision of recommendations for improvement based on findings with respect to clauses (i) through (ix).CommentsClose CommentsPermalink
`(B) DIAGNOSTIC IMAGING SERVICES FACILITY- The term `diagnostic imaging services facility' has the meaning given the term `facility' in section 354(a)(3) of the Public Health Service Act (
`(C) IMAGE- The term `image' means the portrayal of internal structures of the human body for the purpose of detecting and determining the presence or extent of disease or injury and may be produced through various techniques or modalities, including radiant energy or ionizing radiation and ultrasound and magnetic resonance. Such term does not include image guided procedures.CommentsClose CommentsPermalink
`(D) MEDICAL IMAGING SERVICE- The term `medical imaging service' means a service that involves the science of an image.'.CommentsClose CommentsPermalink
(b) Adjustment in Practice Expense to Reflect Higher Presumed Utilization- Section 1848 of the Social Security Act (
(1) in subsection (b)(4)--CommentsClose CommentsPermalink
(A) in subparagraph (B), by striking `subparagraph (A)' and inserting `this paragraph'; andCommentsClose CommentsPermalink
(B) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(D) ADJUSTMENT IN PRACTICE EXPENSE TO REFLECT HIGHER PRESUMED UTILIZATION- In computing the number of practice expense relative value units under subsection (c)(2)(C)(ii) with respect to imaging services described in subparagraph (B), the Secretary shall adjust such number of units so it reflects a 75 percent (rather than 50 percent) presumed rate of utilization of imaging equipment.'; andCommentsClose CommentsPermalink
(2) in subsection (c)(2)(B)(v)(II), by inserting `AND OTHER PROVISIONS' after `OPD PAYMENT CAP'.CommentsClose CommentsPermalink
(c) Adjustment in Technical Component `discount' on Single-Session Imaging to Consecutive Body Parts- Section 1848(b)(4) of such Act is further amended by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(E) ADJUSTMENT IN TECHNICAL COMPONENT DISCOUNT ON SINGLE-SESSION IMAGING INVOLVING CONSECUTIVE BODY PARTS- The Secretary shall increase the reduction in expenditures attributable to the multiple procedure payment reduction applicable to the technical component for imaging under the final rule published by the Secretary in the Federal Register on November 21, 2005 (42 CFR 405, et al.) from 25 percent to 50 percent.'.CommentsClose CommentsPermalink
(d) Adjustment in Assumed Interest Rate for Capital Purchases- Section 1848(b)(4) of such Act is further amended by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(F) ADJUSTMENT IN ASSUMED INTEREST RATE FOR CAPITAL PURCHASES- In computing the practice expense component for imaging services under this section, the Secretary shall change the interest rate assumption for capital purchases of imaging devices to reflect the prevailing rate in the market, but in no case higher than 11 percent.'.CommentsClose CommentsPermalink
(e) Disallowance of Global Billing- Effective for claims filed for imaging services (as defined in subsection (b)(4)(B) of section 1848 of the Social Security Act) furnished on or after the first day of the first month that begins more than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall not accept (or pay) a claim under such section unless the claim is made separately for each component of such services.CommentsClose CommentsPermalink
(f) Effective Date- Except as otherwise provided, this section, and the amendments made by this section, shall apply to services furnished on or after January 1, 2008.CommentsClose CommentsPermalink
SEC. 310. REDUCING FREQUENCY OF MEETINGS OF THE PRACTICING PHYSICIANS ADVISORY COUNCIL.
Section 1868(a)(2) of the Social Security Act (
TITLE IV--MEDICARE ADVANTAGE REFORMS
Subtitle A--Payment Reform
SEC. 401. EQUALIZING PAYMENTS BETWEEN MEDICARE ADVANTAGE PLANS AND FEE-FOR-SERVICE MEDICARE.
(a) Phase in of Payment Based on Fee-for-Service Costs- Section 1853 of the Social Security Act (
(1) in subsection (j)(1)(A)--CommentsClose CommentsPermalink
(A) by striking `beginning with 2007' and inserting `for 2007 and 2008'; andCommentsClose CommentsPermalink
(B) by inserting after `(k)(1)' the following: `, or, beginning with 2009, 1/12 of the blended benchmark amount determined under subsection (l)(1)'; andCommentsClose CommentsPermalink
(2) by adding at the end the following new subsection:CommentsClose CommentsPermalink
`(l) Determination of Blended Benchmark Amount-CommentsClose CommentsPermalink
`(1) IN GENERAL- For purposes of subsection (j), subject to paragraphs (2) and (3), the term `blended benchmark amount' means for an area--CommentsClose CommentsPermalink
`(A) for 2009 the sum of--CommentsClose CommentsPermalink
`(i) 2/3 of the applicable amount (as defined in subsection (k)(1)) for the area and year; andCommentsClose CommentsPermalink
`(ii) 1/3 of the amount specified in subsection (c)(1)(D)(i) for the area and year;CommentsClose CommentsPermalink
`(B) for 2010 the sum of--CommentsClose CommentsPermalink
`(i) 1/3 of the applicable amount for the area and year; andCommentsClose CommentsPermalink
`(ii) 2/3 of the amount specified in subsection (c)(1)(D)(i) for the area and year; andCommentsClose CommentsPermalink
`(C) for a subsequent year the amount specified in subsection (c)(1)(D)(i) for the area and year.CommentsClose CommentsPermalink
`(2) FEE-FOR-SERVICE PAYMENT FLOOR- In no case shall the blended benchmark amount for an area and year be less than the amount specified in subsection (c)(1)(D)(i) for the area and year.CommentsClose CommentsPermalink
`(3) EXCEPTION FOR PACE PLANS- This subsection shall not apply to payments to a PACE program under section 1894.'.CommentsClose CommentsPermalink
(b) Phase in of Payment Based on IME Costs-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1853(c)(1)(D)(i) of such Act (
(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply to the capitation rate for years beginning with 2009.CommentsClose CommentsPermalink
(c) Limitation on Plan Enrollment in Cases of Excess Bids for 2009 and 2010-CommentsClose CommentsPermalink
(1) IN GENERAL- In the case of a Medicare Part C organization that offers a Medicare Part C plan in the 50 States or the District of Columbia for which--CommentsClose CommentsPermalink
(A) bid amount described in paragraph (2) for a Medicare Part C plan for 2009 or 2010, exceedsCommentsClose CommentsPermalink
(B) the percent specified in paragraph (4) of the fee-for-service amount described in paragraph (3),CommentsClose CommentsPermalink
the Medicare Part C plan may not enroll any new enrollees in the plan during the annual, coordinated election period (under section 1851(e)(3)(B) of such Act (
(2) BID AMOUNT FOR PART A AND B SERVICES-CommentsClose CommentsPermalink
(A) IN GENERAL- Except as provided in subparagraph (B), the bid amount described in this paragraph is the unadjusted Medicare Part C statutory non-drug monthly bid amount (as defined in section 1854(b)(2)(E) of the Social Security Act (
(B) TREATMENT OF MSA PLANS- In the case of an MSA plan (as defined in section 1859(b)(3) of the Social Security Act,
(3) FEE-FOR-SERVICE AMOUNT DESCRIBED-CommentsClose CommentsPermalink
(A) IN GENERAL- Subject to subparagraph (B), the fee-for-service amount described in this paragraph for an Medicare Part C local area is the amount described in section 1853(c)(1)(D)(i) of the Social Security Act (
(B) TREATMENT OF MULTI-COUNTY PLANS- In the case of an MA plan the service area for which covers more than one Medicare Part C local area, the fee-for-service amount described in this paragraph is the amount described in section 1853(c)(1)(D)(i) of the Social Security Act for each such area served, weighted for each such area by the proportion of the enrollment of the plan that resides in the county (as determined based on amounts posted by the Administrator of the Centers for Medicare & Medicaid Services in the April bid notice for the year involved).CommentsClose CommentsPermalink
(4) PERCENTAGE PHASE DOWN- For purposes of paragraph (1), the percentage specified in this paragraph--CommentsClose CommentsPermalink
(A) for 2009 is 106 percent; andCommentsClose CommentsPermalink
(B) for 2010 is 103 percent.CommentsClose CommentsPermalink
(5) EXEMPTION OF AGE-INS- For purposes of paragraph (1), the term `new enrollee' with respect to a Medicare Part C plan offered by a Medicare Part C organization, does not include an individual who was enrolled in a plan offered by the organization in the month immediately before the month in which the individual was eligible to enroll in such a Medicare Part C plan offered by the organization.CommentsClose CommentsPermalink
(d) Annual Rebasing of Fee-for-Service Rates- Section 1853(c)(1)(D)(ii) of the Social Security Act (
(1) by inserting `(before 2009)' after `for subsequent years'; andCommentsClose CommentsPermalink
(2) by inserting before the period at the end the following: `and for each year beginning with 2009'.CommentsClose CommentsPermalink
(e) Repeal of PPO Stabilization Fund- Section 1858 of the Social Security Act (
(1) by striking subsection (e); andCommentsClose CommentsPermalink
(2) in subsection (f)(1), by striking `subject to subsection (e),'.CommentsClose CommentsPermalink
Subtitle B--Beneficiary Protections
SEC. 411. NAIC DEVELOPMENT OF MARKETING, ADVERTISING, AND RELATED PROTECTIONS.
(a) In General- Section 1852 of the Social Security Act (
`(m) Application of Model Marketing and Enrollment Standards-CommentsClose CommentsPermalink
`(1) IN GENERAL- The National Association of Insurance Commissioners (in this subsection referred to as the `NAIC') is requested to develop, and to submit to the Secretary of Health and Human Services not later than 12 months after the date of the enactment of this Act, model regulations (in this section referred to as `model regulations') regarding Medicare plan marketing, enrollment, broker and agent training and certification, agent and broker commissions, and market conduct by plans, agents and brokers for implementation (under paragraph (7)) under this part and part D, including for enforcement by States under section 1856(b)(3).CommentsClose CommentsPermalink
`(2) MARKETING GUIDELINES-CommentsClose CommentsPermalink
`(A) IN GENERAL- The model regulations shall address the sales and advertising techniques used by Medicare private plans, agents and brokers in selling plans, including defining and prohibiting cold calls, unsolicited door-to-door sales, cross-selling, and co-branding.CommentsClose CommentsPermalink
`(B) SPECIAL CONSIDERATIONS- The model regulations shall specifically address the marketing--CommentsClose CommentsPermalink
`(i) of plans to full benefit dual-eligible individuals and qualified medicare beneficiaries;CommentsClose CommentsPermalink
`(ii) of plans to populations with limited English proficiency;CommentsClose CommentsPermalink
`(iii) of plans to beneficiaries in senior living facilities; andCommentsClose CommentsPermalink
`(iv) of plans at educational events.CommentsClose CommentsPermalink
`(3) ENROLLMENT GUIDELINES-CommentsClose CommentsPermalink
`(A) IN GENERAL- The model regulations shall address the disclosures Medicare private plans, agents, and brokers must make when enrolling beneficiaries, and a process--CommentsClose CommentsPermalink
`(i) for affirmative beneficiary sign off before enrollment in a plan; andCommentsClose CommentsPermalink
`(ii) in the case of Medicare Part C plans, for plans to conduct a beneficiary call-back to confirm beneficiary sign off and enrollment.CommentsClose CommentsPermalink
`(B) SPECIFIC CONSIDERATIONS- The model regulations shall specially address beneficiary understanding of the Medicare plan through required disclosure (or beneficiary verification) of each of the following:CommentsClose CommentsPermalink
`(i) The type of Medicare private plan involved.CommentsClose CommentsPermalink
`(ii) Attributes of the plan, including premiums, cost sharing, formularies (if applicable), benefits, and provider access limitations in the plan.CommentsClose CommentsPermalink
`(iii) Comparative quality of the plan.CommentsClose CommentsPermalink
`(iv) The fact that plan attributes may change annually.CommentsClose CommentsPermalink
`(4) APPOINTMENT, CERTIFICATION AND TRAINING OF AGENTS AND BROKERS- The model regulations shall establish procedures and requirements for appointment, certification (and periodic recertification), and training of agents and brokers that market or sell Medicare private plans consistent with existing State appointment and certification procedures and with this paragraph.CommentsClose CommentsPermalink
`(5) AGENT AND BROKER COMMISSIONS-CommentsClose CommentsPermalink
`(A) IN GENERAL- The model regulations shall establish standards for fair and appropriate commissions for agents and brokers consistent with this paragraph.CommentsClose CommentsPermalink
`(B) LIMITATION ON TYPES OF COMMISSION- The model regulations shall specifically prohibit the following:CommentsClose CommentsPermalink
`(i) Differential commissions--CommentsClose CommentsPermalink
`(I) for Medicare Part C plans based on the type of Medicare private plan; orCommentsClose CommentsPermalink
`(II) prescription drug plans under part D based on the type of prescription drug plan.CommentsClose CommentsPermalink
`(ii) Commissions in the first year that are more than 200 percent of subsequent year commissions.CommentsClose CommentsPermalink
`(iii) The payment of extra bonuses or incentives (such as trips, gifts, and other non-commission cash payments).CommentsClose CommentsPermalink
`(C) AGENT DISCLOSURE- In developing the model regulations, the NAIC shall consider requiring agents and brokers to disclose commissions to a beneficiary upon request of the beneficiary before enrollment.CommentsClose CommentsPermalink
`(D) PREVENTION OF FRAUD- The model regulations shall consider the opportunity for fraud and abuse and beneficiary steering in setting standards under this paragraph and shall provide for the ability of State commissioners to investigate commission structures.CommentsClose CommentsPermalink
`(6) MARKET CONDUCT-CommentsClose CommentsPermalink
`(A) IN GENERAL- The model regulations shall establish standards for the market conduct of organizations offering Medicare private plans, and of agents and brokers selling such plans, and for State review of plan market conduct.CommentsClose CommentsPermalink
`(B) MATTERS TO BE INCLUDED- Such standards shall include standards for--CommentsClose CommentsPermalink
`(i) timely payment of claims;CommentsClose CommentsPermalink
`(ii) beneficiary complaint reporting and disclosure; andCommentsClose CommentsPermalink
`(iii) State reporting of market conduct violations and sanctions.CommentsClose CommentsPermalink
`(7) IMPLEMENTATION-CommentsClose CommentsPermalink
`(A) PUBLICATION OF NAIC MODEL REGULATIONS- If the model regulations are submitted on a timely basis under paragraph (1)--CommentsClose CommentsPermalink
`(i) the Secretary shall publish them in the Federal Register upon receipt and request public comment on the issue of whether such regulations are consistent with the requirements established in this subsection for such regulations;CommentsClose CommentsPermalink
`(ii) not later than 6 months after the date of such publication, the Secretary shall determine whether such regulations are so consistent with such requirements and shall publish notice of such determination in the Federal Register;CommentsClose CommentsPermalink
`(iii) if the Secretary makes the determination under clause (ii) that such regulations are consistent with such requirements, in the notice published under clause (ii) the Secretary shall publish notice of adoption of such model regulations as constituting the marketing and enrollment standards adopted under this subsection to be applied under this title; andCommentsClose CommentsPermalink
`(iv) if the Secretary makes the determination under such clause that such regulations are not consistent with such requirements, the procedures of clauses (ii) and (iii) of subparagraph (B) shall apply (in relation to the notice published under clause (ii)), in the same manner as such clauses would apply in the case of publication of a notice under subparagraph (B)(i).CommentsClose CommentsPermalink
`(B) NO MODEL REGULATIONS- If the model regulations are not submitted on a timely basis under paragraph (1)--CommentsClose CommentsPermalink
`(i) the Secretary shall publish notice of such fact in the Federal Register;CommentsClose CommentsPermalink
`(ii) not later than 6 months after the date of publication of such notice, the Secretary shall propose regulations that provide for marketing and enrollment standards that incorporate the requirements of this subsection for the model regulations and request public comments on such proposed regulations; andCommentsClose CommentsPermalink
`(iii) not later than 6 months after the date of publication of such proposed regulations, the Secretary shall publish final regulations that shall constitute the marketing and enrollment standards adopted under this subsection to be applied under this title.CommentsClose CommentsPermalink
`(C) REFERENCES TO MARKETING AND ENROLLMENT STANDARDS- In this title, a reference to marketing and enrollment standards adopted under this subsection is deemed a reference to the regulations constituting such standards adopted under subparagraph (A) or (B), as the case may be.CommentsClose CommentsPermalink
`(D) EFFECTIVE DATE OF STANDARDS- In order to provide for the orderly and timely implementation of marketing and enrollment standards adopted under this subsection, the Secretary, in consultation with the NAIC, shall specify (by program instruction or otherwise) effective dates with respect to all components of such standards consistent with the following:CommentsClose CommentsPermalink
`(i) In the case of components that relate predominantly to operations in relation to Medicare private plans, the effective date shall be for plan years beginning on or after such date (not later than 1 year after the date of promulgation of the standards) as the Secretary specifies.CommentsClose CommentsPermalink
`(ii) In the case of other components, the effective date shall be such date, not later than 1 year after the date of promulgation of the standards, as the Secretary specifies.CommentsClose CommentsPermalink
`(E) CONSULTATION- In promulgating marketing and enrollment standards under this paragraph, the NAIC or Secretary shall consult with a working group composed of representatives of issuers of Medicare private plans, consumer groups, medicare beneficiaries, State Health Insurance Assistance Programs, and other qualified individuals. Such representatives shall be selected in a manner so as to assure balanced representation among the interested groups.CommentsClose CommentsPermalink
`(8) ENFORCEMENT-CommentsClose CommentsPermalink
`(A) IN GENERAL- Any Medicare private plan that violates marketing and enrollment standards is subject to sanctions under section 1857(g).CommentsClose CommentsPermalink
`(B) STATE RESPONSIBILITIES- Nothing in this subsection or section 1857(g) shall prohibit States from imposing sanctions against Medicare private plans, agents, or brokers for violations of the marketing and enrollment standards adopted under section 1852(m). States shall have the sole authority to regulate agents and brokers.CommentsClose CommentsPermalink
`(9) MEDICARE PRIVATE PLAN DEFINED- In this subsection, the term `Medicare private plan' means a Medicare Part C plan and a prescription drug plan under part D.'.CommentsClose CommentsPermalink
(b) Expansion of Exception to Preemption of State Role-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1856(b)(3) of the Social Security Act (
(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply to plans offered on or after July 1, 2008.CommentsClose CommentsPermalink
(c) Application to Prescription Drug Plans-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1860D-1 of such Act is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink
`(d) Application of Marketing and Enrollment Standards- The marketing and enrollment standards adopted under section 1852(m) shall apply to prescription drug plans (and sponsors of such plans) in the same manner as they apply to Medicare Part C plans and organizations offering such plans.'.CommentsClose CommentsPermalink
(2) REFERENCE TO CURRENT LAW PROVISIONS- The amendment made by subsection (a) and (b) apply, pursuant to section 1860D-1(b)(1)(B)(ii) of the Social Security Act (
(d) Contract Requirement to Meet Marketing and Advertising Standards-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1857(d) of the Social Security Act (
`(7) MARKETING AND ADVERTISING STANDARDS- The contract shall require the organization to meet all standards adopted under section 1852(m) (including those enforced by the State involved pursuant to section 1856(b)(3)) relating to marketing and advertising conduct.'.CommentsClose CommentsPermalink
(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply to contracts for plan years beginning on or after January 1, 2011.CommentsClose CommentsPermalink
(e) Application of Sanctions-CommentsClose CommentsPermalink
(1) APPLICATION TO VIOLATION OF MARKETING AND ENROLLMENT STANDARDS- Section 1857(g)(1) of such Act (
(A) by striking `and' at the end of subparagraph (G);CommentsClose CommentsPermalink
(B) by adding `and' at the end of subparagraph (H); andCommentsClose CommentsPermalink
(C) by inserting after subparagraph (H) the following new subparagraph:CommentsClose CommentsPermalink
`(I) violates marketing and enrollment standards adopted under section 1852(m);'.CommentsClose CommentsPermalink
(2) ENHANCED CIVIL MONEY SANCTIONS- Such section is further amended--CommentsClose CommentsPermalink
(A) in paragraph (2)(A), by striking `$25,000', `$100,000', and `$15,000' and inserting `$50,000', `$200,000', and `$30,000', respectively; andCommentsClose CommentsPermalink
(B) in subparagraphs (A), (B), and (D) of paragraph (3), by striking `$25,000', `$10,000', and `$100,000', respectively, and inserting `$50,000', `$20,000', and `$200,000', respectively.CommentsClose CommentsPermalink
(3) EFFECTIVE DATE- The amendments made by paragraph (2) shall apply to violations occurring on or after the date of the enactment of this Act.CommentsClose CommentsPermalink
(f) Disclosure of Market and Advertising Contract Violations and Imposed Sanctions- Section 1857 of such Act is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink
`(j) Disclosure of Market and Advertising Contract Violations and Imposed Sanctions- For years beginning with 2009, the Secretary shall post on its public website for the Medicare program an annual report that--CommentsClose CommentsPermalink
`(1) lists each MA organization for which the Secretary made during the year a determination under subsection (c)(2) the basis of which is described in paragraph (1)(E); andCommentsClose CommentsPermalink
`(2) that describes any applicable sanctions under subsection (g) applied to such organization pursuant to such determination.'.CommentsClose CommentsPermalink
(g) Standard Definitions of Benefits and Formats for Use in Marketing Materials- Section 1851(h) of such Act (
`(6) STANDARD DEFINITIONS OF BENEFITS AND FORMATS FOR USE IN MARKETING MATERIALS-CommentsClose CommentsPermalink
`(A) IN GENERAL- Not later than January 1, 2010, the Secretary, in consultation with the National Association of Insurance Commissioners and a working group of the type described in section 1852(m)(7)(E), shall develop standard descriptions and definitions for benefits under this title for use in marketing material distributed by Medicare Part C organizations and formats for including such descriptions in such marketing material.CommentsClose CommentsPermalink
`(B) REQUIRED USE OF STANDARD DEFINITIONS- For plan years beginning on or after January 1, 2011, the Secretary shall disapprove the distribution of marketing material under paragraph (1)(B) if such marketing material does not use, without modification, the applicable descriptions and formats specified under subparagraph (A).'.CommentsClose CommentsPermalink
(h) Support for State Health Insurance Assistance Programs (SHIPs)- Section 1857(e)(2) of the Social Security Act (
(1) in subparagraph (B), by adding at the end the following: `Of the amounts so collected, no less than $55,000,000 for fiscal year 2009, $65,000,000 for fiscal year 2010, $75,000,000 for fiscal year 2011, and $85,000,000 for fiscal year 2012 and each succeeding fiscal year shall be used to support Medicare Part C and Part D counseling and assistance provided by State Health Insurance Assistance Programs.';CommentsClose CommentsPermalink
(2) in subparagraph (C)--CommentsClose CommentsPermalink
(A) by striking `and' after `$100,000,000,'; andCommentsClose CommentsPermalink
(B) by striking `an amount equal to $200,000,000' and inserting `and ending with fiscal year 2008 an amount equal to $200,000,000, for fiscal year 2009 an amount equal to $255,000,000, for fiscal year 2010 an amount equal to $265,000,000, for fiscal year 2011 an amount equal to $275,000,000, and for fiscal year 2012 and each succeeding fiscal year an amount equal to $285,000,000'; andCommentsClose CommentsPermalink
(3) in subparagraph (D)(ii)--CommentsClose CommentsPermalink
(A) by striking `and' at the end of subclause (IV);CommentsClose CommentsPermalink
(B) in subclause (V), by striking the period at the end and inserting `before fiscal year 2009; and'; andCommentsClose CommentsPermalink
(C) by adding at the end the following new subclause:CommentsClose CommentsPermalink
`(VI) for fiscal year 2009 and each succeeding fiscal year the applicable portion (as so defined) of the amount specified in subparagraph (C) for that fiscal year.'.CommentsClose CommentsPermalink
SEC. 412. LIMITATION ON OUT-OF-POCKET COSTS FOR INDIVIDUAL HEALTH SERVICES.
(a) In General- Section 1852(a)(1) of the Social Security Act (
(1) in subparagraph (A), by inserting before the period at the end the following: `with cost-sharing that is no greater (and may be less) than the cost-sharing that would otherwise be imposed under such program option';CommentsClose CommentsPermalink
(2) in subparagraph (B)(i), by striking `or an actuarially equivalent level of cost-sharing as determined in this part'; andCommentsClose CommentsPermalink
(3) by amending clause (ii) of subparagraph (B) to read as follows:CommentsClose CommentsPermalink
`(ii) PERMITTING USE OF FLAT COPAYMENT OR PER DIEM RATE- Nothing in clause (i) shall be construed as prohibiting a Medicare part C plan from using a flat copayment or per diem rate, in lieu of the cost-sharing that would be imposed under part A or B, so long as the amount of the cost-sharing imposed does not exceed the amount of the cost-sharing that would be imposed under the respective part if the individual were not enrolled in a plan under this part.'.CommentsClose CommentsPermalink
(b) Limitation for Dual Eligibles and Qualified Medicare Beneficiaries- Section 1852(a) of such Act is amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(7) LIMITATION ON COST-SHARING FOR DUAL ELIGIBLES AND QUALIFIED MEDICARE BENEFICIARIES- In the case of a individual who is a full-benefit dual eligible individual (as defined in section 1935(c)(6)) or a qualified medicare beneficiary (as defined in section 1905(p)(1)) who is enrolled in a Medicare Part C plan, the plan may not impose cost-sharing that exceeds the amount of cost-sharing that would be permitted with respect to the individual under this title and title XIX if the individual were not enrolled with such plan.'.CommentsClose CommentsPermalink
(c) Effective Dates-CommentsClose CommentsPermalink
(1) The amendments made by subsection (a) shall apply to plan years beginning on or after January 1, 2009.CommentsClose CommentsPermalink
(2) The amendments made by subsection (b) shall apply to plan years beginning on or after January 1, 2008.CommentsClose CommentsPermalink
SEC. 413. MA PLAN ENROLLMENT MODIFICATIONS.
(a) Improved Plan Enrollment, Disenrollment, and Change of Enrollment-CommentsClose CommentsPermalink
(1) CONTINUOUS OPEN ENROLLMENT FOR FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS AND QUALIFIED MEDICARE BENEFICIARIES (QMB)- Section 1851(e)(2)(D) of the Social Security Act (
(A) in the heading, by inserting `, FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS, AND QUALIFIED MEDICARE BENEFICIARIES' after `INSTITUTIONALIZED INDIVIDUALS';CommentsClose CommentsPermalink
(B) in the matter before clause (i), by inserting `, a full-benefit dual eligible individual (as defined in section 1935(c)(6)), or a qualified medicare beneficiary (as defined in section 1905(p)(1))' after `institutionalized (as defined by the Secretary)'; andCommentsClose CommentsPermalink
(C) in clause (i), by inserting `or disenroll' after `enroll'.CommentsClose CommentsPermalink
(2) SPECIAL ELECTION PERIODS FOR ADDITIONAL CATEGORIES OF INDIVIDUALS- Section 1851(e)(4) of such Act (
(A) in subparagraph (C), by striking at the end `or';CommentsClose CommentsPermalink
(B) in subparagraph (D), by inserting `, taking into account the health or well-being of the individual' before the period and redesignating such subparagraph as subparagraph (F); andCommentsClose CommentsPermalink
(C) by inserting after subparagraph (C) the following new subparagraphs:CommentsClose CommentsPermalink
`(D) the individual is described in section 1902(a)(10)(E)(iii) (relating to specified low-income medicare beneficiaries);CommentsClose CommentsPermalink
`(E) the individual is enrolled in an MA plan and enrollment in the plan is suspended under paragraph (2)(B) or (3)(C) of section 1857(g) because of a failure of the plan to meet applicable requirements; or'.CommentsClose CommentsPermalink
(3) EFFECTIVE DATE- The amendments made by this subsection shall take effect on the date of the enactment of this Act.CommentsClose CommentsPermalink
(b) Access to Medigap Coverage for Individuals Who Leave MA Plans-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1882(s)(3) of the Social Security Act (
(A) in each of clauses (v)(III) and (vi) of subparagraph (B), by striking `12 months' and inserting `24 months'; andCommentsClose CommentsPermalink
(B) in each of subclauses (I) and (II) of subparagraph (F)(i), by striking `12 months' and inserting `24 months'.CommentsClose CommentsPermalink
(2) EFFECTIVE DATE- The amendments made by paragraph (1) shall apply to terminations of enrollments in MA plans occurring on or after the date of the enactment of this Act.CommentsClose CommentsPermalink
(c) Improved Enrollment Policies-CommentsClose CommentsPermalink
(1) NO AUTO-ENROLLMENT OF MEDICAID BENEFICIARIES-CommentsClose CommentsPermalink
(A) IN GENERAL- Section 1851(e) of such Act (
`(7) NO AUTO-ENROLLMENT OF MEDICAID BENEFICIARIES- In no case may the Secretary provide for the enrollment in a MA plan of a Medicare Advantage eligible individual who is eligible to receive medical assistance under title XIX as a full-benefit dual eligible individual or a qualified medicare beneficiary, without the affirmative application of such individual (or authorized representative of the individual) to be enrolled in such plan.'.CommentsClose CommentsPermalink
(B) NO APPLICATION TO PRESCRIPTION DRUG PLANS- Section 1860D-1(b)(1)(B)(iii) of such Act (
(i) by striking `paragraph (2) and' and by inserting `paragraph (2),'; andCommentsClose CommentsPermalink
(ii) by inserting `, and paragraph (7),' after `paragraph (4)'.CommentsClose CommentsPermalink
(C) EFFECTIVE DATE- The amendments made by this paragraph shall apply to enrollments that are effective on or after the date of the enactment of this Act.CommentsClose CommentsPermalink
SEC. 414. INFORMATION FOR BENEFICIARIES ON MA PLAN ADMINISTRATIVE COSTS.
(a) Disclosure of Medical Loss Ratios and Other Expense Data- Section 1851 of the Social Security Act (
`(j) Publication of Medical Loss Ratios and Other Cost-Related Information-CommentsClose CommentsPermalink
`(1) IN GENERAL- The Secretary shall publish, not later than October 1 of each year (beginning with 2009), for each Medicare Part C plan contract, the following:CommentsClose CommentsPermalink
`(A) The medical loss ratio of the plan in the previous year.CommentsClose CommentsPermalink
`(B) The per enrollee payment under this part to the plan, as adjusted to reflect a risk score (based on factors described in section 1853(a)(1)(C)(i)) of 1.0.CommentsClose CommentsPermalink
`(C) The average risk score (as so based).CommentsClose CommentsPermalink
`(2) SUBMISSION OF DATA-CommentsClose CommentsPermalink
`(A) IN GENERAL- Each Medicare Part C organization shall submit to the Secretary, in a form and manner specified by the Secretary, data necessary for the Secretary to publish the information described in paragraph (1) on a timely basis, including the information described in paragraph (3).CommentsClose CommentsPermalink
`(B) DATA FOR 2008 AND 2009- The data submitted under subparagraph (A) for 2008 and for 2009 shall be consistent in content with the data reported as part of the Medicare Part C plan bid in June 2007 for 2008.CommentsClose CommentsPermalink
`(C) MEDICAL LOSS RATIO DATA- The data to be submitted under subparagraph (A) relating to medical loss ratio for a year--CommentsClose CommentsPermalink
`(i) shall be submitted not later than June 1 of the following year; andCommentsClose CommentsPermalink
`(ii) beginning with 2010, shall be submitted based on the standardized elements and definitions developed under paragraph (4).CommentsClose CommentsPermalink
`(D) AUDITED DATA- Data submitted under this paragraph shall be data that has been audited by an independent third party auditor.CommentsClose CommentsPermalink
`(3) MLR INFORMATION- The information described in this paragraph with respect to a Medicare Part C plan for a year is as follows:CommentsClose CommentsPermalink
`(A) The costs for the plan in the previous year for each of the following:CommentsClose CommentsPermalink
`(i) Total medical expenses, separately indicated for benefits for the original medicare fee-for-service program option and for supplemental benefits.CommentsClose CommentsPermalink
`(ii) Non-medical expenses, shown separately for each of the following categories of expenses:CommentsClose CommentsPermalink
`(I) Marketing and sales.CommentsClose CommentsPermalink
`(II) Direct administration.CommentsClose CommentsPermalink
`(III) Indirect administration.CommentsClose CommentsPermalink
`(IV) Net cost of private reinsurance.CommentsClose CommentsPermalink
`(B) Gain or loss margin.CommentsClose CommentsPermalink
`(C) Total revenue requirement, computed as the total of medical and nonmedical expenses and gain or loss margin, multiplied by the gain or loss margin.CommentsClose CommentsPermalink
`(D) Percent of revenue ratio, computed as the total revenue requirement expressed as a percentage of revenue.CommentsClose CommentsPermalink
`(4) DEVELOPMENT OF DATA REPORTING STANDARDS-CommentsClose CommentsPermalink
`(A) IN GENERAL- The Secretary shall develop and implement standardized data elements and definitions for reporting under this subsection, for contract years beginning with 2010, of data necessary for the calculation of the medical loss ratio for Medicare Part C plans. Not later than December 31, 2008, the Secretary shall publish a report describing the elements and definitions so developed.CommentsClose CommentsPermalink
`(B) CONSULTATION- The Secretary shall consult with representatives of Medicare Part C organizations, experts on health plan accounting systems, and representatives of the National Association of Insurance Commissioners, in the development of such data elements and definitions.CommentsClose CommentsPermalink
`(5) MEDICAL LOSS RATIO DEFINED- For purposes of this part, the term `medical loss ratio' means, with respect to an MA plan for a year, the ratio of--CommentsClose CommentsPermalink
`(A) the aggregate benefits (excluding nonmedical expenses described in paragraph (3)(A)(ii)) paid under the plan for the year, toCommentsClose CommentsPermalink
`(B) the aggregate amount of premiums (including basic and supplemental beneficiary premiums) and payments made under sections 1853 and 1860D-15) collected for the plan and year.CommentsClose CommentsPermalink
Such ratio shall be computed without regard to whether the benefits or premiums are for required or supplemental benefits under the plan.'.CommentsClose CommentsPermalink
(b) Audit of Administrative Costs and Compliance With the Federal Acquisition Regulation-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1857(d)(2)(B) of such Act (
(A) by striking `or (ii)' and inserting `(ii)'; andCommentsClose CommentsPermalink
(B) by inserting before the period at the end the following: `, or (iii) to compliance with the requirements of subsection (e)(4) and the extent to which administrative costs comply with the applicable requirements for such costs under the Federal Acquisition Regulation'.CommentsClose CommentsPermalink
(2) EFFECTIVE DATE- The amendments made by this subsection shall apply for contract years beginning after the date of the enactment of this Act.CommentsClose CommentsPermalink
(c) Minimum Medical Loss Ratio- Section 1857(e) of the Social Security Act (
`(4) REQUIREMENT FOR MINIMUM MEDICAL LOSS RATIO- If the Secretary determines for a contract year (beginning with 2010) that an MA plan has failed to have a medical loss ratio (as defined in section 1851(j)(4)) of at least .85--CommentsClose CommentsPermalink
`(A) for that contract year, the Secretary shall reduce the blended benchmark amount under subsection (l) for the second succeeding contract year by the number of percentage points by which such loss ratio was less than 85 percent;CommentsClose CommentsPermalink
`(B) for 3 consecutive contract years, the Secretary shall not permit the enrollment of new enrollees under the plan for coverage during the second succeeding contract year; andCommentsClose CommentsPermalink
`(C) the Secretary shall terminate the plan contract if the plan fails to have such a medical loss ratio for 5 consecutive contract years.'.CommentsClose CommentsPermalink
(d) Information on Medicare Part C Plan Enrollment and Services- Section 1851 of such Act, as amended by subsection (a), is further amended by adding at the end the following new subsection:CommentsClose CommentsPermalink
`(k) Publication of Enrollment and Other Information-CommentsClose CommentsPermalink
`(1) MONTHLY PUBLICATION OF PLAN-SPECIFIC ENROLLMENT DATA- The Secretary shall publish (on the public website of the Centers for Medicare & Medicaid Services or otherwise) not later than 30 days after the end of each month (beginning with January 2008) on the actual enrollment in each Medicare Part C plan by contract and by county.CommentsClose CommentsPermalink
`(2) AVAILABILITY OF OTHER INFORMATION- The Secretary shall make publicly available data and other information in a format that may be readily used for analysis of the Medicare Part C program under this part and will contribute to the understanding of the organization and operation of such program.'.CommentsClose CommentsPermalink
(e) MedPAC Report on Varying Minimum Medical Loss Ratios-CommentsClose CommentsPermalink
(1) STUDY- The Medicare Payment Advisory Commission shall conduct a study of the need and feasibility of providing for different minimum medical loss ratios for different types of Medicare Part C plans, including coordinated care plans, group model plans, coordinated care independent practice association plans, preferred provider organization plans, and private fee-for-services plans.CommentsClose CommentsPermalink
(2) REPORT- Not later than 1 year after the date of the enactment of this Act, submit to Congress a report on the study conducted under paragraph (1).CommentsClose CommentsPermalink
Subtitle C--Quality and Other Provisions
SEC. 421. REQUIRING ALL MA PLANS TO MEET EQUAL STANDARDS.
(a) Collection and Reporting of Information-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1852(e)(1) of the Social Security Act (
(2) REPORTING FOR PRIVATE FEE-FOR-SERVICES AND MSA PLANS- Section 1852(e)(3) of such Act is amended by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(C) DATA COLLECTION REQUIREMENTS BY PRIVATE FEE-FOR-SERVICE PLANS AND MSA PLANS-CommentsClose CommentsPermalink
`(i) USING MEASURES FOR PPOS FOR CONTRACT YEAR 2009- For contract year 2009, the Medicare Part C organization offering a private fee-for-service plan or an MSA plan shall submit to the Secretary for such plan the same information on the same performance measures for which such information is required to be submitted for Medicare Part C plans that are preferred provider organization plans for that year.CommentsClose CommentsPermalink
`(ii) APPLICATION OF SAME MEASURES AS COORDINATED CARE PLANS BEGINNING IN CONTRACT YEAR 2010- For a contract year beginning with 2010, a Medicare Part C organization offering a private fee-for-service plan or an MSA plan shall submit to the Secretary for such plan the same information on the same performance measures for which such information is required to be submitted for such contract year Medicare Part C plans described in section 1851(a)(2)(A)(i) for contract year such contract year.'.CommentsClose CommentsPermalink
(3) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply to contract years beginning on or after January 1, 2009.CommentsClose CommentsPermalink
(b) Employer Plans-CommentsClose CommentsPermalink
(1) IN GENERAL- The first sentence of paragraph (2) of section 1857(i) of such Act (
(2) LIMITATION ON APPLICATION OF WAIVER AUTHORITY- Paragraphs (1) and (2) of such section are each amended by inserting `that were in effect before the date of the enactment of the Children's Health and Medicare Protection Act of 2007' after `waive or modify requirements'.CommentsClose CommentsPermalink
(3) EFFECTIVE DATES- The amendment made by paragraph (1) shall apply for plan years beginning on or after January 1, 2009, and the amendments made by paragraph (2) shall take effect on the date of the enactment of this Act.CommentsClose CommentsPermalink
SEC. 422. DEVELOPMENT OF NEW QUALITY REPORTING MEASURES ON RACIAL DISPARITIES.
(a) New Quality Reporting Measures-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1852(e)(3) of the Social Security Act (
(A) in subparagraph (B)--CommentsClose CommentsPermalink
(i) in clause (i), by striking `The Secretary' and inserting `Subject to subparagraph (D), the Secretary'; andCommentsClose CommentsPermalink
(ii) in clause (ii), by striking `subclause (iii)' and inserting `clause (iii) and subparagraph (C)'; andCommentsClose CommentsPermalink
(B) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(D) ADDITIONAL QUALITY REPORTING MEASURES-CommentsClose CommentsPermalink
`(i) IN GENERAL- The Secretary shall develop by October 1, 2009, quality measures for Medicare Part C plans that measure disparities in the amount and quality of health services provided to racial and ethnic minorities.CommentsClose CommentsPermalink
`(ii) DATA TO MEASURE RACIAL AND ETHNIC DISPARITIES IN THE AMOUNT AND QUALITY OF CARE PROVIDED TO ENROLLEES- The Secretary shall provide for Medicare Part C organizations to submit data under this paragraph, including data similar to those submitted for other quality measures, that permits analysis of disparities among racial and ethnic minorities in health services, quality of care, and health status among Medicare Part C plan enrollees for use in submitting the reports under paragraph (5).'.CommentsClose CommentsPermalink
(2) EFFECTIVE DATE- The amendments made by this subsection shall apply to reporting of quality measures for plan years beginning on or after January 1, 2010.CommentsClose CommentsPermalink
(b) Biennial Report on Racial and Ethnic Minorities- Section 1852(e) of such Act (
`(5) REPORT TO CONGRESS-CommentsClose CommentsPermalink
`(A) IN GENERAL- Not later than 2 years after the date of the enactment of this paragraph, and biennially thereafter, the Secretary shall submit to Congress a report regarding how quality assurance programs conducted under this subsection measure and report on disparities in the amount and quality of health care services furnished to racial and ethnic minorities.CommentsClose CommentsPermalink
`(B) CONTENTS OF REPORT- Each such report shall include the following:CommentsClose CommentsPermalink
`(i) A description of the means by which such programs focus on such racial and ethnic minorities.CommentsClose CommentsPermalink
`(ii) An evaluation of the impact of such programs on eliminating health disparities and on improving health outcomes, continuity and coordination of care, management of chronic conditions, and consumer satisfaction.CommentsClose CommentsPermalink
`(iii) Recommendations on ways to reduce clinical outcome disparities among racial and ethnic minorities.CommentsClose CommentsPermalink
`(iv) Data for each MA plan from HEDIS and other source reporting the disparities in the amount and quality of health services furnished to racial and ethnic minorities.'.CommentsClose CommentsPermalink
SEC. 423. STRENGTHENING AUDIT AUTHORITY.
(a) For Part C Payments Risk Adjustment- Section 1857(d)(1) of the Social Security Act (
(b) Enforcement of Audits and Deficiencies-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1857(e) of such Act is amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(5) ENFORCEMENT OF AUDITS AND DEFICIENCIES-CommentsClose CommentsPermalink
`(A) INFORMATION IN CONTRACT- The Secretary shall require that each contract with a Medicare Part C organization under this section shall include terms that inform the organization of the provisions in subsection (d).CommentsClose CommentsPermalink
`(B) ENFORCEMENT AUTHORITY- The Secretary is authorized, in connection with conducting audits and other activities under subsection (d), to take such actions, including pursuit of financial recoveries, necessary to address deficiencies identified in such audits or other activities.'.CommentsClose CommentsPermalink
(2) APPLICATION UNDER PART D- For provision applying the amendment made by paragraph (1) to prescription drug plans under part D, see section 1860D-12(b)(3)(D) of the Social Security Act.CommentsClose CommentsPermalink
(c) Effective Date- The amendments made by this section shall take effect the date of the enactment of this Act and shall apply to audits and activities conducted for contract years beginning on or after January 1, 2009.CommentsClose CommentsPermalink
SEC. 424. IMPROVING RISK ADJUSTMENT FOR MA PAYMENTS.
(a) In General- Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall submit to Congress a report that evaluates the adequacy of the Medicare Advantage risk adjustment system under section 1853(a)(1)(C) of the Social Security Act (
(b) Particulars- The report under subsection (a) shall include an evaluation of at least the following:CommentsClose CommentsPermalink
(1) The need and feasibility of improving the adequacy of the risk adjustment system in predicting costs for beneficiaries with co-morbid conditions and associated cognitive impairments.CommentsClose CommentsPermalink
(2) The need and feasibility of including further gradations of diseases and conditions (such as the degree of severity of congestive heart failure).CommentsClose CommentsPermalink
(3) The feasibility of measuring difference in coding over time between Medicare part C plans and the medicare traditional fee-for-service program and, to the extent this difference exists, the options for addressing it.CommentsClose CommentsPermalink
(4) The feasibility and value of including part D and other drug utilization data in the risk adjustment model.CommentsClose CommentsPermalink
SEC. 425. ELIMINATING SPECIAL TREATMENT OF PRIVATE FEE-FOR-SERVICE PLANS.
(a) Elimination of Extra Billing Provision- Section 1852(k)(2) of the Social Security Act (
(1) in subparagraph (A)(i), by striking `115 percent' and inserting `100 percent'; andCommentsClose CommentsPermalink
(2) in subparagraph (C)(i), by striking `including any liability for balance billing consistent with this subsection)'.CommentsClose CommentsPermalink
(b) Review of Bid Information- Section 1854(a)(6)(B) of such Act (
(1) in clause (i), by striking `clauses (iii) and (iv)' and inserting `clause (iii)'; andCommentsClose CommentsPermalink
(2) by striking clause (iv).CommentsClose CommentsPermalink
(c) Effective Date- The amendments made by this section shall apply to contract years beginning with 2009.CommentsClose CommentsPermalink
SEC. 426. RENAMING OF MEDICARE ADVANTAGE PROGRAM.
(a) In General- The program under part C of title XVIII of the Social Security Act is henceforth to be known as the `Medicare Part C program'.CommentsClose CommentsPermalink
(b) Change in References-CommentsClose CommentsPermalink
(1) AMENDING SOCIAL SECURITY ACT- The Social Security Act is amended by striking `Medicare Advantage', `MA', and `Medicare+Choice' and inserting `Medicare Part C' each place it appears, with the appropriate, respective typographic formatting, including typeface and capitalization.CommentsClose CommentsPermalink
(2) ADDITIONAL REFERENCES- Notwithstanding section 201(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (
Subtitle D--Extension of Authorities
SEC. 431. EXTENSION AND REVISION OF AUTHORITY FOR SPECIAL NEEDS PLANS (SNPS).
(a) Extending Restriction on Enrollment Authority for SNPs for 3 Years- Subsection (f) of section 1859 of the Social Security Act (
(b) Structure of Authority for SNPs-CommentsClose CommentsPermalink
(1) IN GENERAL- Such section is further amended--CommentsClose CommentsPermalink
(A) in subsection (b)(6)(A), by striking all that follows `means' and inserting the following: `an MA plan--CommentsClose CommentsPermalink
`(i) that serves special needs individuals (as defined in subparagraph (B));CommentsClose CommentsPermalink
`(ii) as of January 1, 2009--CommentsClose CommentsPermalink
`(I) at least 90 percent of the enrollees which are described in subparagraph (B)(i), as determined under regulations in effect as of July 1, 2007;CommentsClose CommentsPermalink
`(II) at least 90 percent of the enrollees in which are described in subparagraph (B)(ii) and are full-benefit dual eligible individuals (as defined in section 1935(c)(6)) or qualified medicare beneficiaries (as defined in section 1905(p)(1)); orCommentsClose CommentsPermalink
`(III) at least 90 percent of the enrollees in which have a severe or disabling chronic condition of the type that the plan is committed to serve as indicated by the data submitted for the risk-adjustment of plan payments; andCommentsClose CommentsPermalink
`(iii) as of January 1, 2009, meets the applicable requirements of paragraph (2) or (3) of subsection (f), as the case may be.'; andCommentsClose CommentsPermalink
(B) in subsection (f)--CommentsClose CommentsPermalink
(i) by amending the heading to read as follows: `Requirements for Enrollment in Part C Plans for Special Needs Beneficiaries';CommentsClose CommentsPermalink
(ii) by designating the sentence beginning `In the case of' as paragraph (1) with the heading `REQUIREMENTS FOR ENROLLMENT- ' and with appropriate indentation; andCommentsClose CommentsPermalink
(iii) by adding at the end the following new paragraphs:CommentsClose CommentsPermalink
`(2) ADDITIONAL REQUIREMENTS FOR INSTITUTIONAL SNPS- In the case of a specialized MA plan for special needs individuals described in subsection (b)(6)(A)(ii)(I), the applicable requirements of this subsection are as follows:CommentsClose CommentsPermalink
`(A) The plan has an agreement with the State that includes provisions regarding cooperation on the coordination of care for such individuals. Such agreement shall include a description of the manner that the State Medicaid program under title XIX will pay for the costs of services for individuals eligible under such title for medical assistance for acute care and long-term care services.CommentsClose CommentsPermalink
`(B) The plan has a contract with long-term care facilities and other providers in the area sufficient to provide care for enrollees described in subsection (b)(6)(B)(i).CommentsClose CommentsPermalink
`(C) The plan reports to the Secretary information on additional quality measures specified by the Secretary under section 1852(e)(3)(D)(iv)(I) for such plans.CommentsClose CommentsPermalink
`(3) ADDITIONAL REQUIREMENTS FOR DUAL SNPS- In the case of a specialized MA plan for special needs individuals described in subsection (b)(6)(A)(ii)(II), the applicable requirements of this subsection are as follows:CommentsClose CommentsPermalink
`(A) The plan has an agreement with the State Medicaid agency that--CommentsClose CommentsPermalink
`(i) includes provisions regarding cooperation on the coordination of the financing of care for such individuals;CommentsClose CommentsPermalink
`(ii) includes a description of the manner that the State Medicaid program under title XIX will pay for the costs of cost-sharing and supplemental services for individuals enrolled in the plan eligible under such title for medical assistance for acute and long-term care services; andCommentsClose CommentsPermalink
`(iii) effective January 1, 2011, provides for capitation payments to cover costs of supplemental benefits for individuals described in subsection (b)(6)(A)(ii)(II).CommentsClose CommentsPermalink
`(B) The out-of-pocket costs for services under parts A and B that are charged to enrollees may not exceed the out-of-pocket costs for same services permitted for such individuals under title XIX.CommentsClose CommentsPermalink
`(C) The plan reports to the Secretary information on additional quality measures specified by the Secretary under section 1852(e)(3)(D)(iv)(II) for such plans.CommentsClose CommentsPermalink
`(4) ADDITIONAL REQUIREMENTS FOR SEVERE OR DISABLING CHRONIC CONDITION SNPS- In the case of a specialized MA plan for special needs individuals described in subsection (b)(6)(A)(ii)(III), the applicable requirements of this subsection are as follows:CommentsClose CommentsPermalink
`(A) The plan is designated to serve, and serves, Medicare beneficiaries with one or more of the following specific severe or disabling chronic conditions:CommentsClose CommentsPermalink
`(i) Cardiovascular.CommentsClose CommentsPermalink
`(ii) Cerebrovascular.CommentsClose CommentsPermalink
`(iii) Congestive health failure.CommentsClose CommentsPermalink
`(iv) Diabetes.CommentsClose CommentsPermalink
`(v) Chronic obstructive pulmonary disease.CommentsClose CommentsPermalink
`(vi) HIV/AIDS.CommentsClose CommentsPermalink
`(B) The plan has an average risk score under section 1853(a)(1)(C) of 1.35 or greater.CommentsClose CommentsPermalink
`(C) The plan has established and actively manages a chronic care improvement program under section 1852(e)(2) for each of the conditions that it serves under subparagraph (A) that significantly exceeds the features and results of such programs established and managed by Medicare Part C plans that are not specialized Medicare Part C plans for special needs individuals of the type described in this paragraph.CommentsClose CommentsPermalink
`(D) The plan has a network of a sufficient number of primary care and specialty physicians, hospitals, and other health care providers under contract to the plan so that the plan can clearly meet the routine and specialty needs of the severely ill and disabled enrollees of the plan throughout the service area of the plan.CommentsClose CommentsPermalink
`(E) The plan reports to the Secretary information on additional quality measures specified by the Secretary under section 1852(e)(3)(D)(iv)(III) for such plans.'.CommentsClose CommentsPermalink
(2) QUALITY STANDARDS AND QUALITY REPORTING- Section 1852(e)(3) of such Act (
(A) in subparagraph (A)(i), by adding at the end the following: `In the case of a specialized Medicare Part C plan for special needs individuals described in paragraph (2), (3), or (4) of section 1859(f), the organization shall provide for the reporting on quality measures developed for the plan under subparagraph (D)(iii).'; andCommentsClose CommentsPermalink
(B) in subparagraph (D), as added by section 422(a)(1), by adding at the end the following new clause:CommentsClose CommentsPermalink
`(iii) SPECIFICATION OF ADDITIONAL QUALITY MEASUREMENTS FOR SPECIALIZED PART C PLANS- For implementation for plan years beginning not later than January 1, 2010, the Secretary shall develop new quality measures appropriate to meeting the needs of--CommentsClose CommentsPermalink
`(I) beneficiaries enrolled in specialized Medicare Part C plans for special needs individuals (described in section 1859(b)(6)(A)(ii)(I)) that serve predominantly individuals who are dual-eligible individuals eligible for medical assistance under title XIX by measuring the special needs for care of individuals who are both Medicare and Medicaid beneficiaries;CommentsClose CommentsPermalink
`(II) beneficiaries enrolled in specialized Medicare Part C plans for special needs individuals (described in section 1859(b)(6)(A)(ii)(II)) that serve predominantly institutionalized individuals by measuring the special needs for care of individuals who are a resident in long-term care institution; andCommentsClose CommentsPermalink
`(III) beneficiaries enrolled in specialized Medicare Part C plans for special needs individuals (described in section 1859(b)(6)(A)(ii)(III)) that serve predominantly individuals with severe or disabling chronic conditions by measuring the special needs for care of such individuals.'.CommentsClose CommentsPermalink
(3) EFFECTIVE DATE; GRANDFATHER- The amendments made by paragraph (1) shall take effect for enrollments occurring on or after January 1, 2009, and shall not apply--CommentsClose CommentsPermalink
(A) to a Medicare Advantage plan with a contract with a State Medicaid integrated Medicare-Medicaid plan program that had been approved by the Centers for Medicare & Medicaid Services as of January 1, 2004; andCommentsClose CommentsPermalink
(B) to plans that are operational as of the date of the enactment of this Act as approved Medicare demonstration projects and that provide services predominantly to individuals with end-stage renal disease.CommentsClose CommentsPermalink
(4) TRANSITION FOR NON-QUALIFYING SNPS-CommentsClose CommentsPermalink
(A) RESTRICTIONS IN 2008 FOR CHRONIC CARE SNPS- In the case of a specialized MA plan for special needs individuals (as defined in section 1859(b)(6)(A) of the Social Security Act (
(i) the plan may not be offered unless it was offered before such date;CommentsClose CommentsPermalink
(ii) no new members may be enrolled with the plan; andCommentsClose CommentsPermalink
(iii) there may be no expansion of the service area of such plan.CommentsClose CommentsPermalink
(B) TRANSITION OF ENROLLEES- The Secretary of Health and Human Services shall provide for an orderly transition of those specialized MA plans for special needs individuals (as defined in section 1859(b)(6)(A) of the Social Security Act (
(c) Sunset of Additional Designation Authority-CommentsClose CommentsPermalink
(1) IN GENERAL- Subsection (d) of section 231 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (
(2) EFFECTIVE DATE- The repeal made by paragraph (1) shall take effect on January 1, 2009, and shall apply to plans offered on or after such date.CommentsClose CommentsPermalink
SEC. 432. EXTENSION AND REVISION OF AUTHORITY FOR MEDICARE REASONABLE COST CONTRACTS.
(a) Extension for 3 Years of Period Reasonable Cost Plans Can Remain in the Market- Section 1876(h)(5)(C)(ii) of the Social Security Act (
(b) Application of Certain Medicare Advantage Requirements to Cost Contracts Extended or Renewed After Enactment- Section 1876(h) of such Act (
(1) by redesignating paragraph (5) as paragraph (6); andCommentsClose CommentsPermalink
(2) by inserting after paragraph (4) the following new paragraph:CommentsClose CommentsPermalink
`(5)(A) Any reasonable cost reimbursement contract with an eligible organization under this subsection that is extended or renewed on or after the date of enactment of the Children's Health and Medicare Protection Act of 2007 shall provide that the provisions of the Medicare Part C program described in subparagraph (B) shall apply to such organization and such contract in a substantially similar manner as such provisions apply to Medicare Part C organizations and Medicare Part C plans under part C.CommentsClose CommentsPermalink
`(B) The provisions described in this subparagraph are as follows:CommentsClose CommentsPermalink
`(i) Section 1851(h) (relating to the approval of marketing material and application forms).CommentsClose CommentsPermalink
`(ii) Section 1852(e) (relating to the requirement of having an ongoing quality improvement program and treatment of accreditation in the same manner as such provisions apply to Medicare Part C local plans that are preferred provider organization plans).CommentsClose CommentsPermalink
`(iii) Section 1852(f) (relating to grievance mechanisms).CommentsClose CommentsPermalink
`(iv) Section 1852(g) (relating to coverage determinations, reconsiderations, and appeals).CommentsClose CommentsPermalink
`(v) Section 1852(j)(4) (relating to limitations on physician incentive plans).CommentsClose CommentsPermalink
`(vi) Section 1854(c) (relating to the requirement of uniform premiums among individuals enrolled in the plan).CommentsClose CommentsPermalink
`(vii) Section 1854(g) (relating to restrictions on imposition of premium taxes with respect to payments to organizations).CommentsClose CommentsPermalink
`(viii) Section 1856(b)(3) (relating to relation to State laws).CommentsClose CommentsPermalink
`(ix) The provisions of part C relating to timelines for contract renewal and beneficiary notification.'.CommentsClose CommentsPermalink
TITLE V--PROVISIONS RELATING TO MEDICARE PART A
SEC. 501. INPATIENT HOSPITAL PAYMENT UPDATES.
(a) For Acute Hospitals- Clause (i) of section 1886(b)(3)(B) of the Social Security Act (
(1) in subclause (XIX), by striking `and';CommentsClose CommentsPermalink
(2) by redesignating subclause (XX) as subclause (XXII); andCommentsClose CommentsPermalink
(3) by inserting after subclause (XIX) the following new subclauses:CommentsClose CommentsPermalink
`(XX) for fiscal year 2007, subject to clause (viii), the market basket percentage increase for hospitals in all areas,CommentsClose CommentsPermalink
`(XXI) for fiscal year 2008, subject to clause (viii), the market basket percentage increase minus 0.25 percentage point for hospitals in all areas, and'.CommentsClose CommentsPermalink
(b) For Other Hospitals- Clause (ii) of such section is amended--CommentsClose CommentsPermalink
(1) in subclause (VII) by striking `and';CommentsClose CommentsPermalink
(2) by redesignating subclause (VIII) as subclause (X); andCommentsClose CommentsPermalink
(3) by inserting after subclause (VII) the following new subclauses:CommentsClose CommentsPermalink
`(VIII) fiscal years 2003 through 2007, is the market basket percentage increase,CommentsClose CommentsPermalink
`(IX) fiscal year 2008, is the market basket percentage increase minus 0.25 percentage point, and'.CommentsClose CommentsPermalink
(c) Delayed Effective Date-CommentsClose CommentsPermalink
(1) ACUTE CARE HOSPITALS- The amendments made by subsection (a) shall not apply to discharges occurring before January 1, 2008.CommentsClose CommentsPermalink
(2) OTHER HOSPITALS- The amendments made by subsection (b) shall be applied, only with respect to cost reporting periods beginning during fiscal year 2008 and not with respect to the computation for any succeeding cost reporting period, by substituting `0.1875 percentage point' for `0.25 percentage point'.CommentsClose CommentsPermalink
SEC. 502. PAYMENT FOR INPATIENT REHABILITATION FACILITY (IRF) SERVICES.
(a) Payment Update-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1886(j)(3)(C) of the Social Security Act (
(2) DELAYED EFFECTIVE DATE- The amendment made by paragraph (1) shall not apply to payment units occurring before January 1, 2008.CommentsClose CommentsPermalink
(b) Inpatient Rehabilitation Facility Classification Criteria-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 5005 of the Deficit Reduction Act of 2005 (
(A) in subsection (a), by striking `apply the applicable percent specified in subsection (b)' and inserting `require a compliance rate that is no greater than the 60 percent compliance rate that became effective for cost reporting periods beginning on or after July 1, 2006,'; andCommentsClose CommentsPermalink
(B) by amending subsection (b) to read as follows:CommentsClose CommentsPermalink
`(b) Continued Use of Comorbidities- For portions of cost reporting periods occurring on or after the date of the enactment of the Children's Health and Medicare Protection Act of 2007, the Secretary shall include patients with comorbidities as described in section 412.23(b)(2)(i) of title 42, Code of Federal Regulations (as in effect as of January 1, 2007), in the inpatient population that counts towards the percent specified in subsection (a).'.CommentsClose CommentsPermalink
(2) EFFECTIVE DATE- The amendment made by paragraph (1)(A) shall apply to portions of cost reporting periods beginning on or after the date of the enactment of this Act.CommentsClose CommentsPermalink
(c) Payment for Certain Medical Conditions Treated in Inpatient Rehabilitation Facilities-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1886(j) of the Social Security Act (
(A) by redesignating paragraph (7) as paragraph (8);CommentsClose CommentsPermalink
(B) by inserting after paragraph (6) the following new paragraph:CommentsClose CommentsPermalink
`(7) SPECIAL PAYMENT RULE FOR CERTAIN MEDICAL CONDITIONS-CommentsClose CommentsPermalink
`(A) IN GENERAL- Subject to subparagraph (H), in the case of discharges occurring on or after October 1, 2008, in lieu of the standardized payment amount (as determined pursuant to the preceding provisions of this subsection) that would otherwise be applicable under this subsection, the Secretary shall substitute, for payment units with respect to an applicable medical condition (as defined in subparagraph (G)(i)) that is treated in an inpatient rehabilitation facility, the modified standardized payment amount determined under subparagraph (B).CommentsClose CommentsPermalink
`(B) MODIFIED STANDARDIZED PAYMENT AMOUNT- The modified standardized payment amount for an applicable medical condition shall be based on the amount determined under subparagraph (C) for such condition, as adjusted under subparagraphs (D), (E), and (F).CommentsClose CommentsPermalink
`(C) AMOUNT DETERMINED-CommentsClose CommentsPermalink
`(i) IN GENERAL- The amount determined under this subparagraph for an applicable medical condition shall be based on the sum of the following:CommentsClose CommentsPermalink
`(I) An amount equal to the average per stay skilled nursing facility payment rate for the applicable medical condition (as determined under clause (ii)).CommentsClose CommentsPermalink
`(II) An amount equal to 25 percent of the difference between the overhead costs (as defined in subparagraph (G)(ii)) component of the average inpatient rehabilitation facility per stay payment amount for the applicable medical condition (as determined under the preceding paragraphs of this subsection) and the overhead costs component of the average per stay skilled nursing facility payment rate for such condition (as determined under clause (ii)).CommentsClose CommentsPermalink
`(III) An amount equal to 33 percent of the difference between the patient care costs (as defined in subparagraph (G)(iii)) component of the average inpatient rehabilitation facility per stay payment amount for the applicable medical condition (as determined under the preceding paragraphs of this subsection) and the patient care costs component of the average per stay skilled nursing facility payment rate for such condition (as determined under clause (ii)).CommentsClose CommentsPermalink
`(ii) DETERMINATION OF AVERAGE PER STAY SKILLED NURSING FACILITY PAYMENT RATE- For purposes of clause (i), the Secretary shall convert skilled nursing facility payment rates for applicable medical conditions, as determined under section 1888(e), to average per stay skilled nursing facility payment rates for each such condition.CommentsClose CommentsPermalink
`(D) ADJUSTMENTS- The Secretary shall adjust the amount determined under subparagraph (C) for an applicable medical condition using the adjustments to the prospective payment rates for inpatient rehabilitation facilities described in paragraphs (2), (3), (4), and (6).CommentsClose CommentsPermalink
`(E) UPDATE FOR INFLATION- Except in the case of a fiscal year for which the Secretary rebases the amounts determined under subparagraph (C) for applicable medical conditions pursuant to subparagraph (F), the Secretary shall annually update the amounts determined under subparagraph (C) for each applicable medical condition by the increase factor for inpatient rehabilitation facilities (as described in paragraph (3)(C)).CommentsClose CommentsPermalink
`(F) REBASING- The Secretary shall periodically (but in no case less than once every 5 years) rebase the amounts determined under subparagraph (C) for applicable medical conditions using the methodology described in such subparagraph and the most recent and complete cost report and claims data available.CommentsClose CommentsPermalink
`(G) DEFINITIONS- In this paragraph:CommentsClose CommentsPermalink
`(i) APPLICABLE MEDICAL CONDITION- The term `applicable medical condition' means--CommentsClose CommentsPermalink
`(I) unilateral knee replacement;CommentsClose CommentsPermalink
`(II) unilateral hip replacement; andCommentsClose CommentsPermalink
`(III) unilateral hip fracture.CommentsClose CommentsPermalink
`(ii) OVERHEAD COSTS- The term `overhead costs' means those Medicare-allowable costs that are contained in the General Service cost centers of the Medicare cost reports for inpatient rehabilitation facilities and for skilled nursing facilities, respectively, as determined by the Secretary.CommentsClose CommentsPermalink
`(iii) PATIENT CARE COSTS- The term `patient care costs' means total Medicare-allowable costs minus overhead costs.CommentsClose CommentsPermalink
`(H) SUNSET- The provisions of this paragraph shall cease to apply as of the date the Secretary implements an integrated, site-neutral payment methodology under this title for post-acute care.'; andCommentsClose CommentsPermalink
(C) in paragraph (8), as redesignated by paragraph (1)--CommentsClose CommentsPermalink
(i) in subparagraph (C), by striking `and' at the end;CommentsClose CommentsPermalink
(ii) in subparagraph (D), by striking the period at the end and inserting `, and'; andCommentsClose CommentsPermalink
(iii) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(E) modified standardized payment amounts under paragraph (7).'.CommentsClose CommentsPermalink
(2) SPECIAL RULE FOR DISCHARGES OCCURRING IN THE SECOND HALF OF FISCAL YEAR 2008-CommentsClose CommentsPermalink
(A) IN GENERAL- In the case of discharges from an inpatient rehabilitation facility occurring during the period beginning on April 1, 2008, and ending on September 30, 2008, for applicable medical conditions (as defined in paragraph (7)(G)(i) of section 1886(j) of the Social Security Act (
(B) IMPLEMENTATION- Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement this subsection by program instruction or otherwise. Paragraph (8)(E) of such section 1886(j) of the Social Security Act, as added by paragraph (1)(C), shall apply for purposes of this subsection in the same manner as such paragraph applies for purposes of paragraph (7) of such section 1886(j).CommentsClose CommentsPermalink
(d) Recommendations for Classifying Inpatient Rehabilitation Hospitals and Units-CommentsClose CommentsPermalink
(1) REPORT TO CONGRESS- Not later than 12 months after the date of the enactment of this Act, the Secretary of Health and Human Services, in consultation with physicians (including geriatricians and physiatrists), administrators of inpatient rehabilitation, acute care hospitals, skilled nursing facilities, and other settings providing rehabilitation services, Medicare beneficiaries, trade organizations representing inpatient rehabilitation hospitals and units and skilled nursing facilities, and the Medicare Payment Advisory Commission, shall submit to the Committee on Ways and Means of the House of Representatives and the Committee on Finance of the Senate a report that includes--CommentsClose CommentsPermalink
(A) an examination of Medicare beneficiaries' access to medically necessary rehabilitation services;CommentsClose CommentsPermalink
(B) alternatives or refinements to the 75 percent rule policy for determining exclusion criteria for inpatient rehabilitation hospital and unit designation under the Medicare program, including determining clinical appropriateness of inpatient rehabilitation hospital and unit admissions and alternative criteria which would consider a patient's functional status, diagnosis, co-morbidities, and other relevant factors; andCommentsClose CommentsPermalink
(C) an examination that identifies any condition for which individuals are commonly admitted to inpatient rehabilitation hospitals that is not included as a condition described in section 412.23(b)(2)(iii) of title 42, Code of Federal Regulations, to determine the appropriate setting of care, and any variation in patient outcomes and costs, across settings of care, for treatment of such conditions.CommentsClose CommentsPermalink
For the purposes of this subsection, the term `75 percent rule' means the requirement of section 412.23(b)(2) of title 42, Code of Federal Regulations, that 75 percent of the patients of a rehabilitation hospital or converted rehabilitation unit are in 1 or more of 13 listed treatment categories.CommentsClose CommentsPermalink
(2) CONSIDERATIONS- In developing the report described in paragraph (1), the Secretary shall include the following:CommentsClose CommentsPermalink
(A) The potential effect of the 75 percent rule on access to rehabilitation care by Medicare beneficiaries for the treatment of a condition, whether or not such condition is described in section 412.23(b)(2)(iii) of title 42, Code of Federal Regulations.CommentsClose CommentsPermalink
(B) An analysis of the effectiveness of rehabilitation care for the treatment of conditions, whether or not such conditions are described in section 412.23(b)(2)(iii) of title 42, Code of Federal Regulations, available to Medicare beneficiaries in various health care settings, taking into account variation in patient outcomes and costs across different settings of care, and which may include whether the Medicare program and Medicare beneficiaries may incur higher costs of care for the entire episode of illness due to readmissions, extended lengths of stay, and other factors.CommentsClose CommentsPermalink
SEC. 503. LONG-TERM CARE HOSPITALS.
(a) Long-Term Care Hospital Payment Update-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1886 of the Social Security Act (
`(m) Prospective Payment for Long-Term Care Hospitals-CommentsClose CommentsPermalink
`(1) REFERENCE TO ESTABLISHMENT AND IMPLEMENTATION OF SYSTEM- For provisions related to the establishment and implementation of a prospective payment system for payments under this title for inpatient hospital services furnished by a long-term care hospital described in subsection (d)(1)(B)(iv), see section 123 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 and section 307(b) of Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000.CommentsClose CommentsPermalink
`(2) UPDATE FOR RATE YEAR 2008- In implementing the system described in paragraph (1) for discharges occurring during the rate year ending in 2008 for a hospital, the base rate for such discharges for the hospital shall be the same as the base rate for discharges for the hospital occurring during the previous rate year.'.CommentsClose CommentsPermalink
(2) DELAYED EFFECTIVE DATE- Subsection (m)(2) of section 1886 of the Social Security Act, as added by paragraph (1), shall not apply to discharges occurring on or after July 1, 2007, and before January 1, 2008.CommentsClose CommentsPermalink
(b) Payment for Long-Term Care Hospital Services; Patient and Facility Criteria-CommentsClose CommentsPermalink
(1) DEFINITION OF LONG-TERM CARE HOSPITAL-CommentsClose CommentsPermalink
(A) DEFINITION- Section 1861 of the Social Security Act (
`Long-Term Care Hospital
`(ddd) The term `long-term care hospital' means an institution which--CommentsClose CommentsPermalink
`(1) is primarily engaged in providing inpatient services, by or under the supervision of a physician, to Medicare beneficiaries whose medically complex conditions require a long hospital stay and programs of care provided by a long-term care hospital;CommentsClose CommentsPermalink
`(2) has an average inpatient length of stay (as determined by the Secretary) for Medicare beneficiaries of greater than 25 days, or as otherwise defined in section 1886(d)(1)(B)(iv);CommentsClose CommentsPermalink
`(3) satisfies the requirements of subsection (e);CommentsClose CommentsPermalink
`(4) meets the following facility criteria:CommentsClose CommentsPermalink
`(A) the institution has a patient review process, documented in the patient medical record, that screens patients prior to admission for appropriateness of admission to a long-term care hospital, validates within 48 hours of admission that patients meet admission criteria for long-term care hospitals, regularly evaluates patients throughout their stay for continuation of care in a long-term care hospital, and assesses the available discharge options when patients no longer meet such continued stay criteria;CommentsClose CommentsPermalink
`(B) the institution has active physician involvement with patients during their treatment through an organized medical staff, physician-directed treatment with physician on-site availability on a daily basis to review patient progress, and consulting physicians on call and capable of being at the patient's side within a moderate period of time, as determined by the Secretary;CommentsClose CommentsPermalink
`(C) the institution has interdisciplinary team treatment for patients, requiring interdisciplinary teams of health care professionals, including physicians, to prepare and carry out an individualized treatment plan for each patient; andCommentsClose CommentsPermalink
`(5) meets patient criteria relating to patient mix and severity appropriate to the medically complex cases that long-term care hospitals are designed to treat, as measured under section 1886(n).'.CommentsClose CommentsPermalink
(B) NEW PATIENT CRITERIA FOR LONG-TERM CARE HOSPITAL PROSPECTIVE PAYMENT- Section 1886 of such Act (
`(n) Patient Criteria for Prospective Payment to Long-Term Care Hospitals-CommentsClose CommentsPermalink
`(1) IN GENERAL- To be eligible for prospective payment under this section as a long-term care hospital, a long-term care hospital must admit not less than a majority of patients who have a high level of severity, as defined by the Secretary, and who are assigned to one or more of the following major diagnostic categories:CommentsClose CommentsPermalink
`(A) Circulatory diagnoses.CommentsClose CommentsPermalink
`(B) Digestive, endocrine, and metabolic diagnoses.CommentsClose CommentsPermalink
`(C) Infection disease diagnoses.CommentsClose CommentsPermalink
`(D) Neurological diagnoses.CommentsClose CommentsPermalink
`(E) Renal diagnoses.CommentsClose CommentsPermalink
`(F) Respiratory diagnoses.CommentsClose CommentsPermalink
`(G) Skin diagnoses.CommentsClose CommentsPermalink
`(H) Other major diagnostic categories as selected by the Secretary.CommentsClose CommentsPermalink
`(2) MAJOR DIAGNOSTIC CATEGORY DEFINED- In paragraph (1), the term `major diagnostic category' means the medical categories formed by dividing all possible principle diagnosis into mutually exclusive diagnosis areas which are referred to in 67 Federal Register 49985 (August 1, 2002).'.CommentsClose CommentsPermalink
(C) ESTABLISHMENT OF REHABILITATION UNITS WITHIN CERTAIN LONG-TERM CARE HOSPITALS- If the Secretary of Health and Human Services does not include rehabilitation services within a major diagnostic category under section 1886(n)(2) of the Social Security Act, as added by subparagraph (B), the Secretary shall approve for purposes of title XVIII of such Act distinct part inpatient rehabilitation hospital units in long-term care hospitals consistent with the following:CommentsClose CommentsPermalink
(i) A hospital that, on or before October 1, 2004, was classified by the Secretary as a long-term care hospital, as described in section 1886(d)(1)(B)(iv)(I) of such Act (
(ii) Services provided in inpatient rehabilitation units established under clause (i) shall not be reimbursed as long-term care hospital services under section 1886 of such Act and shall be subject to payment policies established by the Secretary to reimburse services provided by inpatient hospital rehabilitation units.CommentsClose CommentsPermalink
(D) EFFECTIVE DATE- The amendments made by subparagraphs (A) and (B), and the provisions of subparagraph (C), shall apply to discharges occurring on or after January 1, 2008.CommentsClose CommentsPermalink
(2) IMPLEMENTATION OF FACILITY AND PATIENT CRITERIA-CommentsClose CommentsPermalink
(A) REPORT- No later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services (in this section referred to as the `Secretary') shall submit to the appropriate committees of Congress a report containing recommendations regarding the promulgation of the national long-term care hospital facility and patient criteria for application under paragraphs (4) and (5) of section 1861(ccc) and section 1886(n) of the Social Security Act, as added by subparagraphs (A) and (B), respectively, of paragraph (1). In the report, the Secretary shall consider recommendations contained in a report to Congress by the Medicare Payment Advisory Commission in June 2004 for long-term care hospital-specific facility and patient criteria to ensure that patients admitted to long-term care hospitals are medically complex and appropriate to receive long-term care hospital services.CommentsClose CommentsPermalink
(B) IMPLEMENTATION- No later than 1 year after the date of submittal of the report under subparagraph (A), the Secretary shall, after rulemaking, implement the national long-term care hospital facility and patient criteria referred to in such subparagraph. Such long-term care hospital facility and patient criteria shall be used to screen patients in determining the medical necessity and appropriateness of a Medicare beneficiary's admission to, continued stay at, and discharge from, long-term care hospitals under the Medicare program and shall take into account the medical judgment of the patient's physician, as provided for under sections 1814(a)(3) and 1835(a)(2)(B) of the Social Security Act (
(3) EXPANDED REVIEW OF MEDICAL NECESSITY-CommentsClose CommentsPermalink
(A) IN GENERAL- The Secretary of Health and Human Services shall provide, under contracts with one or more appropriate fiscal intermediaries or medicare administrative contractors under section 1874A(a)(4)(G) of the Social Security Act (
(B) REVIEW METHODOLOGY- The medical necessity reviews under paragraph (A) shall be conducted for each such long-term care hospital on an annual basis in accordance with rules (including a sample methodology) specified by the Secretary. Such sample methodology shall--CommentsClose CommentsPermalink
(i) provide for a statistically valid and representative sample of admissions of such individuals sufficient to provide results at a 95 percent confidence interval; andCommentsClose CommentsPermalink
(ii) guarantee that at least 75 percent of overpayments received by long-term care hospitals for medically unnecessary admissions and continued stays of individuals in long-term care hospitals will be identified and recovered and that related days of care will not be counted toward the length of stay requirement contained in section 1886(d)(1)(B)(iv) of the Social Security Act (
(C) CONTINUATION OF REVIEWS- Under contracts under this paragraph, the Secretary shall establish a denial rate with respect to such reviews that, if exceeded, could require further review of the medical necessity of admissions and continued stay in the hospital involved.CommentsClose CommentsPermalink
(D) TERMINATION OF REQUIRED REVIEWS-CommentsClose CommentsPermalink
(i) IN GENERAL- Subject to clause (iii), the previous provisions of this subsection shall cease to apply as of the date specified in clause (ii).CommentsClose CommentsPermalink
(ii) DATE SPECIFIED- The date specified in this clause is the later of January 1, 2013, or the date of implementation of national long-term care hospital facility and patient criteria under section paragraph (2)(B).CommentsClose CommentsPermalink
(iii) CONTINUATION- As of the date specified in clause (ii), the Secretary shall determine whether to continue to guarantee, through continued medical review and sampling under this paragraph, recovery of at least 75 percent of overpayments received by long-term care hospitals due to medically unnecessary admissions and continued stays.CommentsClose CommentsPermalink
(E) FUNDING- The costs to fiscal intermediaries or medicare administrative contractors conducting the medical necessity reviews under subparagraph (A) shall be funded from the aggregate overpayments recouped by the Secretary of Health and Human Services from long-term care hospitals due to medically unnecessary admissions and continued stays. The Secretary may use an amount not in excess of 40 percent of the overpayments recouped under this paragraph to compensate the fiscal intermediaries or Medicare administrative contractors for the costs of services performed.CommentsClose CommentsPermalink
(4) LIMITED, QUALIFIED MORATORIUM OF LONG-TERM CARE HOSPITALS-CommentsClose CommentsPermalink
(A) IN GENERAL- Subject to subparagraph (B), the Secretary shall impose a temporary moratorium on the certification of new long-term care hospitals (and satellite facilities), and new long-term care hospital and satellite facility beds, for purposes of the Medicare program under title XVIII of the Social Security Act. The moratorium shall terminate at the end of the 4-year period beginning on the date of the enactment of this Act.CommentsClose CommentsPermalink
(B) EXCEPTIONS-CommentsClose CommentsPermalink
(i) IN GENERAL- The moratorium under subparagraph (A) shall not apply as follows:CommentsClose CommentsPermalink
(I) To a long-term care hospital, satellite facility, or additional beds under development as of the date of the enactment of this Act.CommentsClose CommentsPermalink
(II) To an existing long-term care hospital that requests to increase its number of long-term care hospital beds, if the Secretary determines there is a need at the long-term care hospital for additional beds to accommodate--CommentsClose CommentsPermalink
(aa) infectious disease issues for isolation of patients;CommentsClose CommentsPermalink
(bb) bedside dialysis services;CommentsClose CommentsPermalink
(cc) single-sex accommodation issues;CommentsClose CommentsPermalink
(dd) behavioral issues; orCommentsClose CommentsPermalink
(ee) any requirements of State or local law.CommentsClose CommentsPermalink
(III) To an existing long-term care hospital that requests an increase in beds because of the closure of a long-term care hospital or significant decrease in the number of long-term care hospital beds, in a State where there is only one other long-term care hospital.CommentsClose CommentsPermalink
There shall be no administrative or judicial review from a decision of the Secretary under this subparagraph.CommentsClose CommentsPermalink
(ii) `UNDER DEVELOPMENT' DEFINED- For purposes of clause (i)(I), a long-term care hospital or satellite facility is considered to be `under development' as of a date if any of the following have occurred on or before such date:CommentsClose CommentsPermalink
(I) The hospital or a related party has a binding written agreement with an outside, unrelated party for the construction, reconstruction, lease, rental, or financing of the long-term care hospital and the hospital has expended, before the date of the enactment of this Act, at least 10 percent of the estimated cost of the project (or, if less, $2,500,000).CommentsClose CommentsPermalink
(II) Actual construction, renovation or demolition for the long-term care hospital has begun and the hospital has expended, before the date of the enactment of this Act, at least 10 percent of the estimated cost of the project (or, if less, $2,500,000).CommentsClose CommentsPermalink
(III) A certificate of need has been approved in a State where one is required or other necessary approvals from appropriate State agencies have been received for the operation of the hospital.CommentsClose CommentsPermalink
(IV) The hospital documents that, within 3 months after the date of the enactment of this Act, it is within a 6-month long-term care hospital demonstration period required by section 412.23(e)(1)-(3) of title 42, Code of Federal Regulations, to demonstrate that it has a greater than 25 day average length of stay.CommentsClose CommentsPermalink
(5) NO APPLICATION OF 25 PERCENT PATIENT THRESHOLD PAYMENT ADJUSTMENT TO FREESTANDING AND GRANDFATHERED LTCHS- The Secretary shall not apply, during the 5-year period beginning on the date of the enactment of this Act, section 412.536 of title 42, Code of Federal Regulations, or any similar provision, to freestanding long-term care hospitals and the Secretary shall not apply such section or section 412.534 of title 42, Code of Federal Regulations, or any similar provisions, to a long-term care hospital identified by section 4417(a) of the Balanced Budget Act of 1997 (
(6) PAYMENT FOR HOSPITALS-WITHIN-HOSPITALS-CommentsClose CommentsPermalink
(A) IN GENERAL- Payments to an applicable long-term care hospital or satellite facility which is located in a rural area or which is co-located with an urban single or MSA dominant hospital under paragraphs (d)(1), (e)(1), and (e)(4) of section 412.534 of title 42, Code of Federal Regulations, shall not be subject to any payment adjustment under such section if no more than 75 percent of the hospital's Medicare discharges (other than discharges described in paragraph (d)(2) or (e)(3) of such section) are admitted from a co-located hospital.CommentsClose CommentsPermalink
(B) CO-LOCATED LONG-TERM CARE HOSPITALS AND SATELLITE FACILITIES-CommentsClose CommentsPermalink
(i) IN GENERAL- Payment to an applicable long-term care hospital or satellite facility which is co-located with another hospital shall not be subject to any payment adjustment under section 412.534 of title 42, Code of Federal Regulations, if no more than 50 percent of the hospital's Medicare discharges (other than discharges described in section 412.534(c)(3) of such title) are admitted from a co-located hospital.CommentsClose CommentsPermalink
(ii) APPLICABLE LONG-TERM CARE HOSPITAL OR SATELLITE FACILITY DEFINED- In this paragraph, the term `applicable long-term care hospital or satellite facility' means a hospital or satellite facility that is subject to the transition rules under section 412.534(g) of title 42, Code of Federal Regulations.CommentsClose CommentsPermalink
(C) EFFECTIVE DATE- Subparagraphs (A) and (B) shall apply to discharges occurring on or after October 1, 2007, and before October 1, 2012.CommentsClose CommentsPermalink
(7) NO APPLICATION OF VERY SHORT-STAY OUTLIER POLICY- The Secretary shall not apply, during the 5-year period beginning on the date of the enactment of this Act, the amendments finalized on May 11, 2007 (72 Federal Register 26904) made to the short-stay outlier payment provision for long-term care hospitals contained in section 412.529(c)(3)(i) of title 42, Code of Federal Regulations, or any similar provision.CommentsClose CommentsPermalink
(8) NO APPLICATION OF ONE TIME ADJUSTMENT TO STANDARD AMOUNT- The Secretary shall not, during the 5-year period beginning on the date of the enactment of this Act, make the one-time prospective adjustment to long-term care hospital prospective payment rates provided for in section 412.523(d)(3) of title 42, Code of Federal Regulations, or any similar provision.CommentsClose CommentsPermalink
(c) Separate Classification for Certain Long-Stay Cancer Hospitals-CommentsClose CommentsPermalink
(1) IN GENERAL- Subsection (d)(1)(B) of section 1886 of the Social Security Act (
(A) in clause (iv)--CommentsClose CommentsPermalink
(i) in subclause (I), by striking `(iv)(I)' and inserting `(iv)' and by striking `or' at the end; andCommentsClose CommentsPermalink
(ii) in subclause (II)--CommentsClose CommentsPermalink
(I) by striking `, or' at the end and inserting a semicolon; andCommentsClose CommentsPermalink
(II) by redesignating such subclause as clause (vi) and by moving it to immediately follow clause (v); andCommentsClose CommentsPermalink
(B) in clause (v), by striking the semicolon at the end and inserting `, or'.CommentsClose CommentsPermalink
(2) CONFORMING PAYMENT REFERENCES- Subsection (b) of such section is amended--CommentsClose CommentsPermalink
(A) in paragraph (2)(E)(ii), by adding at the end the following new subclause:CommentsClose CommentsPermalink
`(III) Hospitals described in clause (vi) of such subsection.';CommentsClose CommentsPermalink
(B) in paragraph (3)(F)(iii), by adding at the end the following new subclause:CommentsClose CommentsPermalink
`(VI) Hospitals described in clause (vi) of such subsection.';CommentsClose CommentsPermalink
(C) in paragraphs (3)(G)(ii), (3)(H)(i), and (3)(H)(ii)(I), by inserting `or (vi)' after `clause (iv)' each place it appears;CommentsClose CommentsPermalink
(D) in paragraph (3)(H)(iv), by adding at the end the following new subclause:CommentsClose CommentsPermalink
`(IV) Hospitals described in clause (vi) of such subsection.';CommentsClose CommentsPermalink
(E) in paragraph (3)(J), by striking `subsection (d)(1)(B)(iv)' and inserting `clause (iv) or (vi) of subsection (d)(1)(B)'; andCommentsClose CommentsPermalink
(F) in paragraph (7)(B), by adding at the end the following new clause:CommentsClose CommentsPermalink
`(iv) Hospitals described in clause (vi) of such subsection.'.CommentsClose CommentsPermalink
(3) ADDITIONAL CONFORMING AMENDMENTS- The second sentence of subsection (d)(1)(B) of such section is amended--CommentsClose CommentsPermalink
(A) by inserting `(as in effect as of such date)' after `clause (iv)'; andCommentsClose CommentsPermalink
(B) by inserting `(or, in the case of a hospital classified under clause (iv)(II), as so in effect, shall be classified under clause (vi) on and after the effective date of such clause)' after `so classified'.CommentsClose CommentsPermalink
(4) IN GENERAL- In the case of a hospital that is classified under clause (iv)(II) of section 1886(d)(1)(B) of the Social Security Act immediately before the date of the enactment of this Act and which is classified under clause (vi) of such section after such date of enactment, payments under section 1886 of such Act for cost reporting periods beginning after the date of the enactment of this Act shall be based upon payment rates in effect for the cost reporting period for such hospital beginning during fiscal year 2001, increased for each succeeding cost reporting period (beginning before the date of the enactment of this Act) by the applicable percentage increase under section 1886(b)(3)(B)(ii) of such Act.CommentsClose CommentsPermalink
(5) CLARIFICATION OF TREATMENT OF SATELLITE FACILITIES AND REMOTE LOCATIONS- A long-stay cancer hospital described in section 1886(d)(1)(B)(vi) of the Social Security Act, as designated under paragraph (1), shall include satellites or remote site locations for such hospital established before or after the date of the enactment of this Act without regard to section 412.22(h)(2)(i) of title 42, Code of Federal Regulations, if the provider-based requirements under section 413.65 of such title, applicable certification requirements under title XVIII of the Social Security Act, and such other applicable State licensure and certificate of need requirements are met with respect to such satellites or remote site locations.CommentsClose CommentsPermalink
SEC. 504. INCREASING THE DSH ADJUSTMENT CAP.
(a) In General- Section 1886(d)(5)(F)(xiv) of the Social Security Act (
(1) in subclause (II), by striking `12 percent' and inserting `the percent specified in subclause (III)'; andCommentsClose CommentsPermalink
(2) by adding at the end the following new subclause:CommentsClose CommentsPermalink
`(III) The percent specified in this subclause is, in the case of discharges occurring--CommentsClose CommentsPermalink
`(a) before October 1, 2007, 12 percent;CommentsClose CommentsPermalink
`(b) during fiscal year 2008, 16 percent;CommentsClose CommentsPermalink
`(c) during fiscal year 2009, 18 percent; andCommentsClose CommentsPermalink
`(d) on or after October 1, 2009, 12 percent.'.CommentsClose CommentsPermalink
(b) Special Rule in Computing Disproportionate Patient Percentage-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1886(d)(5)(F)(vi) of such Act (
(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply to discharges in cost reporting periods of hospitals beginning on or after January 1, 2008.CommentsClose CommentsPermalink
SEC. 505. PPS-EXEMPT CANCER HOSPITALS.
(a) Authorizing Rebasing for PPS-Exempt Cancer Hospitals- Section 1886(b)(3)(F) of the Social Security Act (
`(iv) In the case of a hospital (or unit described in the matter following clause (v) of subsection (d)(1)(B)) that received payment under this subsection for inpatient hospital services furnished during cost reporting periods beginning before October 1, 1999, that is within a class of hospital described in clause (iii) (other than subclause (IV), relating to long-term care hospitals, and that requests the Secretary (in a form and manner specified by the Secretary) to effect a rebasing under this clause for the hospital, the Secretary may compute the target amount for the hospital's 12-month cost reporting period beginning during fiscal year 2008 as an amount equal to the average described in clause (ii) but determined as if any reference in such clause to `the date of the enactment of this subparagraph' were a reference to `the date of the enactment of this clause'.'.CommentsClose CommentsPermalink
(b) Additional Cancer Hospital Provisions-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1886(d)(1) of the Social Security Act (
(A) in subparagraph (B)(v)--CommentsClose CommentsPermalink
(i) by striking `or' at the end of subclause (II); andCommentsClose CommentsPermalink
(ii) by adding at the end the following:CommentsClose CommentsPermalink
`(IV) a hospital that is a nonprofit corporation, the sole member of which is affiliated with a university that has been the recipient of a cancer center support grant from the National Cancer Institute of the National Institutes of Health, and which sole member (or its predecessors or such university) was recognized as a comprehensive cancer center by the National Cancer Institute of the National Institutes of Health as of April 20, 1983, if the hospital's articles of incorporation specify that at least 50 percent of its total discharges have a principal finding of neoplastic disease (as defined in subparagraph (E)) and if, of December 31, 2005, the hospital was licensed for less than 150 acute care beds, orCommentsClose CommentsPermalink
`(V) a hospital (aa) that the Secretary has determined to be, at any time on or before December 31, 2011, a hospital involved extensively in treatment for, or research on, cancer, (bb) that is (as of the date of such determination) a free-standing facility, (cc) for which the hospital's predecessor provider entity was University Hospitals of Cleveland with medicare provider number 36-0137;';CommentsClose CommentsPermalink
(B) in subparagraph (B), by inserting after clause (vi), as redesignated by section 503(c)(1)(A)(ii)(II), the following new clause:CommentsClose CommentsPermalink
`(vii) a hospital that--CommentsClose CommentsPermalink
`(I) is located in a State that as of December 31, 2006, had only one center under section 414 of the Public Health Service Act that has been designated by the National Cancer Institute as a comprehensive center currently serving all 21 counties in the most densely populated State in the nation (U.S. Census estimate for 2005: 8,717,925 persons; 1,134.5 persons per square mile), serving more than 70,000 patient visits annually;CommentsClose CommentsPermalink
`(II) as of December 31, 2006, served as the teaching and clinical care, research and training hospital for the Center described in subclause (II), providing significant financial and operational support to such Center;CommentsClose CommentsPermalink
`(III) as of December 31, 2006, served as a core and essential element in such Center which conducts more than 130 clinical trial activities, national cooperative group studies, investigator-initiated and peer review studies and has received as of 2005 at least $93,000,000 in research grant awards;CommentsClose CommentsPermalink
`(IV) as of December 31, 2006, includes dedicated patient care units organized primarily for the treatment of and research on cancer with approximately 125 beds, 75 percent of which are dedicated to cancer patients, and contains a radiation oncology department as well as specialized emergency services for oncology patients; andCommentsClose CommentsPermalink
`(V) as of December 31, 2004, is identified as the focus of the Center's inpatient activities in the Center's application as a NCI-designated comprehensive cancer center and shares the NCI comprehensive cancer designation with the Center;'; andCommentsClose CommentsPermalink
(C) in subparagraph (E)--CommentsClose CommentsPermalink
(i) by striking `subclauses (II) and (III)' and inserting `subclauses (II), (III), and (IV)'; andCommentsClose CommentsPermalink
(ii) by inserting `and subparagraph (B)(vi)' after `subparagraph (B)(v)'.CommentsClose CommentsPermalink
(2) EFFECTIVE DATES; PAYMENTS-CommentsClose CommentsPermalink
(A) APPLICATION TO COST REPORTING PERIODS-CommentsClose CommentsPermalink
(i) Any classification by reason of section 1886(d)(1)(B)(vi) of the Social Security Act (
(ii) The provisions of section 1886(d)(1)(B)(v)(IV) of the Social Security Act, as added by paragraph (1), shall take effect on January 1, 2008.CommentsClose CommentsPermalink
(B) BASE TARGET AMOUNT- Notwithstanding subsection (b)(3)(E) of section 1886 of the Social Security Act (
(i) the hospital shall be permitted to resubmit the 2006 Medicare 2552 cost report incorporating a cancer hospital sub-provider number and to apply the Medicare ratio-of-cost-to-charge settlement methodology for outpatient cancer services; andCommentsClose CommentsPermalink
(ii) the hospital's target amount under subsection (b)(3)(E)(i) of such section for the first cost reporting period beginning on or after January 1, 2006, shall be the allowable operating costs of inpatient hospital services (referred to in subclause (I) of such subsection) for such first cost reporting period.CommentsClose CommentsPermalink
(C) DEADLINE FOR PAYMENTS- Any payments owed to a hospital as a result of this subsection for periods occurring before the date of the enactment of this Act shall be made expeditiously, but in no event later than 1 year after such date of enactment.CommentsClose CommentsPermalink
(3) APPLICATION TO CERTAIN HOSPITALS-CommentsClose CommentsPermalink
(A) INAPPLICABILITY OF CERTAIN REQUIREMENTS- The provisions of section 412.22(e) of title 42, Code of Federal Regulations, shall not apply to a hospital described in section 1886(d)(1)(B)(v)(V) of the Social Security Act, as added by paragraph (1).CommentsClose CommentsPermalink
(B) APPLICATION TO COST REPORTING PERIODS- If the Secretary makes a determination that a hospital is described in section 1886(d)(1)(B)(v)(V) of the Social Security Act, as added by paragraph (1), such determination shall apply as of the first cost reporting period beginning on or after the date of such determination.CommentsClose CommentsPermalink
(C) BASE PERIOD- Notwithstanding the provisions of section 1886(b)(3)(E) of the Social Security Act (
(D) RULE- A hospital described in subclause (V) of section 1886(b)(1)(B)(v) of the Social Security Act, as added by paragraph (1), shall not qualify as a hospital described in such subclause for any cost reporting period in which less than 50 percent of its total discharges have a principal finding of neoplastic disease. With respect to the first cost reporting period for which a determination described in subparagraph (B) has been made, the Secretary shall accept a self-certification by the hospital, which shall be applicable to such first cost reporting period, that the hospital intends to have total discharges during such first cost reporting period of which 50 percent or more have a principal finding of neoplastic disease.CommentsClose CommentsPermalink
(c) MedPAC Report on PPS-Exempt Cancer Hospitals- Not later than March 1, 2009, the Medicare Payment Advisory Commission (established under section 1805 of the Social Security Act (
(1) Measures of payment adequacy and Medicare margins for PPS-exempt cancer hospitals, as established under section 1886(d)(1)(B)(v) of the Social Security Act (
(2) To the extent a PPS-exempt cancer hospital was previously affiliated with another hospital, the margins of the PPS-exempt hospital and the other hospital as separate entities and the margins of such hospitals that existed when the hospitals were previously affiliated.CommentsClose CommentsPermalink
(3) Payment adequacy for cancer discharges under the Medicare inpatient hospital prospective payment system.CommentsClose CommentsPermalink
SEC. 506. SKILLED NURSING FACILITY PAYMENT UPDATE.
(a) In General- Section 1888(e)(4)(E)(ii) of the Social Security Act (
(1) in subclause (III), by striking `and' at the end;CommentsClose CommentsPermalink
(2) by redesignating subclause (IV) as subclause (VI); andCommentsClose CommentsPermalink
(3) by inserting after subclause (III) the following new subclauses:CommentsClose CommentsPermalink
`(IV) for each of fiscal years 2004, 2005, 2006, and 2007, the rate computed for the previous fiscal year increased by the skilled nursing facility market basket percentage change for the fiscal year involved;CommentsClose CommentsPermalink
`(V) for fiscal year 2008, the rate computed for the previous fiscal year; and'.CommentsClose CommentsPermalink
(b) Delayed Effective Date- Section 1888(e)(4)(E)(ii)(V) of the Social Security Act, as inserted by subsection (a)(3), shall not apply to payment for days before January 1, 2008.CommentsClose CommentsPermalink
SEC. 507. REVOCATION OF UNIQUE DEEMING AUTHORITY OF THE JOINT COMMISSION FOR THE ACCREDITATION OF HEALTHCARE ORGANIZATIONS.
(a) Revocation- Section 1865 of the Social Security Act (
(1) by striking subsection (a); andCommentsClose CommentsPermalink
(2) by redesignating subsections (b), (c), (d), and (e) as subsections (a), (b), (c), and (d), respectively.CommentsClose CommentsPermalink
(b) Conforming Amendments- (1) Such section is further amended--CommentsClose CommentsPermalink
(A) in subsection (a)(1), as so redesignated, by striking `In addition, if' and inserting `If';CommentsClose CommentsPermalink
(B) in subsection (b), as so redesignated--CommentsClose CommentsPermalink
(i) by striking `released to him by the Joint Commission on Accreditation of Hospitals,' and inserting `released to the Secretary by'; andCommentsClose CommentsPermalink
(ii) by striking the comma after `Association';CommentsClose CommentsPermalink
(C) in subsection (c), as so redesignated, by striking `pursuant to subsection (a) or (b)(1)' and inserting `pursuant to subsection (a)(1)'; andCommentsClose CommentsPermalink
(D) in subsection (d), as so redesignated, by striking `pursuant to subsection (a) or (b)(1)' and inserting `pursuant to subsection (a)(1)'.CommentsClose CommentsPermalink
(2) Section 1861(e) of such Act (
(3) Section 1864(c) of such Act (
(4) Section 1875(b) of such Act (
(5) Section 1834(a)(20)(B) of such Act (
(6) Section 1852(e)(4)(C) of such Act (
(c) Authority to Recognize JCAHO as a National Accreditation Body- The Secretary of Health and Human Services may recognize the Joint Commission on Accreditation of Healthcare Organizations as a national accreditation body under section 1865 of the Social Security Act (
(d) Effective Date; Transition Rule- (1) Subject to paragraph (2), the amendments made by this section shall apply with respect to accreditations of hospitals granted on or after the date that is 18 months after the date of the enactment of this Act.CommentsClose CommentsPermalink
(2) For purposes of title XVIII of the Social Security Act (
SEC. 508. TREATMENT OF MEDICARE HOSPITAL RECLASSIFICATIONS.
(a) Extending Certain Medicare Hospital Wage Index Reclassifications Through Fiscal Year 2009-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 106(a) of the Medicare Improvements and Extension Act of 2006 (division B of
(2) SPECIAL EXCEPTION RECLASSIFICATIONS- The Secretary of Health and Human Services shall extend for discharges occurring through September 30, 2009, the special exception reclassification made under the authority of section 1886(d)(5)(I)(i) of the Social Security Act (
(b) Disregarding Section 508 Hospital Reclassifications for Purposes of Group Reclassifications- Section 508 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (
`(g) Disregarding Hospital Reclassifications for Purposes of Group Reclassifications- For purposes of the reclassification of a group of hospitals in a geographic area under section 1886(d), a hospital reclassified under this section (including any such reclassification which is extended under section 106(a) of the Medicare Improvements and Extension Act of 2006) shall not be taken into account and shall not prevent the other hospitals in such area from establishing such a group for such purpose.'.CommentsClose CommentsPermalink
(c) Other Hospital Reclassification Provisions- Notwithstanding any other provision of law--CommentsClose CommentsPermalink
(1) In the case of a subsection (d) hospital (as defined for purposes of section 1886 of the Social Security Act (
(2) For purposes of making payments under section 1886(d) of the Social Security Act (
(3) For purposes of making payments under section 1886(d) of the Social Security Act (
(A) such hospitals are located in a city with a population of no less than 20,000 and no greater than 30,000; andCommentsClose CommentsPermalink
(B) such hospitals are less than 3/4 miles apart.CommentsClose CommentsPermalink
(4) For purposes of making payments under section 1886(d) of the Social Security Act (
(5) For purposes of making payments under section 1886(d) of the Social Security Act (
(A) is licensed by the State in which it is located as a specialty hospital;CommentsClose CommentsPermalink
(B) specializes in the treatment of cardiac, vascular, and pulmonary diseases;CommentsClose CommentsPermalink
(C) provides at least 100 beds; andCommentsClose CommentsPermalink
(D) is located in Burlington County, New Jersey.CommentsClose CommentsPermalink
(6)(A) Any hospital described in subparagraph (B) shall be treated as located in the core based statistical area described in subparagraph (C) for purposes of making payments under section 1886(d) of the Social Security Act (
(B) A hospital described in this subparagraph is any hospital that--CommentsClose CommentsPermalink
(i) is located in a core based statistical area (CBSA) that--CommentsClose CommentsPermalink
(I) had a population (as reported in the decennial census for the year 2000) of at least 500,000, but not more than 750,000;CommentsClose CommentsPermalink
(II) had a population (as reported in such census) that was at least 10,000 below the population for the area as reported in the previous decennial census; andCommentsClose CommentsPermalink
(III) has as of January 1, 2006, at least 5, and no more than 7, subsection (d) hospitals; andCommentsClose CommentsPermalink
(ii) demonstrates that its average hourly wage amount (as determined consistent with section 1886(d)(10)(D)(vi) of the Social Security Act is not less than 96 percent of such average hourly wage amount rate for all subsection (d) hospitals located in same core base statistical area of the hospital.CommentsClose CommentsPermalink
(C) The area described in this subparagraph, with respect to a hospital described in subparagraph (B), is the core based statistical area that--CommentsClose CommentsPermalink
(i) is within the same State as, and is adjacent to, the core based statistical area in which the hospital is located; andCommentsClose CommentsPermalink
(ii) has an average hourly wage amount (described in subparagraph (B)(ii)) that is closest to (but does not exceed) such average hourly wage amount of the hospital.CommentsClose CommentsPermalink
(7) For purposes of making payments under section 1886(d) of the Social Security Act (
(8) For purposes of making payment under section 1886(d) of the Social Security Act (
(9) For purposes of making payment under section 1886(d) of the Social Security Act (
(10) In the case of a hospital located in Massachusetts or Clinton County, New York, that is reclassified based on wages under paragraph (8) or (10) of section 1886(d) of the Social Security Act into an area the area wage index for which is increased under section 4410(a) of the Balanced Budget Act of 1997 (Public Law 10533), such increased area wage index shall also apply to such hospital under such section 1886(d).CommentsClose CommentsPermalink
(11) For purposes of applying the area wage index under section 1886(d) of the Social Security Act (
(12) For purposes of making payment under section 1886(d) of the Social Security Act (
(13) For purposes of the previous provisions of this subsection (other than paragraph (1))--CommentsClose CommentsPermalink
(A) any reclassification effected under such provisions shall be treated as a decision of the Medicare Geographic Classification Review Board under section 1886(d) of the Social Security Act and subject to budget neutrality under paragraph (8)(D) of such section; andCommentsClose CommentsPermalink
(B) such provisions shall only apply to discharges occurring on or after October 1, 2008, during the 3-year reclassification period beginning on such date.CommentsClose CommentsPermalink
SEC. 509. MEDICARE CRITICAL ACCESS HOSPITAL DESIGNATIONS.
(a) In General-CommentsClose CommentsPermalink
(1) Section 405(h) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (
`(3) EXCEPTION-CommentsClose CommentsPermalink
`(A) IN GENERAL- The amendment made by paragraph (1) shall not apply to the certification by the State of Minnesota on or after January 1, 2006, under section 1820(c)(2)(B)(i)(II) of the Social Security Act (
`(B) CRITERIA DESCRIBED- A hospital meets the criteria described in this subparagraph if the hospital--CommentsClose CommentsPermalink
`(i) has been granted an exception by the State to an otherwise applicable statutory restriction on hospital construction or licensing prior to the date of enactment of this subparagraph; andCommentsClose CommentsPermalink
`(ii) is located on property which the State has approved for conveyance to a county within the State prior to such date of enactment.'.CommentsClose CommentsPermalink
(2) Section 1820(c)(2)(B)(i)(I) of the Social Security Act (
(b) Effective Date- The amendment made by subsection (a)(2) shall apply to cost reporting periods beginning on or after the date of the enactment of this Act.CommentsClose CommentsPermalink
TITLE VI--OTHER PROVISIONS RELATING TO MEDICARE PART B
Subtitle A--Payment and Coverage Improvements
SEC. 601. PAYMENT FOR THERAPY SERVICES.
(a) Extension of Exceptions Process for Medicare Therapy Caps- Section 1833(g)(5) of the Social Security Act (
(b) Study and Report-CommentsClose CommentsPermalink
(1) STUDY- The Secretary of Health and Human Services, in consultation with appropriate stakeholders, shall conduct a study on refined and alternative payment systems to the Medicare payment cap under section 1833(g) of the Social Security Act (
(A) The creation of multiple payment caps for such services to better reflect costs associated with specific health conditions.CommentsClose CommentsPermalink
(B) The development of a prospective payment system, including an episode-based system of payments, for such services.CommentsClose CommentsPermalink
(C) The data needed for the development of a system of multiple payment caps (or an alternative payment methodology) for such services and the availability of such data.CommentsClose CommentsPermalink
(2) REPORT- Not later than January 1, 2009, the Secretary shall submit to Congress a report on the study conducted under paragraph (1).CommentsClose CommentsPermalink
SEC. 602. MEDICARE SEPARATE DEFINITION OF OUTPATIENT SPEECH-LANGUAGE PATHOLOGY SERVICES.
(a) In General- Section 1861(ll) of the Social Security Act (
(1) by redesignating paragraphs (2) and (3) as paragraphs (3) and (4), respectively; andCommentsClose CommentsPermalink
(2) by inserting after paragraph (1) the following new paragraph:CommentsClose CommentsPermalink
`(2) The term `outpatient speech-language pathology services' has the meaning given the term `outpatient physical therapy services' in subsection (p), except that in applying such subsection--CommentsClose CommentsPermalink
`(A) `speech-language pathology' shall be substituted for `physical therapy' each place it appears; andCommentsClose CommentsPermalink
`(B) `speech-language pathologist' shall be substituted for `physical therapist' each place it appears.'.CommentsClose CommentsPermalink
(b) Conforming Amendments-CommentsClose CommentsPermalink
(1) Section 1832(a)(2)(C) of the Social Security Act (
(A) by striking `and outpatient' and inserting `, outpatient'; andCommentsClose CommentsPermalink
(B) by inserting before the semicolon at the end the following: `, and outpatient speech-language pathology services (other than services to which the second sentence of section 1861(p) applies through the application of section 1861(ll)(2))'.CommentsClose CommentsPermalink
(2) Subparagraphs (A) and (B) of section 1833(a)(8) of such Act (
(3) Section 1833(g)(1) of such Act (
(A) by inserting `and speech-language pathology services of the type described in such section through the application of section 1861(ll)(2)' after `1861(p)'; andCommentsClose CommentsPermalink
(B) by inserting `and speech-language pathology services' after `and physical therapy services'.CommentsClose CommentsPermalink
(4) The second sentence of section 1835(a) of such Act (
(A) by striking `section 1861(g)' and inserting `subsection (g) or (ll)(2) of section 1861' each place it appears; andCommentsClose CommentsPermalink
(B) by inserting `or outpatient speech-language pathology services, respectively' after `occupational therapy services'.CommentsClose CommentsPermalink
(5) Section 1861(p) of such Act (
(6) Section 1861(s)(2)(D) of such Act (
(7) Section 1862(a)(20) of such Act (
(A) by striking `outpatient occupational therapy services or outpatient physical therapy services' and inserting `outpatient physical therapy services, outpatient speech-language pathology services, or outpatient occupational therapy services'; andCommentsClose CommentsPermalink
(B) by striking `section 1861(g)' and inserting `subsection (g) or (ll)(2) of section 1861'.CommentsClose CommentsPermalink
(8) Section 1866(e)(1) of such Act (
(A) by striking `section 1861(g)' and inserting `subsection (g) or (ll)(2) of section 1861' the first two places it appears;CommentsClose CommentsPermalink
(B) by striking `defined) or' and inserting `defined),'; andCommentsClose CommentsPermalink
(C) by inserting before the semicolon at the end the following: `, or (through the operation of section 1861(ll)(2)) with respect to the furnishing of outpatient speech-language pathology'.CommentsClose CommentsPermalink
(c) Effective Date- The amendments made by this section shall apply to services furnished on or after January 1, 2008.CommentsClose CommentsPermalink
(d) Construction- Nothing in this section shall be construed to affect existing regulations and policies of the Centers for Medicare & Medicaid Services that require physician oversight of care as a condition of payment for speech-language pathology services under part B of the medicare program.CommentsClose CommentsPermalink
SEC. 603. INCREASED REIMBURSEMENT RATE FOR CERTIFIED NURSE-MIDWIVES.
(a) In General- Section 1833(a)(1)(K) of the Social Security Act (42 U.S.C.1395l(a)(1)(K)) is amended by striking `(but in no event' and all that follows through `performed by a physician)'.CommentsClose CommentsPermalink
(b) Effective Date- The amendment made by subsection (a) shall apply to services furnished on or after April 1, 2008.CommentsClose CommentsPermalink
SEC. 604. ADJUSTMENT IN OUTPATIENT HOSPITAL FEE SCHEDULE INCREASE FACTOR.
The first sentence of section 1833(t)(3)(C)(iv) of the Social Security Act (
SEC. 605. EXCEPTION TO 60-DAY LIMIT ON MEDICARE SUBSTITUTE BILLING ARRANGEMENTS IN CASE OF PHYSICIANS ORDERED TO ACTIVE DUTY IN THE ARMED FORCES.
(a) In General- Section 1842(b)(6)(D)(iii) of the Social Security Act (
(b) Effective Date- The amendment made by subsection (a) shall apply to services furnished on or after the date of the enactment of this section.CommentsClose CommentsPermalink
SEC. 606. EXCLUDING CLINICAL SOCIAL WORKER SERVICES FROM COVERAGE UNDER THE MEDICARE SKILLED NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM AND CONSOLIDATED PAYMENT.
(a) In General- Section 1888(e)(2)(A)(ii) of the Social Security Act (
(b) Conforming Amendment- Section 1861(hh)(2) of the Social Security Act (
(c) Effective Date- The amendments made by this section shall apply to items and services furnished on or after January 1, 2008.CommentsClose CommentsPermalink
SEC. 607. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES AND MENTAL HEALTH COUNSELOR SERVICES.
(a) Coverage of Marriage and Family Therapist Services-CommentsClose CommentsPermalink
(1) COVERAGE OF SERVICES- Section 1861(s)(2) of the Social Security Act (
(A) in subparagraph (AA), by striking `and' at the end;CommentsClose CommentsPermalink
(B) in subparagraph (BB), by adding `and' at the end; andCommentsClose CommentsPermalink
(C) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(CC) marriage and family therapist services (as defined in subsection (eee));'.CommentsClose CommentsPermalink
(2) DEFINITION- Section 1861 of the Social Security Act (
`Marriage and Family Therapist Services
`(eee)(1) The term `marriage and family therapist services' means services performed by a marriage and family therapist (as defined in paragraph (2)) for the diagnosis and treatment of mental illnesses, which the marriage and family therapist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are performed, provided such services are covered under this title, as would otherwise be covered if furnished by a physician or as incident to a physician's professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services.CommentsClose CommentsPermalink
`(2) The term `marriage and family therapist' means an individual who--CommentsClose CommentsPermalink
`(A) possesses a master's or doctoral degree which qualifies for licensure or certification as a marriage and family therapist pursuant to State law;CommentsClose CommentsPermalink
`(B) after obtaining such degree has performed at least 2 years of clinical supervised experience in marriage and family therapy; andCommentsClose CommentsPermalink
`(C) is licensed or certified as a marriage and family therapist in the State in which marriage and family therapist services are performed.'.CommentsClose CommentsPermalink
(3) PROVISION FOR PAYMENT UNDER PART B- Section 1832(a)(2)(B) of the Social Security Act (
`(v) marriage and family therapist services;'.CommentsClose CommentsPermalink
(4) AMOUNT OF PAYMENT-CommentsClose CommentsPermalink
(A) IN GENERAL- Section 1833(a)(1) of the Social Security Act (
(i) by striking `and' before `(W)'; andCommentsClose CommentsPermalink
(ii) by inserting before the semicolon at the end the following: `, and (X) with respect to marriage and family therapist services under section 1861(s)(2)(CC), the amounts paid shall be 80 percent of the lesser of: (i) the actual charge for the services; or (ii) 75 percent of the amount determined for payment of a psychologist under subparagraph (L)'.CommentsClose CommentsPermalink
(B) DEVELOPMENT OF CRITERIA WITH RESPECT TO CONSULTATION WITH A PHYSICIAN- The Secretary of Health and Human Services shall, taking into consideration concerns for patient confidentiality, develop criteria with respect to payment for marriage and family therapist services for which payment may be made directly to the marriage and family therapist under part B of title XVIII of the Social Security Act (
(5) EXCLUSION OF MARRIAGE AND FAMILY THERAPIST SERVICES FROM SKILLED NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM- Section 1888(e)(2)(A)(ii) of the Social Security Act (
(6) COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES PROVIDED IN RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS- Section 1861(aa)(1)(B) of the Social Security Act (
(7) INCLUSION OF MARRIAGE AND FAMILY THERAPISTS AS PRACTITIONERS FOR ASSIGNMENT OF CLAIMS- Section 1842(b)(18)(C) of the Social Security Act (
`(vii) A marriage and family therapist (as defined in section 1861(eee)(2)).'.CommentsClose CommentsPermalink
(b) Coverage of Mental Health Counselor Services-CommentsClose CommentsPermalink
(1) COVERAGE OF SERVICES- Section 1861(s)(2) of the Social Security Act (
(A) in subparagraph (BB), by striking `and' at the end;CommentsClose CommentsPermalink
(B) in subparagraph (CC), by inserting `and' at the end; andCommentsClose CommentsPermalink
(C) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(DD) mental health counselor services (as defined in subsection (fff)(2));'.CommentsClose CommentsPermalink
(2) DEFINITION- Section 1861 of the Social Security Act (
`Mental Health Counselor; Mental Health Counselor Services
`(fff)(1) The term `mental health counselor' means an individual who--CommentsClose CommentsPermalink
`(A) possesses a master's or doctor's degree which qualifies the individual for licensure or certification for the practice of mental health counseling in the State in which the services are performed;CommentsClose CommentsPermalink
`(B) after obtaining such a degree has performed at least 2 years of supervised mental health counselor practice; andCommentsClose CommentsPermalink
`(C) is licensed or certified as a mental health counselor or professional counselor by the State in which the services are performed.CommentsClose CommentsPermalink
`(2) The term `mental health counselor services' means services performed by a mental health counselor (as defined in paragraph (1)) for the diagnosis and treatment of mental illnesses which the mental health counselor is legally authorized to perform under State law (or the State regulatory mechanism provided by the State law) of the State in which such services are performed, provided such services are covered under this title, as would otherwise be covered if furnished by a physician or as incident to a physician's professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services.'.CommentsClose CommentsPermalink
(3) PROVISION FOR PAYMENT UNDER PART B- Section 1832(a)(2)(B) of the Social Security Act (
`(vi) mental health counselor services;'.CommentsClose CommentsPermalink
(4) AMOUNT OF PAYMENT-CommentsClose CommentsPermalink
(A) IN GENERAL- Section 1833(a)(1) of the Social Security Act (
(i) by striking `and' before `(X)'; andCommentsClose CommentsPermalink
(ii) by inserting before the semicolon at the end the following: `, and (Y) with respect to mental health counselor services under section 1861(s)(2)(DD), the amounts paid shall be 80 percent of the lesser of: (i) the actual charge for the services; or (ii) 75 percent of the amount determined for payment of a psychologist under subparagraph (L)'.CommentsClose CommentsPermalink
(B) DEVELOPMENT OF CRITERIA WITH RESPECT TO CONSULTATION WITH A PHYSICIAN- The Secretary of Health and Human Services shall, taking into consideration concerns for patient confidentiality, develop criteria with respect to payment for mental health counselor services for which payment may be made directly to the mental health counselor under part B of title XVIII of the Social Security Act (
(5) EXCLUSION OF MENTAL HEALTH COUNSELOR SERVICES FROM SKILLED NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM- Section 1888(e)(2)(A)(ii) of the Social Security Act (
(6) COVERAGE OF MENTAL HEALTH COUNSELOR SERVICES PROVIDED IN RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS- Section 1861(aa)(1)(B) of the Social Security Act (
(7) INCLUSION OF MENTAL HEALTH COUNSELORS AS PRACTITIONERS FOR ASSIGNMENT OF CLAIMS- Section 1842(b)(18)(C) of the Social Security Act (
`(viii) A mental health counselor (as defined in section 1861(fff)(1)).'.CommentsClose CommentsPermalink
(c) Effective Date- The amendments made by this section shall apply to items and services furnished on or after January 1, 2008.CommentsClose CommentsPermalink
SEC. 608. RENTAL AND PURCHASE OF POWER-DRIVEN WHEELCHAIRS.
(a) In General- Section 1834(a)(7) of the Social Security Act (
(1) in subparagraph (A)--CommentsClose CommentsPermalink
(A) in clause (i)(I), by striking `Except as provided in clause (iii), payment' and inserting `Payment';CommentsClose CommentsPermalink
(B) by striking clause (iii); andCommentsClose CommentsPermalink
(C) in clause (iv)--CommentsClose CommentsPermalink
(i) by redesignating such clause as clause (iii); andCommentsClose CommentsPermalink
(ii) by striking `or in the case of a power-driven wheelchair for which a purchase agreement has been entered into under clause (iii)'; andCommentsClose CommentsPermalink
(2) in subparagraph (C)(ii)(II), by striking `or (A)(iii)'.CommentsClose CommentsPermalink
(b) Effective Date-CommentsClose CommentsPermalink
(1) IN GENERAL- Subject to paragraph (1), the amendments made by subsection (a) shall take effect on January 1, 2008, and shall apply to power-driven wheelchairs furnished on or after such date.CommentsClose CommentsPermalink
(2) APPLICATION TO COMPETITIVE ACQUISITION- The amendments made by subsection (a) shall not apply to contracts entered into under section 1847 of the Social Security Act (
SEC. 609. RENTAL AND PURCHASE OF OXYGEN EQUIPMENT.
(a) In General- Section 1834(a)(5)(F) of the Social Security Act (
(1) in clause (i)--CommentsClose CommentsPermalink
(A) by striking `Payment' and inserting `Subject to clause (iii), payment'; andCommentsClose CommentsPermalink
(B) by striking `36 months' and inserting `18 months';CommentsClose CommentsPermalink
(2) in clause (ii)(I), by striking `36th continuous month' and inserting `18th continuous month'; andCommentsClose CommentsPermalink
(3) by adding at the end the following new clause:CommentsClose CommentsPermalink
`(iii) SPECIAL RULE FOR OXYGEN GENERATING PORTABLE EQUIPMENT- In the case of oxygen generating portable equipment referred to in the final rule published in the Federal Register on November 9, 2006 (71 Fed. Reg. 65897-65899), in applying clauses (i) and (ii)(I) each reference to `18 months' is deemed a reference to `36 months'.'.CommentsClose CommentsPermalink
(b) Effective Date-CommentsClose CommentsPermalink
(1) IN GENERAL- Subject to paragraph (3), the amendments made by subsection (a) shall apply to oxygen equipment furnished on or after January 1, 2008.CommentsClose CommentsPermalink
(2) TRANSITION- In the case of an individual receiving oxygen equipment on December 31, 2007, for which payment is made under section 1834(a) of the Social Security Act (
(3) APPLICATION TO COMPETITIVE ACQUISITION- The amendments made by subsection (a) shall not apply to contracts entered into under section 1847 of the Social Security Act (
(c) Study and Report-CommentsClose CommentsPermalink
(1) STUDY- The Secretary of Health and Human Services shall conduct a study to examine the service component and the equipment component of the provision of oxygen to Medicare beneficiaries. The study shall assess--CommentsClose CommentsPermalink
(A) the type of services provided and variation across suppliers in providing such services;CommentsClose CommentsPermalink
(B) whether the services are medically necessary or affect patient outcomes;CommentsClose CommentsPermalink
(C) whether the Medicare program pays appropriately for equipment in connection with the provision of oxygen;CommentsClose CommentsPermalink
(D) whether such program pays appropriately for necessary services;CommentsClose CommentsPermalink
(E) whether such payment in connection with the provision of oxygen should be divided between equipment and services, and if so, how; andCommentsClose CommentsPermalink
(F) how such payment rate compares to a competitively bid rate.CommentsClose CommentsPermalink
(2) REPORT- Not later than 18 months after the date of the enactment of this Act, the Secretary of Health and Human Services shall submit to Congress a report on the study conducted under paragraph (1).CommentsClose CommentsPermalink
SEC. 610. ADJUSTMENT FOR MEDICARE MENTAL HEALTH SERVICES.
(a) In General- For purposes of payment for services furnished under the physician fee schedule under section 1848 of the Social Security Act (
(b) Definitions- For purposes of subsection (a):CommentsClose CommentsPermalink
(1) APPLICABLE PERIOD- The term `applicable period' means the period beginning on January 1, 2008, and ending on December 31 of the year before the effective date of the first review after January 1, 2008, of work relative value units conducted under section 1848(c)(2)(B)(i) of the Social Security Act.CommentsClose CommentsPermalink
(2) APPLICABLE SERVICES- The term `applicable services' means procedure codes for services--CommentsClose CommentsPermalink
(A) in the categories of psychiatric therapeutic procedures furnished in office or other outpatient facility settings, or inpatient hospital, partial hospital or residential care facility settings; andCommentsClose CommentsPermalink
(B) which cover insight oriented, behavior modifying, or supportive psychotherapy and interactive psychotherapy services in the Healthcare Common Procedure Coding System established by the Secretary of Health and Human Services under section 1848(c)(5) of such Act.CommentsClose CommentsPermalink
(c) Implementation- Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement this section by program instruction or otherwise.CommentsClose CommentsPermalink
SEC. 611. EXTENSION OF BRACHYTHERAPY SPECIAL RULE.
Section 1833(t)(16)(C) of the Social Security Act (
SEC. 612. PAYMENT FOR PART B DRUGS.
(a) Application of Consistent Volume Weighting in Computation of ASP- In order to assure that payments for drugs and biologicals under section 1847A of the Social Security Act (
(b) Improvements in the Competitive Acquisition Program (CAP)-CommentsClose CommentsPermalink
(1) CONTINUOUS OPEN ENROLLMENT; AUTOMATIC REENROLLMENT WITHOUT NEED FOR REAPPLICATION- Subsection (a)(1)(A) of section 1847B of the Social Security Act (
(A) in clause (ii), by striking `annually' and inserting `on an ongoing basis';CommentsClose CommentsPermalink
(B) in clause (iii), by striking `an annual selection' and inserting `a selection (which may be changed on an annual basis)'; andCommentsClose CommentsPermalink
(C) by adding at the end the following: `An election and selection described in clauses (ii) and (iii) shall continue to be effective without the need for any periodic reelection or reapplication or selection.'.CommentsClose CommentsPermalink
(2) PERMITTING APPROPRIATE DELIVERY AND TRANSPORT OF DRUGS- Subsection (b)(4)(E) of such section is amended--CommentsClose CommentsPermalink
(A) by striking `or' at the end of clause (i);CommentsClose CommentsPermalink
(B) by striking the period at the end of clause (ii) and inserting a semicolon; andCommentsClose CommentsPermalink
(C) by adding at the end the following new clauses:CommentsClose CommentsPermalink
`(iii) prevent a contractor from delivering drugs to a satellite office designated by the prescribing physician; orCommentsClose CommentsPermalink
`(iv) prevent a contractor from allowing a selecting physician to transport drugs or biologicals to the site of administration consistent with State law and other applicable laws and regulations.'.CommentsClose CommentsPermalink
(3) PHYSICIAN OUTREACH AND EDUCATION- Subsection (a)(1) of such section is amended by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(E) PHYSICIAN OUTREACH AND EDUCATION- The Secretary shall conduct a program of outreach to education physicians concerning the program and the ongoing opportunity of physicians to elect to obtain drugs and biologicals under the program.'.CommentsClose CommentsPermalink
(4) REBIDDING OF CONTRACTS- The Secretary of Health and Human Services shall provide for the rebidding of contracts under section 1847B(c) of the Social Security Act (
(c) Treatment of Certain Drugs- Section 1847A(b) of the Social Security Act (
(1) in paragraph (1), by inserting `paragraph (6) and' after `Subject to'; andCommentsClose CommentsPermalink
(2) by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(6) SPECIAL RULE- Beginning with January 1, 2008, the payment amount for--CommentsClose CommentsPermalink
`(A) each single source drug or biological described in section 1842(o)(1)(G) (including a single source drug or biological that is treated as a multiple source drug because of the application of subsection (c)(6)(C)(ii)) is the lower of--CommentsClose CommentsPermalink
`(i) the payment amount that would be determined for such drug or biological applying such subsection; orCommentsClose CommentsPermalink
`(ii) the payment amount that would have been determined for such drug or biological if such subsection were not applied; andCommentsClose CommentsPermalink
`(B) a multiple source drug (excluding a drug or biological that is treated as a multiple source drug because of the application of such subsection) is the lower of--CommentsClose CommentsPermalink
`(i) the payment amount that would be determined for such drug or biological taking into account the application of such subsection; orCommentsClose CommentsPermalink
`(ii) the payment amount that would have been determined for such drug or biological if such subsection were not applied.'.CommentsClose CommentsPermalink
(d) Effective Date- Except as otherwise provided, the amendments made by this section shall apply to drugs furnished on or after January 1, 2008.CommentsClose CommentsPermalink
Subtitle B--Extension of Medicare Rural Access Protections
SEC. 621. 2-YEAR EXTENSION OF FLOOR ON MEDICARE WORK GEOGRAPHIC ADJUSTMENT.
Section 1848(e)(1)(E) of such Act (
SEC. 622. 2-YEAR EXTENSION OF SPECIAL TREATMENT OF CERTAIN PHYSICIAN PATHOLOGY SERVICES UNDER MEDICARE.
Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, as amended by section 732 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, and section 104 of the Medicare Improvements and Extension Act of 2006 (division B of
SEC. 623. 2-YEAR EXTENSION OF MEDICARE REASONABLE COSTS PAYMENTS FOR CERTAIN CLINICAL DIAGNOSTIC LABORATORY TESTS FURNISHED TO HOSPITAL PATIENTS IN CERTAIN RURAL AREAS.
Section 416(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (
SEC. 624. 2-YEAR EXTENSION OF MEDICARE INCENTIVE PAYMENT PROGRAM FOR PHYSICIAN SCARCITY AREAS.
(a) In General- Section 1833(u)(1) of the Social Security Act (
(b) Transition- With respect to physicians' services furnished during 2008 and 2009, for purposes of subsection (a), the Secretary of Health and Human Services shall use the primary care scarcity areas and the specialty care scarcity areas (as identified in section 1833(u)(4)) that the Secretary was using under such subsection with respect to physicians' services furnished on December 31, 2007.CommentsClose CommentsPermalink
SEC. 625. 2-YEAR EXTENSION OF MEDICARE INCREASE PAYMENTS FOR GROUND AMBULANCE SERVICES IN RURAL AREAS.
Section 1834(l)(13) of the Social Security Act (
(1) in subparagraph (A)--CommentsClose CommentsPermalink
(A) in the matter before clause (i), by striking `furnished on or after July 1, 2004, and before January 1, 2007,';CommentsClose CommentsPermalink
(B) in clause (i), by inserting `for services furnished on or after July 1, 2004, and before January 1, 2007, and on or after January 1, 2008, and before January 1, 2010,' after `in such paragraph,'; andCommentsClose CommentsPermalink
(C) in clause (ii), by inserting `for services furnished on or after July 1, 2004, and before January 1, 2007,' after `in clause (i),'; andCommentsClose CommentsPermalink
(2) in subparagraph (B)--CommentsClose CommentsPermalink
(A) in the heading, by striking `AFTER 2006' and inserting `FOR SUBSEQUENT PERIODS';CommentsClose CommentsPermalink
(B) by inserting `clauses (i) and (ii) of' before `subparagraph (A)'; andCommentsClose CommentsPermalink
(C) by striking `in such subparagraph' and inserting `in the respective clause'.CommentsClose CommentsPermalink
SEC. 626. EXTENDING HOLD HARMLESS FOR SMALL RURAL HOSPITALS UNDER THE HOPD PROSPECTIVE PAYMENT SYSTEM.
Section 1833(t)(7)(D)(i)(II) of the Social Security Act (
(1) by striking `January 1, 2009' and inserting `January 1, 2010';CommentsClose CommentsPermalink
(2) by striking `2007, or 2008,'; andCommentsClose CommentsPermalink
(3) by striking `90 percent, and 85 percent, respectively.' and inserting `and with respect to such services furnished after 2006 the applicable percentage shall be 90 percent.'.CommentsClose CommentsPermalink
Subtitle C--End Stage Renal Disease Program
SEC. 631. CHRONIC KIDNEY DISEASE DEMONSTRATION PROJECTS.
(a) In General- The Secretary of Health and Human Services (in this section referred to as the `Secretary'), acting through the Director of the National Institutes of Health, shall establish demonstration projects to--CommentsClose CommentsPermalink
(1) increase public and medical community awareness (particularly of those who treat patients with diabetes and hypertension) about the factors that lead to chronic kidney disease, how to prevent it, how to diagnose it, and how to treat it;CommentsClose CommentsPermalink
(2) increase screening and use of prevention techniques for chronic kidney disease for Medicare beneficiaries and the general public (particularly among patients with diabetes and hypertension, where prevention techniques are well established and early detection makes prevention possible); andCommentsClose CommentsPermalink
(3) enhance surveillance systems and expand research to better assess the prevalence and incidence of chronic kidney disease, (building on work done by Centers for Disease Control and Prevention).CommentsClose CommentsPermalink
(b) Scope and Duration-CommentsClose CommentsPermalink
(1) SCOPE- The Secretary shall select at least 3 States in which to conduct demonstration projects under this section. In selecting the States under this paragraph, the Secretary shall take into account the size of the population of individuals with end-stage renal disease who are enrolled in part B of title XVIII of the Social Security Act and ensure the participation of individuals who reside in rural and urban areas.CommentsClose CommentsPermalink
(2) DURATION- The demonstration projects under this section shall be conducted for a period that is not longer than 5 years and shall begin on January 1, 2009.CommentsClose CommentsPermalink
(c) Evaluation and Report-CommentsClose CommentsPermalink
(1) EVALUATION- The Secretary shall conduct an evaluation of the demonstration projects conducted under this section.CommentsClose CommentsPermalink
(2) REPORT- Not later than 12 months after the date on which the demonstration projects under this section are completed, the Secretary shall submit to Congress a report on the evaluation conducted under paragraph (1) together with recommendations for such legislation and administrative action as the Secretary determines appropriate.CommentsClose CommentsPermalink
SEC. 632. MEDICARE COVERAGE OF KIDNEY DISEASE PATIENT EDUCATION SERVICES.
(a) Coverage of Kidney Disease Education Services-CommentsClose CommentsPermalink
(1) COVERAGE- Section 1861(s)(2) of the Social Security Act (
(A) in subparagraph (CC), by striking `and' after the semicolon at the end;CommentsClose CommentsPermalink
(B) in subparagraph (DD), by adding `and' after the semicolon at the end; andCommentsClose CommentsPermalink
(C) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(EE) kidney disease education services (as defined in subsection (ggg));'.CommentsClose CommentsPermalink
(2) SERVICES DESCRIBED- Section 1861 of the Social Security Act (
`Kidney Disease Education Services
`(ggg)(1) The term `kidney disease education services' means educational services that are--CommentsClose CommentsPermalink
`(A) furnished to an individual with stage IV chronic kidney disease who, according to accepted clinical guidelines identified by the Secretary, will require dialysis or a kidney transplant;CommentsClose CommentsPermalink
`(B) furnished, upon the referral of the physician managing the individual's kidney condition, by a qualified person (as defined in paragraph (2)); andCommentsClose CommentsPermalink
`(C) designed--CommentsClose CommentsPermalink
`(i) to provide comprehensive information (consistent with the standards developed under paragraph (3)) regarding--CommentsClose CommentsPermalink
`(I) the management of comorbidities, including for purposes of delaying the need for dialysis;CommentsClose CommentsPermalink
`(II) the prevention of uremic complications; andCommentsClose CommentsPermalink
`(III) each option for renal replacement therapy (including hemodialysis and peritoneal dialysis at home and in-center as well as vascular access options and transplantation);CommentsClose CommentsPermalink
`(ii) to ensure that the individual has the opportunity to actively participate in the choice of therapy; andCommentsClose CommentsPermalink
`(iii) to be tailored to meet the needs of the individual involved.CommentsClose CommentsPermalink
`(2) The term `qualified person' means a physician, physician assistant, nurse practitioner, or clinical nurse specialist who furnishes services for which payment may be made under the fee schedule established under section 1848. Such term does not include a renal dialysis facility.CommentsClose CommentsPermalink
`(3) The Secretary shall set standards for the content of such information to be provided under paragraph (1)(C)(i) after consulting with physicians, other health professionals, health educators, professional organizations, accrediting organizations, kidney patient organizations, dialysis facilities, transplant centers, network organizations described in section 1881(c)(2), and other knowledgeable persons. To the extent possible the Secretary shall consult with a person or entity described in the previous sentence, other than a dialysis facility, that has not received industry funding from a drug or biological manufacturer or dialysis facility.CommentsClose CommentsPermalink
`(4) In promulgating regulations to carry out this subsection, the Secretary shall ensure that each individual who is eligible for benefits for kidney disease education services under this title receives such services in a timely manner to maximize the benefit of those services.CommentsClose CommentsPermalink
`(5) The Secretary shall monitor the implementation of this subsection to ensure that individuals who are eligible for benefits for kidney disease education services receive such services in the manner described in paragraph (4).CommentsClose CommentsPermalink
`(6) No individual shall be eligible to be provided more than 6 sessions of kidney disease education services under this title.'.CommentsClose CommentsPermalink
(3) PAYMENT UNDER THE PHYSICIAN FEE SCHEDULE- Section 1848(j)(3) of the Social Security Act (
(4) LIMITATION ON NUMBER OF SESSIONS- Section 1862(a)(1) of the Social Security Act (
(A) in subparagraph (M), by striking `and' at the end;CommentsClose CommentsPermalink
(B) in subparagraph (N), by striking the semicolon at the end and inserting `, and'; andCommentsClose CommentsPermalink
(C) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(O) in the case of kidney disease education services (as defined in section 1861(ggg)), which are furnished in excess of the number of sessions covered under such section;'.CommentsClose CommentsPermalink
(5) GAO REPORT- Not later than September 1, 2010, the Comptroller General of the United States shall submit to Congress a report on the following:CommentsClose CommentsPermalink
(A) The number of Medicare beneficiaries who are eligible to receive benefits for kidney disease education services (as defined in section 1861(ggg) of the Social Security Act, as added by paragraph (2)) under title XVIII of such Act and who receive such services.CommentsClose CommentsPermalink
(B) The extent to which there is a sufficient amount of physicians, physician assistants, nurse practitioners, and clinical nurse specialists to furnish kidney disease education services (as so defined) under such title and whether or not renal dialysis facilities (and appropriate employees of such facilities) should be included as an entity eligible under such section to furnish such services.CommentsClose CommentsPermalink
(C) Recommendations, if appropriate, for renal dialysis facilities (and appropriate employees of such facilities) to structure kidney disease education services (as so defined) in a manner that is objective and unbiased and that provides a range of options and alternative locations for renal replacement therapy and management of co-morbidities that may delay the need for dialysis.CommentsClose CommentsPermalink
(b) Effective Date- The amendments made by this section shall apply to services furnished on or after January 1, 2009.CommentsClose CommentsPermalink
SEC. 633. REQUIRED TRAINING FOR PATIENT CARE DIALYSIS TECHNICIANS.
Section 1881 of the Social Security Act (
`(h)(1) Except as provided in paragraph (2), a provider of services or a renal dialysis facility may not use, for more than 12 months during 2009, or for any period beginning on January 1, 2010, any individual as a patient care dialysis technician unless the individual--CommentsClose CommentsPermalink
`(A) has completed a training program in the care and treatment of an individual with chronic kidney failure who is undergoing dialysis treatment; andCommentsClose CommentsPermalink
`(B) has been certified by a nationally recognized certification entity for dialysis technicians.CommentsClose CommentsPermalink
`(2)(A) A provider of services or a renal dialysis facility may permit an individual enrolled in a training program described in paragraph (1)(A) to serve as a patient care dialysis technician while they are so enrolled.CommentsClose CommentsPermalink
`(B) The requirements described in subparagraphs (A), (B), and (C) of paragraph (1) do not apply to an individual who has performed dialysis-related services for at least 5 years.CommentsClose CommentsPermalink
`(3) For purposes of paragraph (1), if, since the most recent completion by an individual of a training program described in paragraph (1)(A), there has been a period of 24 consecutive months during which the individual has not furnished dialysis-related services for monetary compensation, such individual shall be required to complete a new training program or become recertified as described in paragraph (1)(B).CommentsClose CommentsPermalink
`(4) A provider of services or a renal dialysis facility shall provide such regular performance review and regular in-service education as assures that individuals serving as patient care dialysis technicians for the provider or facility are competent to perform dialysis-related services.'.CommentsClose CommentsPermalink
SEC. 634. MEDPAC REPORT ON TREATMENT MODALITIES FOR PATIENTS WITH KIDNEY FAILURE.
(a) Evaluation-CommentsClose CommentsPermalink
(1) IN GENERAL- Not later than March 1, 2009, the Medicare Payment Advisory Commission (established under section 1805 of the Social Security Act) shall submit to the Secretary and Congress a report evaluating the barriers that exist to increasing the number of individuals with end-stage renal disease who elect to receive home dialysis services under the Medicare program under title XVIII of the Social Security Act (
(2) REPORT DETAILS- The report shall include the following:CommentsClose CommentsPermalink
(A) A review of Medicare home dialysis demonstration projects initiated before the date of the enactment of this Act, and the results of such demonstration projects and recommendations for future Medicare home dialysis demonstration projects or Medicare program changes that will test models that can improve Medicare beneficiary access to home dialysis.CommentsClose CommentsPermalink
(B) A comparison of current Medicare home dialysis costs and payments with current in-center and hospital dialysis costs and payments.CommentsClose CommentsPermalink
(C) An analysis of the adequacy of Medicare reimbursement for patient training for home dialysis (including hemodialysis and peritoneal dialysis) and recommendations for ensuring appropriate payment for such home dialysis training.CommentsClose CommentsPermalink
(D) A catalogue and evaluation of the incentives and disincentives in the current reimbursement system that influence whether patients receive home dialysis services or other treatment modalities.CommentsClose CommentsPermalink
(E) An evaluation of patient education services and how such services impact the treatment choices made by patients.CommentsClose CommentsPermalink
(F) Recommendations for implementing incentives to encourage patients to elect to receive home dialysis services or other treatment modalities under the Medicare program.CommentsClose CommentsPermalink
(3) SCOPE OF REVIEW- In preparing the report under paragraph (1), the Medicare Payment Advisory Commission shall consider a variety of perspectives, including the perspectives of physicians, other health care professionals, hospitals, dialysis facilities, health plans, purchasers, and patients.CommentsClose CommentsPermalink
SEC. 635. ADJUSTMENT FOR ERYTHROPOIETIN STIMULATING AGENTS (ESAS).
(a) In General- Subsection (b)(13) of section 1881 of the Social Security Act (
(1) in subparagraph (A)(iii), by striking `For such drugs' and inserting `Subject to subparagraph (C), for such drugs'; andCommentsClose CommentsPermalink
(2) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(C)(i) The payment amounts under this title for erythropoietin furnished during 2008 or 2009 to an individual with end stage renal disease by a large dialysis facility (as defined in subparagraph (D)) (whether to individuals in the facility or at home), in an amount equal to $8.75 per thousand units (rounded to the nearest 100 units) or, if less, 102 percent of the average sales price (as determined under section 1847A) for such drug or biological.CommentsClose CommentsPermalink
`(ii) The payment amounts under this title for darbepoetin alfa furnished during 2008 or 2009 to an individual with end stage renal disease by a large dialysis facility (as defined in clause (iii)) (whether to individuals in the facility or at home), in an amount equal to $2.92 per microgram or, if less, 102 percent of the average sales price (as determined under section 1847A) for such drug or biological.CommentsClose CommentsPermalink
`(iii) For purposes of this subparagraph, the term `large dialysis facility' means a provider of services or renal dialysis facility that is owned or managed by a corporate entity that, as of July 24, 2007, owns or manages 300 or more such providers or facilities, and includes a successor to such a corporate entity.'.CommentsClose CommentsPermalink
(b) No Impact on Drug Add-on Payment- Nothing in the amendments made by subsection (a) shall be construed to affect the amount of any payment adjustment made under section 1881(b)(12)(B)(ii) of the Social Security Act (
SEC. 636. SITE NEUTRAL COMPOSITE RATE.
Subsection (b)(12)(A) of section 1881 of the Social Security Act (
SEC. 637. DEVELOPMENT OF ESRD BUNDLING SYSTEM AND QUALITY INCENTIVE PAYMENTS.
(a) Development of ESRD Bundling System- Subsection (b) of section 1881 of the Social Security Act (
(1) in paragraph (12)(A), by striking `In lieu of payment' and inserting `Subject to paragraph (14), in lieu of payment';CommentsClose CommentsPermalink
(2) in the second sentence of paragraph (12)(F)--CommentsClose CommentsPermalink
(A) by inserting `or paragraph (14)' after `this paragraph'; andCommentsClose CommentsPermalink
(B) by inserting `or under the system under paragraph (14)' after `subparagraph (B)';CommentsClose CommentsPermalink
(3) in paragraph (12)(H)--CommentsClose CommentsPermalink
(A) by inserting `or paragraph (14)' after `under this paragraph' the first place it appears; andCommentsClose CommentsPermalink
(B) by inserting before the period at the end the following: `or, under paragraph (14), the identification of renal dialysis services included in the bundled payment, the adjustment for outliers, the identification of facilities to which the phase-in may apply, and the determination of payment amounts under subparagraph (A) under such paragraph, and the application of paragraph (13)(C)(iii)';CommentsClose CommentsPermalink
(4) in paragraph (13)--CommentsClose CommentsPermalink
(A) in subparagraph (A), by striking `The payment amounts' and inserting `subject to paragraph (14), the payment amounts'; andCommentsClose CommentsPermalink
(B) in subparagraph (B)--CommentsClose CommentsPermalink
(i) in clause (i), by striking `(i)' after `(B)' and by inserting `, subject to paragraph (14)' before the period at the end; andCommentsClose CommentsPermalink
(ii) by striking clause (ii); andCommentsClose CommentsPermalink
(5) by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(14)(A) Subject to subparagraph (E), for services furnished on or after January 1, 2010, the Secretary shall implement a payment system under which a single payment is made under this title for renal dialysis services (as defined in subparagraph (B)) in lieu of any other payment (including a payment adjustment under paragraph (12)(B)(ii)) for such services and items furnished pursuant to paragraph (4). In implementing the system the Secretary shall ensure that the estimated total amount of payments under this title for 2010 for renal dialysis services shall equal 96 percent of the estimated amount of payments for such services, including payments under paragraph (12)(B)(ii), that would have been made if such system had not been implemented.CommentsClose CommentsPermalink
`(B) For purposes of this paragraph, the term `renal dialysis services' includes--CommentsClose CommentsPermalink
`(i) items and services included in the composite rate for renal dialysis services as of December 31, 2009;CommentsClose CommentsPermalink
`(ii) erythropoietin stimulating agents furnished to individuals with end stage renal disease;CommentsClose CommentsPermalink
`(iii) other drugs and biologicals and diagnostic laboratory tests, that the Secretary identifies as commonly used in the treatment of such patients and for which payment was (before the application of this paragraph) made separately under this title, and any oral equivalent form of such drugs and biologicals or of drugs and biologicals described in clause (ii); andCommentsClose CommentsPermalink
`(iv) home dialysis training for which payment was (before the application of this paragraph) made separately under this section.CommentsClose CommentsPermalink
Such term does not include vaccines.CommentsClose CommentsPermalink
`(C) The system under this paragraph may provide for payment on the basis of services furnished during a week or month or such other appropriate unit of payment as the Secretary specifies.CommentsClose CommentsPermalink
`(D) Such system--CommentsClose CommentsPermalink
`(i) shall include a payment adjustment based on case mix that may take into account patient weight, body mass index, comorbidities, length of time on dialysis, age, race, ethnicity, and other appropriate factors;CommentsClose CommentsPermalink
`(ii) shall include a payment adjustment for high cost outliers due to unusual variations in the type or amount of medically necessary care, including variations in the amount of erythropoietin stimulating agents necessary for anemia management; andCommentsClose CommentsPermalink
`(iii) may include such other payment adjustments as the Secretary determines appropriate, such as a payment adjustment--CommentsClose CommentsPermalink
`(I) by a geographic index, such as the index referred to in paragraph (12)(D), as the Secretary determines to be appropriate;CommentsClose CommentsPermalink
`(II) for pediatric providers of services and renal dialysis facilities;CommentsClose CommentsPermalink
`(III) for low volume providers of services and renal dialysis facilities;CommentsClose CommentsPermalink
`(IV) for providers of services or renal dialysis facilities located in rural areas; andCommentsClose CommentsPermalink
`(V) for providers of services or renal dialysis facilities that are not large dialysis facilities.CommentsClose CommentsPermalink
`(E) The Secretary may provide for a phase-in of the payment system described in subparagraph (A) for services furnished by a provider of services or renal dialysis facility described in any of subclauses (II) through (V) of subparagraph (D)(iii), but such payment system shall be fully implemented for services furnished in the case of any such provider or facility on or after January 1, 2013.CommentsClose CommentsPermalink
`(F) The Secretary shall apply the annual increase that would otherwise apply under subparagraph (F) of paragraph (12) to payment amounts established under such paragraph (if this paragraph did not apply) in an appropriate manner under this paragraph.'.CommentsClose CommentsPermalink
(b) Prohibition of Unbundling- Section 1862(a) of such Act (
(1) by striking `or' at the end of paragraph (21);CommentsClose CommentsPermalink
(2) by striking the period at the end of paragraph (22) and inserting `; or'; andCommentsClose CommentsPermalink
(3) by inserting after paragraph (22) the following new paragraph:CommentsClose CommentsPermalink
`(23) where such expenses are for renal dialysis services (as defined in subparagraph (B) of section 1881(b)(14)) for which payment is made under such section (other than under subparagraph (E) of such section) unless such payment is made under such section to a provider of services or a renal dialysis facility for such services.'.CommentsClose CommentsPermalink
(c) Quality Incentive Payments- Section 1881 of such Act is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink
`(i) Quality Incentive Payments in the End-Stage Renal Disease Program-CommentsClose CommentsPermalink
`(1) QUALITY INCENTIVE PAYMENTS FOR SERVICES FURNISHED IN 2008, 2009, AND 2010-CommentsClose CommentsPermalink
`(A) IN GENERAL- With respect to renal dialysis services furnished during a performance period (as defined in subparagraph (B)) by a provider of services or renal dialysis facility that the Secretary determines meets the applicable performance standard for the period under subparagraph (C) and reports on measures for 2009 and 2010 under subparagraph (D) for such services, in addition to the amount otherwise paid under this section, subject to subparagraph (G), there also shall be paid to the provider or facility an amount equal to the applicable percentage (specified in subparagraph (E) for the period) of the Secretary's estimate (based on claims submitted not later than two months after the end of the performance period) of the amount specified in subparagraph (F) for such period.CommentsClose CommentsPermalink
`(B) PERFORMANCE PERIOD- In this paragraph, the term `performance period' means each of the following:CommentsClose CommentsPermalink
`(i) The period beginning on July 1, 2008, and ending on December 31, 2008.CommentsClose CommentsPermalink
`(ii) 2009.CommentsClose CommentsPermalink
`(iii) 2010.CommentsClose CommentsPermalink
`(C) PERFORMANCE STANDARD-CommentsClose CommentsPermalink
`(i) 2008- For the performance period occurring in 2008, the applicable performance standards for a provider or facility under this subparagraph are--CommentsClose CommentsPermalink
`(I) 92 percent or more of individuals with end stage renal disease receiving erythopoetin stimulating agents who have an average hematocrit of 33.0 percent or more; andCommentsClose CommentsPermalink
`(II) less than a percentage, specified by the Secretary, of individuals with end stage renal disease receiving erythopoetin stimulating agents who have an average hematocrit of 39.0 percent or more.CommentsClose CommentsPermalink
`(ii) 2009 AND 2010- For the 2009 and 2010 performance periods, the applicable performance standard for a provider or facility under this subparagraph is successful performance (relative to national average) on--CommentsClose CommentsPermalink
`(I) such measures of anemia management as the Secretary shall specify, including measures of hemoglobin levels or hematocrit levels for erythropoietin stimulating agents that are consistent with the labeling for dosage of erythropoietin stimulating agents approved by the Food and Drug Administration for treatment of anemia in patients with end stage renal disease, taking into account variations in hemoglobin ranges or hematocrit levels of patients; andCommentsClose CommentsPermalink
`(II) such other measures, relating to subjects described in subparagraph (D)(i), as the Secretary may specify.CommentsClose CommentsPermalink
`(D) REPORTING PERFORMANCE MEASURES- The performance measures under this subparagraph to be reported shall include--CommentsClose CommentsPermalink
`(i) such measures as the Secretary specifies, before the beginning of the performance period involved and taking into account measures endorsed by the National Quality Forum, including, to the extent feasible measures on--CommentsClose CommentsPermalink
`(I) iron management;CommentsClose CommentsPermalink
`(II) dialysis adequacy; andCommentsClose CommentsPermalink
`(III) vascular access, including for maximizing the placement of arterial venous fistula; andCommentsClose CommentsPermalink
`(ii) to the extent feasible, such measure (or measures) of patient satisfaction as the Secretary shall specify.CommentsClose CommentsPermalink
The provider or facility submitting information on such measures shall attest to the completeness and accuracy of such information.CommentsClose CommentsPermalink
`(E) APPLICABLE PERCENTAGE- The applicable percentage specified in this subparagraph for--CommentsClose CommentsPermalink
`(i) the performance period occurring in 2008, is 1.0 percent;CommentsClose CommentsPermalink
`(ii) the 2009 performance period, is 2.0 percent; andCommentsClose CommentsPermalink
`(iii) the 2010 performance period, is 3.0 percent.CommentsClose CommentsPermalink
In the case of any performance period which is less than an entire year, the applicable percentage specified in this subparagraph shall be multiplied by the ratio of the number of months in the year to the number of months in such performance period. In the case of 2010, the applicable percentage specified in this subparagraph shall be multiplied by the Secretary's estimate of the ratio of the aggregate payment amount described in subparagraph (F)(i) that would apply in 2010 if paragraph (14) did not apply, to the aggregate payment base under subparagraph (F)(ii) for 2010.CommentsClose CommentsPermalink
`(F) PAYMENT BASE- The payment base described in this subparagraph for a provider or facility is--CommentsClose CommentsPermalink
`(i) for performance periods before 2010, the payment amount determined under paragraph (12) for services furnished by the provider or facility during the performance period, including the drug payment adjustment described in subparagraph (B)(ii) of such paragraph; andCommentsClose CommentsPermalink
`(ii) for the 2010 performance period is the amount determined under paragraph (14) for services furnished by the provider or facility during the period.CommentsClose CommentsPermalink
`(G) LIMITATION ON FUNDING-CommentsClose CommentsPermalink
`(i) IN GENERAL- If the Secretary determines that the total payments under this paragraph for a performance period is projected to exceed the dollar amount specified in clause (ii) for such period, the Secretary shall reduce, in a pro rata manner, the amount of such payments for each provider or facility for such period to eliminate any such projected excess for the period.CommentsClose CommentsPermalink
`(ii) DOLLAR AMOUNT- The dollar amount specified in this clause--CommentsClose CommentsPermalink
`(I) for the performance period occurring in 2008, is $50,000,000;CommentsClose CommentsPermalink
`(II) for the 2009 performance period is $100,000,000; andCommentsClose CommentsPermalink
`(III) for the 2010 performance period is $150,000,000.CommentsClose CommentsPermalink
`(H) FORM OF PAYMENT- The payment under this paragraph shall be in the form of a single consolidated payment.CommentsClose CommentsPermalink
`(2) QUALITY INCENTIVE PAYMENTS FOR FACILITIES AND PROVIDERS FOR 2011-CommentsClose CommentsPermalink
`(A) INCREASED PAYMENT- For 2011, in the case of a provider or facility that, for the performance period (as defined in subparagraph (B))--CommentsClose CommentsPermalink
`(i) meets (or exceeds) the performance standard for anemia management specified in paragraph (1)(C)(ii)(I);CommentsClose CommentsPermalink
`(ii) has substantially improved performance or exceeds a performance standard (as determined under subparagraph (E)); andCommentsClose CommentsPermalink
`(iii) reports measures specified in paragraph (1)(D),CommentsClose CommentsPermalink
with respect to renal dialysis services furnished by the provider or facility during the quality bonus payment period (as specified in subparagraph (C)) the payment amount otherwise made to such provider or facility under subsection (b)(14) shall be increased, subject to subparagraph (F), by the applicable percentage specified in subparagraph (D). Payment amounts under paragraph (1) shall not be counted for purposes of applying the previous sentence.CommentsClose CommentsPermalink
`(B) PERFORMANCE PERIOD- In this paragraph, the term `performance period' means a multi-month period specified by the Secretary.CommentsClose CommentsPermalink
`(C) QUALITY BONUS PAYMENT PERIOD- In this paragraph, the term `quality bonus payment period' means, with respect to a performance period, a multi-month period beginning on January 1, 2011, specified by the Secretary that begins at least 3 months (but not more than 9 months) after the end of the performance period.CommentsClose CommentsPermalink
`(D) APPLICABLE PERCENTAGE- The applicable percentage specified in this subparagraph is a percentage, not to exceed the 4.0 percent, specified by the Secretary consistent with subparagraph (F). Such percentage may vary based on the level of performance and improvement. The applicable percentage specified in this subparagraph shall be multiplied by the ratio applied under the third sentence of paragraph (1)(E) for 2010.CommentsClose CommentsPermalink
`(E) PERFORMANCE STANDARD- Based on performance of a provider of services or a renal dialysis facility on performance measures described in paragraph (1)(D) for a performance period, the Secretary shall determine a composite score for such period.CommentsClose CommentsPermalink
`(F) LIMITATION ON FUNDING- If the Secretary determines that the total amount to be paid under this paragraph for a quality bonus payment period is projected to exceed $200,000,000, the Secretary shall reduce, in a uniform manner, the applicable percentage otherwise applied under subparagraph (D) for services furnished during the period to eliminate any such projected excess.CommentsClose CommentsPermalink
`(3) APPLICATION-CommentsClose CommentsPermalink
`(A) IMPLEMENTATION- Notwithstanding any other provision of law, the Secretary may implement by program instruction or otherwise this subsection.CommentsClose CommentsPermalink
`(B) LIMITATIONS ON REVIEW-CommentsClose CommentsPermalink
`(i) IN GENERAL- There shall be no administrative or judicial review under section 1869 or 1878 or otherwise of--CommentsClose CommentsPermalink
`(I) the determination of performance measures and standards under this subsection;CommentsClose CommentsPermalink
`(II) the determination of successful reporting, including a determination of composite scores; andCommentsClose CommentsPermalink
`(III) the determination of the quality incentive payments made under this subsection.CommentsClose CommentsPermalink
`(ii) TREATMENT OF DETERMINATIONS- A determination under this subparagraph shall not be treated as a determination for purposes of section 1869.CommentsClose CommentsPermalink
`(4) TECHNICAL ASSISTANCE- The Secretary shall identify or establish an appropriately skilled group or organization, such as the ESRD Networks, to provide technical assistance to consistently low-performing facilities or providers that are in the bottom quintile.CommentsClose CommentsPermalink
`(5) PUBLIC REPORTING-CommentsClose CommentsPermalink
`(A) ANNUAL NOTICE- The Secretary shall provide an annual written notification to each individual who is receiving renal dialysis services from a provider of services or renal dialysis facility that--CommentsClose CommentsPermalink
`(i) informs such individual of the composite scores described in subparagraph (A) and other relevant quality measures with respect to providers of services or renal dialysis facilities in the local area;CommentsClose CommentsPermalink
`(ii) compares such scores and measures to the average local and national scores and measures; andCommentsClose CommentsPermalink
`(iii) provides information on how to access additional information on quality of such services furnished and options for alternative providers and facilities.CommentsClose CommentsPermalink
`(B) CERTIFICATES- The Secretary shall provide certificates to facilities and providers who provide services to individuals with end-stage renal disease under this title to display in patient areas. The certificate shall indicate the composite score obtained by the facility or provider under the quality initiative.CommentsClose CommentsPermalink
`(C) WEB-BASED QUALITY LIST- The Secretary shall establish a web-based list of facilities and providers who furnish renal dialysis services under this section that indicates their composite score of each provider and facility.CommentsClose CommentsPermalink
`(6) RECOMMENDATIONS FOR REPORTING AND QUALITY INCENTIVE INITIATIVE FOR PHYSICIANS- The Secretary shall develop recommendations for applying quality incentive payments under this subsection to physicians who receive the monthly capitated payment under this title. Such recommendations shall include the following:CommentsClose CommentsPermalink
`(A) Recommendations to include pediatric specific measures for physicians with at least 50 percent of their patients with end stage renal disease being individuals under 18 years of age.CommentsClose CommentsPermalink
`(B) Recommendations on how to structure quality incentive payments for physicians who demonstrate improvements in quality or who attain quality standards, as specified by the Secretary.CommentsClose CommentsPermalink
`(7) REPORTS-CommentsClose CommentsPermalink
`(A) INITIAL REPORT- Not later than January 1, 2013, the Secretary shall submit to Congress a report on the implementation of the bundled payment system under subsection (b)(14) and the quality initiative under this subsection. Such report shall include the following information:CommentsClose CommentsPermalink
`(i) A comparison of the aggregate payments under subsection (b)(14) for items and services to the cost of such items and services.CommentsClose CommentsPermalink
`(ii) The changes in utilization rates for erythropoietin stimulating agents.CommentsClose CommentsPermalink
`(iii) The mode of administering such agents, including information on the proportion of such individuals receiving such agents intravenously as compared to subcutaneously.CommentsClose CommentsPermalink
`(iv) The frequency of dialysis.CommentsClose CommentsPermalink
`(v) Other differences in practice patterns, such as the adoption of new technology, different modes of practice, and variations in use of drugs other than drugs described in clause (iii).CommentsClose CommentsPermalink
`(vi) The performance of facilities and providers under paragraph (2).CommentsClose CommentsPermalink
`(vii) Other recommendations for legislative and administrative actions determined appropriate by the Secretary.CommentsClose CommentsPermalink
`(B) SUBSEQUENT REPORT- Not later than January 1, 2015, the Secretary shall submit to Congress a report that contains the information described in each of clauses (ii) through (vii) of subparagraph (A) and a comparison of the results of the payment system under subsection (b)(14) for renal dialysis services furnished during the 2-year period beginning on January 1, 2013, and the results of such payment system for such services furnished during the previous two-year period.'.CommentsClose CommentsPermalink
SEC. 638. MEDPAC REPORT ON ESRD BUNDLING SYSTEM.
Not later than March 1, 2012, the Medicare Payment Advisory Commission (established under section 1805 of the Social Security Act) shall submit to Congress a report on the implementation of the payment system under section 1881(b)(14) of the Social Security Act (as added by section 7) for renal dialysis services and related services (defined in subparagraph (B) of such section). Such report shall include, with respect to such payment system for such services, an analysis of each of the following:CommentsClose CommentsPermalink
(1) An analysis of the overall adequacy of payment under such system for all such services.CommentsClose CommentsPermalink
(2) An analysis that compares the adequacy of payment under such system for services furnished by--CommentsClose CommentsPermalink
(A) a provider of services or renal dialysis facility that is described in section 1881(b)(13)(C)(iv) of the Social Security Act;CommentsClose CommentsPermalink
(B) a provider of services or renal dialysis facility not described in such section;CommentsClose CommentsPermalink
(C) a hospital-based facility;CommentsClose CommentsPermalink
(D) a freestanding renal dialysis facility;CommentsClose CommentsPermalink
(E) a renal dialysis facility located in an urban area; andCommentsClose CommentsPermalink
(F) a renal dialysis facility located in a rural area.CommentsClose CommentsPermalink
(3) An analysis of the financial status of providers of such services and renal dialysis facilities, including access to capital, return on equity, and return on capital.CommentsClose CommentsPermalink
(4) An analysis of the adequacy of payment under such method and the adequacy of the quality improvement payments under section 1881(i) of the Social Security Act in ensuring that payments for such services under the Medicare program are consistent with costs for such services.CommentsClose CommentsPermalink
(5) Recommendations, if appropriate, for modifications to such payment system.CommentsClose CommentsPermalink
SEC. 639. OIG STUDY AND REPORT ON ERYTHROPOIETIN.
(a) Study- The Inspector General of the Department of Health and Human Services shall conduct a study on the following:CommentsClose CommentsPermalink
(1) The dosing guidelines, standards, protocols, and algorithms for erythropoietin stimulating agents recommended or used by providers of services and renal dialysis facilities that are described in section 1881(b)(13)(C)(iv) of the Social Security Act and providers and facilities that are not described in such section.CommentsClose CommentsPermalink
(2) The extent to which such guidelines, standards, protocols, and algorithms are consistent with the labeling of the Food and Drug Administration for such agents.CommentsClose CommentsPermalink
(3) The extent to which physicians sign standing orders for such agents that are consistent with such guidelines, standards, protocols, and algorithms recommended or used by the provider or facility involved.CommentsClose CommentsPermalink
(4) The extent to which the prescribing decisions of physicians, with respect to such agents, are independent of--CommentsClose CommentsPermalink
(A) such relevant guidelines, standards, protocols, and algorithms; orCommentsClose CommentsPermalink
(B) recommendations of an anemia management nurse or other appropriate employee of the provider or facility involved.CommentsClose CommentsPermalink
(5) The role of medical directors of providers of services and renal dialysis facilities and the financial relationships between such providers and facilities and the physicians hired as medical directors of such providers and facilities, respectively.CommentsClose CommentsPermalink
(b) Report- Not later than January 1, 2009, the Inspector General of the Department of Health and Human Services shall submit to Congress a report on the study conducted under subsection (a), together with such recommendations as the Inspector General determines appropriate.CommentsClose CommentsPermalink
Subtitle D--Miscellaneous
SEC. 651. LIMITATION ON EXCEPTION TO THE PROHIBITION ON CERTAIN PHYSICIAN REFERRALS FOR HOSPITALS.
(a) In General- Section 1877 of the Social Security Act (
(1) in subsection (d)(2)--CommentsClose CommentsPermalink
(A) in subparagraph (A), by striking `and' at the end;CommentsClose CommentsPermalink
(B) in subparagraph (B), by striking the period at the end and inserting `; and'; andCommentsClose CommentsPermalink
(C) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(C) if the entity is a hospital, the hospital meets the requirements of paragraph (3)(D).';CommentsClose CommentsPermalink
(2) in subsection (d)(3)--CommentsClose CommentsPermalink
(A) in subparagraph (B), by striking `and' at the end;CommentsClose CommentsPermalink
(B) in subparagraph (C), by striking the period at the end and inserting `; and'; andCommentsClose CommentsPermalink
(C) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink
`(D) the hospital meets the requirements described in subsection (i)(1) not later than 18 months after the date of the enactment of this subparagraph.'; andCommentsClose CommentsPermalink
(3) by adding at the end the following new subsection:CommentsClose CommentsPermalink
`(i) Requirements for Hospitals to Qualify for Hospital Exception to Ownership or Investment Prohibition-CommentsClose CommentsPermalink
`(1) REQUIREMENTS DESCRIBED- For purposes of paragraphs subsection (d)(3)(D), the requirements described in this paragraph for a hospital are as follows:CommentsClose CommentsPermalink
`(A) PROVIDER AGREEMENT- The hospital had a provider agreement under section 1866 in effect on July 24, 2007.CommentsClose CommentsPermalink
`(B) PROHIBITION OF EXPANSION OF FACILITY CAPACITY- The number of operating rooms and beds of the hospital at any time on or after the date of the enactment of this subsection are no greater than the number of operating rooms and beds as of such date.CommentsClose CommentsPermalink
`(C) PREVENTING CONFLICTS OF INTEREST-CommentsClose CommentsPermalink
`(i) The hospital submits to the Secretary an annual report containing a detailed description of--CommentsClose CommentsPermalink
`(I) the identity of each physician owner and any other owners of the hospital; andCommentsClose CommentsPermalink
`(II) the nature and extent of all ownership interests in the hospital.CommentsClose CommentsPermalink
`(ii) The hospital has procedures in place to require that any referring physician owner discloses to the patient being referred, by a time that permits the patient to make a meaningful decision regarding the receipt of care, as determined by the Secretary--CommentsClose CommentsPermalink
`(I) the ownership interest of such referring physician in the hospital; andCommentsClose CommentsPermalink
`(II) if applicable, any such ownership interest of the treating physician.CommentsClose CommentsPermalink
`(iii) The hospital does not condition any physician ownership interests either directly or indirectly on the physician owner making or influencing referrals to the hospital or otherwise generating business for the hospital.CommentsClose CommentsPermalink
`(D) ENSURING BONA FIDE INVESTMENT-CommentsClose CommentsPermalink
`(i) Physician owners in the aggregate do not own more than 40 percent of the total value of the investment interests held in the hospital or in an entity whose assets include the hospital.CommentsClose CommentsPermalink
`(ii) The investment interest of any individual physician owner does not exceed 2 percent of the total value of the investment interests held in the hospital or in an entity whose assets include the hospital.CommentsClose CommentsPermalink
`(iii) Any ownership or investment interests that the hospital offers to a physician owner are not offered on more favorable terms than the terms offered to a person who is not a physician owner.CommentsClose CommentsPermalink
`(iv) The hospital does not directly or indirectly provide loans or financing for any physician owner investments in the hospital.CommentsClose CommentsPermalink
`(v) The hospital does not directly or indirectly guarantee a loan, make a payment toward a loan, or otherwise subsidize a loan, for any individual physician owner or group of physician owners that is related to acquiring any ownership interest in the hospital.CommentsClose CommentsPermalink
`(vi) Investment returns are distributed to investors in the hospital in an amount that is directly proportional to the investment of capital by the physician owner in the hospital.CommentsClose CommentsPermalink
`(vii) Physician owners do not receive, directly or indirectly, any guaranteed receipt of or right to purchase other business interests related to the hospital, including the purchase or lease of any property under the control of other investors in the hospital or located near the premises of the hospital.CommentsClose CommentsPermalink
`(viii) The hospital does not offer a physician owner the opportunity to purchase or lease any property under the control of the hospital or any other investor in the hospital on more favorable terms than the terms offered to an individual who is not a physician owner.CommentsClose CommentsPermalink
`(E) PATIENT SAFETY-CommentsClose CommentsPermalink
`(i) Insofar as the hospital admits a patient and does not have any physician available on the premises to provide services during all hours in which the hospital is providing services to such patient, before admitting the patient--CommentsClose CommentsPermalink
`(I) the hospital discloses such fact to a patient; andCommentsClose CommentsPermalink
`(II) following such disclosure, the hospital receives from the patient a signed acknowledgment that the patient understands such fact.CommentsClose CommentsPermalink
`(ii) The hospital has the capacity to--CommentsClose CommentsPermalink
`(I) provide assessment and initial treatment for patients; andCommentsClose CommentsPermalink
`(II) refer and transfer patients to hospitals with the capability to treat the needs of the patient involved.CommentsClose CommentsPermalink
`(2) PUBLICATION OF INFORMATION REPORTED- The Secretary shall publish, and update on an annual basis, the information submitted by hospitals under paragraph (1)(C)(i) on the public Internet website of the Centers for Medicare & Medicaid Services.CommentsClose CommentsPermalink
`(3) COLLECTION OF OWNERSHIP AND INVESTMENT INFORMATION- For purposes of clauses (i) and (ii) of paragraph (1)(D), the Secretary shall collect physician ownership and investment information for each hospital as it existed on the date of the enactment of this subsection.CommentsClose CommentsPermalink
`(4) PHYSICIAN OWNER DEFINED- For purposes of this subsection, the term `physician owner' means a physician (or an immediate family member of such physician) with a direct or an indirect ownership interest in the hospital.'.CommentsClose CommentsPermalink
(b) Enforcement-CommentsClose CommentsPermalink
(1) ENSURING COMPLIANCE- The Secretary of Health and Human Services shall establish policies and procedures to ensure compliance with the requirements described in such section 1877(i)(1) of the Social Security Act, as added by subsection (a)(3), beginning on the date such requirements first apply. Such policies and procedures may include unannounced site reviews of hospitals.CommentsClose CommentsPermalink
(2) AUDITS- Beginning not later than 18 months after the date of the enactment of this Act, the Secretary of Health and Human Services shall conduct audits to determine if hospitals violate the requirements referred to in paragraph (1).CommentsClose CommentsPermalink
TITLE VII--PROVISIONS RELATING TO MEDICARE PARTS A AND B
SEC. 701. HOME HEALTH PAYMENT UPDATE FOR 2008.
Section 1895(b)(3)(B)(ii) of the Social Security Act (
(1) in subclause (IV) at the end, by striking `and';CommentsClose CommentsPermalink
(2) by redesignating subclause (V) as subclause (VII); andCommentsClose CommentsPermalink
(3) by inserting after subclause (IV) the following new subclauses:CommentsClose CommentsPermalink
`(V) 2007, subject to clause (v), the home health market basket percentage increase;CommentsClose CommentsPermalink
`(VI) 2008, subject to clause (v), 0 percent; and'.CommentsClose CommentsPermalink
SEC. 702. 2-YEAR EXTENSION OF TEMPORARY MEDICARE PAYMENT INCREASE FOR HOME HEALTH SERVICES FURNISHED IN A RURAL AREA.
Section 421 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (
(1) in the heading, by striking `one-year' and inserting `temporary'; andCommentsClose CommentsPermalink
(2) in subsection (a), by striking `and episodes and visits beginning on or after January 1, 2006, and before January 1, 2007' and inserting `episodes and visits beginning on or after January 1, 2006, and before January 1, 2007, and episodes and visits beginning on or after January 1, 2008, and before January 1, 2010'.CommentsClose CommentsPermalink
SEC. 703. EXTENSION OF MEDICARE SECONDARY PAYER FOR BENEFICIARIES WITH END STAGE RENAL DISEASE FOR LARGE GROUP PLANS.
(a) In General- Section 1862(b)(1)(C) of the Social Security Act (
(1) by redesignating clauses (i) and (ii) as subclauses (I) and (II), respectively, and indenting accordingly;CommentsClose CommentsPermalink
(2) by amending the text preceding subclause (I), as so redesignated, to read as follows:CommentsClose CommentsPermalink
`(C) INDIVIDUALS WITH END STAGE RENAL DISEASE-CommentsClose CommentsPermalink
`(i) IN GENERAL- A group health plan (as defined in subparagraph (A)(v))--';CommentsClose CommentsPermalink
(3) in the matter following subclause (II), as so redesignated--CommentsClose CommentsPermalink
(A) by striking `clause (i)' and inserting `subclause (I)';CommentsClose CommentsPermalink
(B) by striking `clause (ii)' and inserting `subclause (II)';CommentsClose CommentsPermalink
(C) by striking `clauses (i) and (ii)' and inserting `subclauses (I) and (II)'; andCommentsClose CommentsPermalink
(D) in the last sentence, by striking `Effective for items' and inserting `Subject to clause (ii), effective for items'; andCommentsClose CommentsPermalink
(4) by adding at the end the following new clause:CommentsClose CommentsPermalink
`(ii) SPECIAL RULE FOR LARGE GROUP PLANS- In applying clause (i) to a large group health plan (as defined in subparagraph (B)(iii)). effective for items and services furnished on or after January 1, 2008, (with respect to periods beginning on or after the date that is 30 months prior to January 1, 2008), subclauses (I) and (II) of such clause shall be applied by substituting `42-month' for `12-month' each place it appears.'.CommentsClose CommentsPermalink
SEC. 704. PLAN FOR MEDICARE PAYMENT ADJUSTMENTS FOR NEVER EVENTS.
(a) In General- The Secretary of Health and Human Services (in this section referred to as the `Secretary') shall develop a plan (in this section referred to as the `never events plan') to implement, beginning in fiscal year 2010, a policy to reduce or eliminate payments under title XVIII of the Social Security Act for never events.CommentsClose CommentsPermalink
(b) Never Event Defined- For purposes of this section, the term `never event' means an event involving the delivery of (or failure to deliver) physicians' services, inpatient or outpatient hospital services, or facility services furnished in an ambulatory surgical facility in which there is an error in medical care that is clearly identifiable, usually preventable, and serious in consequences to patients, and that indicates a deficiency in the safety and process controls of the services furnished with respect to the physician, hospital, or ambulatory surgical center involved.CommentsClose CommentsPermalink
(c) Plan Details-CommentsClose CommentsPermalink
(1) DEFINING NEVER EVENTS- With respect to criteria for identifying never events under the never events plan, the Secretary should consider whether the event meets the following characteristics:CommentsClose CommentsPermalink
(A) CLEARLY IDENTIFIABLE- The event is clearly identifiable and measurable and feasible to include in a reporting system for never events.CommentsClose CommentsPermalink
(B) USUALLY PREVENTABLE- The event is usually preventable taking into consideration that, because of the complexity of medical care, certain medical events are not always avoidable.CommentsClose CommentsPermalink
(C) SERIOUS- The event is serious and could result in death or loss of a body part, disability, or more than transient loss of a body function.CommentsClose CommentsPermalink
(D) DEFICIENCY IN SAFETY AND PROCESS CONTROLS- The event is indicative of a problem in safety systems and process controls used by the physician, hospital, or ambulatory surgical center involved and is indicative of the reliability of the quality of services provided by the physician, hospital, or ambulatory surgical center, respectively.CommentsClose CommentsPermalink
(2) IDENTIFICATION AND PAYMENT ISSUES- With respect to policies under the never events plan for identifying and reducing (or eliminating) payment for never events, the Secretary shall consider--CommentsClose CommentsPermalink
(A) mechanisms used by hospitals and physicians in reporting and coding of services that would reliably identify never events; andCommentsClose CommentsPermalink
(B) modifications in billing and payment mechanisms that would enable the Secretary to efficiently and accurately reduce or eliminate payments for never events.CommentsClose CommentsPermalink
(3) PRIORITIES- Under the never events plan the Secretary shall identify priorities regarding the services to focus on and, among those, the never events for which payments should be reduced or eliminated.CommentsClose CommentsPermalink
(4) CONSULTATION- In developing the never events plan, the Secretary shall consult with affected parties that are relevant to payment reductions in response to never events.CommentsClose CommentsPermalink
(d) Congressional Report- By not later than June 1, 2008, the Secretary shall submit a report to Congress on the never events plan developed under this subsection and shall include in the report recommendations on specific methods for implementation of the plan on a timely basis.CommentsClose CommentsPermalink
SEC. 705. REINSTATEMENT OF RESIDENCY SLOTS.
(a) In General- Section 1886(h) of the Social Security Act (
(1) in paragraph (4)(H), by adding at the end the following new clauses:CommentsClose CommentsPermalink
`(v) INCREASE IN RESIDENT LIMIT DUE TO CLOSURE OF OTHER HOSPITALS- If one or more hospitals with approved medical residency training programs, which are located within the same metropolitan statistical area as of January 1, 2001, closed, the Secretary shall increase by not more than 10 (subject to the limitation set forth in the last sentence of this clause) the otherwise applicable resident limit under subparagraph (F) for each hospital within the same metropolitan statistical area that meets all the following criteria:CommentsClose CommentsPermalink
`(I) The hospital is described in subsection (d)(5)(F)(i).CommentsClose CommentsPermalink
`(II) The hospital instituted a medical residency training program in internal medicine that was accredited by the American Osteopathic Association on or after January 1, 2004.CommentsClose CommentsPermalink
`(III) The hospital had a provider number and a resident limit as of January 1, 2000, and remained open as of October 1, 2007.CommentsClose CommentsPermalink
`(IV) The hospital did not receive an increase in its resident limit under paragraph (7)(B).CommentsClose CommentsPermalink
`(V) The hospital maintains no more than 400 beds.CommentsClose CommentsPermalink
In no event may the resident limit for any hospital be increased above 50 through application of this clause and in no event may the total of the residency positions added by this clause for all hospitals exceed 10.CommentsClose CommentsPermalink
`(vi) INCREASE IN RESIDENCY SLOTS- In the case of a hospital located in Peoria County, Illinois, that has more than 500 beds, the Secretary shall increase by two the otherwise applicable resident limit under subparagraph (F) for such hospital.'; andCommentsClose CommentsPermalink
(2) in paragraph (7)--CommentsClose CommentsPermalink
(A) by redesignating subparagraph (D) as subparagraph (E); andCommentsClose CommentsPermalink
(B) by inserting after subparagraph (C) the following new subparagraph:CommentsClose CommentsPermalink
`(D) ADJUSTMENT BASED ON SETTLED COST REPORT- In the case of a hospital with a dual accredited osteopathic and allopathic family practice program for which--CommentsClose CommentsPermalink
`(i) the otherwise applicable resident limit was reduced under subparagraph (A)(i)(I); andCommentsClose CommentsPermalink
`(ii) such reduction was based on a reference resident level that was determined using a cost report and where a revised or corrected notice of program reimbursement was issued between September 1, 2006 and September 15, 2006, whether as a result of an appeal or otherwise, and the reference resident level under such settled cost report is higher than the level used for the reduction under subparagraph (A)(i)(I);CommentsClose CommentsPermalink
the Secretary shall apply subparagraph (A)(i)(I) using the higher resident reference level and make any necessary adjustments to such reduction. Any such necessary adjustments shall be effective for portions of cost reporting periods occurring on or after July 1, 2005.'.CommentsClose CommentsPermalink
(b) Effective Dates- The amendment made by paragraph (1) shall be effective for cost reporting periods beginning on or after October 1, 2007, and the amendments made by paragraph (2) shall take effect as if included in the enactment of section 422 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (
SEC. 706. STUDIES RELATING TO HOME HEALTH.
(a) In General- The Medicare Payment Advisory Commission shall conduct a study of Medicare beneficiaries utilizing home health care services to determine--CommentsClose CommentsPermalink
(1) the impact that remote monitoring equipment and related services have on improving health care outcomes in the home health care setting for beneficiaries with chronic conditions;CommentsClose CommentsPermalink
(2) the differences in the percentage of inpatient hospital admissions and emergency room visits for beneficiaries with a similar health care risk profile who utilize remote monitoring equipment and services compared to those who do not use such equipment and services;CommentsClose CommentsPermalink
(3) the percentage of Medicare beneficiaries currently utilizing remote monitoring equipment and related services;CommentsClose CommentsPermalink
(4) the estimated reduction in aggregate expenditures under parts A and B of title XVIII of the Social Security Act expenditures if home health agencies increased their utilization of remote monitoring equipment and related services for patients with chronic disease conditions; andCommentsClose CommentsPermalink
(5) the variation of utilization of remote monitoring equipment and related services within geographic regions and by size of home health agency.CommentsClose CommentsPermalink
(b) Data Collection- As a condition of a home health agency's participation in the program under title XVIII of the Social Security Act, beginning no later than January 1, 2008, the Secretary of Health and Human Services shall require such agencies to collect, in a form and manner determined by the Secretary, the following data:CommentsClose CommentsPermalink
(1) The extent of home health agency's usage of remote monitoring equipment and related services for beneficiaries with chronic conditions.CommentsClose CommentsPermalink
(2) Whether such equipment and services are used to monitor patients' with chronic conditions vital signs on a daily basis.CommentsClose CommentsPermalink
(3) Whether standing physician orders accompany the use of remote monitoring equipment and services.CommentsClose CommentsPermalink
(4) The costs of remote monitoring equipment and related services.CommentsClose CommentsPermalink
(c) Report to Congress- Not later than June 1, 2010, the Commission shall report to Congress on its findings on the study conducted under subsection (a). Such report shall include recommendations regarding how Congress may enact reimbursement policies that increase the appropriate utilization of remote monitoring equipment and services under the home health program for Medicare beneficiaries with chronic conditions in a manner that facilitates health care outcomes and leads to the long-term reduction of aggregate expenditures under the Medicare program.CommentsClose CommentsPermalink
SEC. 707. RURAL HOME HEALTH QUALITY DEMONSTRATION PROJECTS.
(a) In General- Not later than 180 days after the date of the enactment of this Act, the Secretary of Health and Human Services (in this section referred to as the `Secretary') shall make grants to eligible entities for demonstration projects to assist home health agencies to better serve their Medicare populations while aiming to reduce costs to the Medicare program through utilization of technologies, including telemonitoring and other telehealth technologies, health information technologies, and telecommunications technologies that--CommentsClose CommentsPermalink
(1) implement procedures and standards that reduce the need for inpatient hospital services and health center visits; andCommentsClose CommentsPermalink
(2) address the aims of safety, effectiveness, patient- or community-centeredness, timeliness, efficiency, and equity identified by the Institute of Medicine of the National Academies in its report entitled `Crossing the Quality Chasm: A New Health System for the 21st Century' released on March 1, 2001, when determining when and what care is needed.CommentsClose CommentsPermalink
(b) Eligible Entities- In this section, the term `eligible entity' means a State that includes--CommentsClose CommentsPermalink
(1) a rural academic medical center;CommentsClose CommentsPermalink
(2) no urban regional medical center; andCommentsClose CommentsPermalink
(3) a Medicare population whose enrollees in the Medicare Part C program is less than 3 percent.CommentsClose CommentsPermalink
(c) Consultation- In developing the program for awarding grants under this section, the Secretary shall consult with the Administrator of the Centers for Medicare & Medicaid Services, home health agencies, rural health care researchers, and private and non-profit groups (including national associations) which are undertaking similar efforts.CommentsClose CommentsPermalink
(d) Duration- Each demonstration project under this section shall be for a period of 2 years.CommentsClose CommentsPermalink
(e) Report- Not later than one year after the conclusion of all of the demonstration projects funded under this section, the Secretary shall submit a report to the Congress on the results of such projects. The report shall include--CommentsClose CommentsPermalink
(1) an evaluation of technologies utilized and effects on patient access to home health care, patient outcomes, and an analysis of the cost effectiveness of each such project; andCommentsClose CommentsPermalink
(2) recommendations on Federal legislation, regulations, or administrative policies to enhance rural home health quality and outcomes.CommentsClose CommentsPermalink
(f) Funding- Out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary for fiscal year 2008, $3,000,000 to carry out this section. Funds appropriated under this subsection shall remain available until expended.CommentsClose CommentsPermalink
TITLE VIII--MEDICAID
Subtitle A--Protecting Existing Coverage
SEC. 801. MODERNIZING TRANSITIONAL MEDICAID.
(a) Four-Year Extension-CommentsClose CommentsPermalink
(1) IN GENERAL- Sections 1902(e)(1)(B) and 1925(f) of the Social Security Act (
(2) EFFECTIVE DATE- The amendments made by this subsection shall take effect on October 1, 2007.CommentsClose CommentsPermalink
(b) State Option of Initial 12-Month Eligibility- Section 1925 of the Social Security Act (
(1) in subsection (a)(1), by inserting `but subject to paragraph (5)' after `Notwithstanding any other provision of this title';CommentsClose CommentsPermalink
(2) by adding at the end of subsection (a) the following:CommentsClose CommentsPermalink
`(5) OPTION OF 12-MONTH INITIAL ELIGIBILITY PERIOD- A State may elect to treat any reference in this subsection to a 6-month period (or 6 months) as a reference to a 12-month period (or 12 months). In the case of such an election, subsection (b) shall not apply.'; andCommentsClose CommentsPermalink
(3) in subsection (b)(1), by inserting `but subject to subsection (a)(5)' after `Notwithstanding any other provision of this title'.CommentsClose CommentsPermalink
(c) Removal of Requirement for Previous Receipt of Medical Assistance- Section 1925(a)(1) of such Act (
(1) by inserting `subparagraph (B) and' before `paragraph (5)';CommentsClose CommentsPermalink
(2) by redesignating the matter after `REQUIREMENT- ' as a subparagraph (A) with the heading `IN GENERAL- ' and with the same indentation as subparagraph (B) (as added by paragraph (3)); andCommentsClose CommentsPermalink
(3) by adding at the end the following:CommentsClose CommentsPermalink
`(B) STATE OPTION TO WAIVE REQUIREMENT FOR 3 MONTHS BEFORE RECEIPT OF MEDICAL ASSISTANCE- A State may, at its option, elect also to apply subparagraph (A) in the case of a family that was receiving such aid for fewer than three months or that had applied for and was eligible for such aid for fewer than 3 months during the 6 immediately preceding months described in such subparagraph.'.CommentsClose CommentsPermalink
(d) CMS Report on Enrollment and Participation Rates Under TMA- Section 1925 of such Act (
`(g) Collection and Reporting of Participation Information-CommentsClose CommentsPermalink
`(1) COLLECTION OF INFORMATION FROM STATES- Each State shall collect and submit to the Secretary (and make publicly available), in a format specified by the Secretary, information on average monthly enrollment and average monthly participation rates for adults and children under this section and of the number and percentage of children who become ineligible for medical assistance under this section whose medical assistance is continued under another eligibility category or who are enrolled under the State's child health plan under title XXI. Such information shall be submitted at the same time and frequency in which other enrollment information under this title is submitted to the Secretary.CommentsClose CommentsPermalink
`(2) ANNUAL REPORTS TO CONGRESS- Using the information submitted under paragraph (1), the Secretary shall submit to Congress annual reports concerning enrollment and participation rates described in such paragraph.'.CommentsClose CommentsPermalink
(e) Effective Date- The amendments made by subsections (b) through (d) shall take effect on the date of the enactment of this Act.CommentsClose CommentsPermalink
SEC. 802. FAMILY PLANNING SERVICES.
(a) Coverage as Optional Categorically Needy Group-CommentsClose CommentsPermalink
(1) IN GENERAL- Section 1902(a)(10)(A)(ii) of the Social Security Act (
(A) in subclause (XVIII), by striking `or' at the end;CommentsClose CommentsPermalink
(B) in subclause (XIX), by adding `or' at the end; andCommentsClose CommentsPermalink
(C) by adding at the end the following new subclause:CommentsClose CommentsPermalink
`(XX) who are described in subsection (ee) (relating to individuals who meet certain income standards);'.CommentsClose CommentsPermalink
(2) GROUP DESCRIBED- Section 1902 of the Social Security Act (
`(ee)(1) Individuals described in this subsection are individuals--CommentsClose CommentsPermalink
`(A) whose income does not exceed an income eligibility level established by the State that does not exceed the highest income eligibility level established under the State plan under this title (or under its State child health plan under title XXI) for pregnant women; andCommentsClose CommentsPermalink
`(B) who are not pregnant.CommentsClose CommentsPermalink
`(2) At the option of a State, individuals described in this subsection may include individuals who are determined to meet the eligibility requirements referred to in paragraph (1) under the terms, conditions, and procedures applicable to making eligibility determinations for medical assistance under this title under a waiver to provide the benefits described in clause (XV) of the matter following subparagraph (G) of section 1902(a)(10) granted to the State under section 1115 as of January 1, 2007.'.CommentsClose CommentsPermalink
(3) LIMITATION ON BENEFITS- Section 1902(a)(10) of the Social Security Act (
(A) by striking `and (XIV)' and inserting `(XIV)'; andCommentsClose CommentsPermalink
(B) by inserting `, and (XV) the medical assistance made available to an individual described in subsection (ee) shall be limited to family planning services and supplies described in section 1905(a)(4)(C) including medical diagnosis or treatment services that are provided pursuant to a family planning service in a family planning setting provided during the period in which such an individual is eligible' after `cervical cancer'.CommentsClose CommentsPermalink
(4) CONFORMING AMENDMENTS- Section 1905(a) of the Social Security Act (
(A) in clause (xii), by striking `or' at the end;CommentsClose CommentsPermalink
(B) in clause (xiii), by adding `or' at the end; andCommentsClose CommentsPermalink
(C) by inserting after clause (xiii) the following:CommentsClose CommentsPermalink
`(xiv) individuals described in section 1902(ee),'.CommentsClose CommentsPermalink
(b) Presumptive Eligibility-CommentsClose CommentsPermalink
(1) IN GENERAL- Title XIX of the Social Security Act (
`PRESUMPTIVE ELIGIBILITY FOR FAMILY PLANNING SERVICES
`Sec. 1920C. (a) State Option- State plan approved under section 1902 may provide for making medical assistance available to an individual described in section 1902(ee) (relating to individuals who meet certain income eligibility standard) during a presumptive eligibility period. In the case of an individual described in section 1902(ee), such medical assistance shall be limited to family planning services and supplies described in 1905(a)(4)(C) and, at the State's option, medical diagnosis or treatment services that are provided in conjunction with a family planning service in a family planning setting provided during the period in which such an individual is eligible.CommentsClose CommentsPermalink
`(b) Definitions- For purposes of this section:CommentsClose CommentsPermalink
`(1) PRESUMPTIVE ELIGIBILITY PERIOD- The term `presumptive eligibility period' means, with respect to an individual described in subsection (a), the period that--CommentsClose CommentsPermalink
`(A) begins with the date on which a qualified entity determines, on the basis of preliminary information, that the individual is described in section 1902(ee); andCommentsClose CommentsPermalink
`(B) ends with (and includes) the earlier of--CommentsClose CommentsPermalink
`(i) the day on which a determination is made with respect to the eligibility of such individual for services under the State plan; orCommentsClose CommentsPermalink
`(ii) in the case of such an individual who does not file an application by the last day of the month following the month during which the entity makes the determination referred to in subparagraph (A), such last day.CommentsClose CommentsPermalink
`(2) QUALIFIED ENTITY-CommentsClose CommentsPermalink
`(A) IN GENERAL- Subject to subparagraph (B), the term `qualified entity' means any entity that--CommentsClose CommentsPermalink
`(i) is eligible for payments under a State plan approved under this title; andCommentsClose CommentsPermalink
`(ii) is determined by the State agency to be capable of making determinations of the type described in paragraph (1)(A).CommentsClose CommentsPermalink
`(B) RULE OF CONSTRUCTION- Nothing in this paragraph shall be construed as preventing a State from limiting the classes of entities that may become qualified entities in order to prevent fraud and abuse.CommentsClose CommentsPermalink
`(c) Administration-CommentsClose CommentsPermalink
`(1) IN GENERAL- The State agency shall provide qualified entities with--CommentsClose CommentsPermalink
`(A) such forms as are necessary for an application to be made by an individual described in subsection (a) for medical assistance under the State plan; andCommentsClose CommentsPermalink
`(B) information on how to assist such individuals in completing and filing such forms.CommentsClose CommentsPermalink
`(2) NOTIFICATION REQUIREMENTS- A qualified entity that determines under subsection (b)(1)(A) that an individual described in subsection (a) is presumptively eligible for medical assistance under a State plan shall--CommentsClose CommentsPermalink
`(A) notify the State agency of the determination within 5 working days after the date on which determination is made; andCommentsClose CommentsPermalink
`(B) inform such individual at the time the determination is made that an application for medical assistance is required to be made by not later than the last day of the month following the month during which the determination is made.CommentsClose CommentsPermalink
`(3) APPLICATION FOR MEDICAL ASSISTANCE- In the case of an individual described in subsection (a) who is determined by a qualified entity to be presumptively eligible for medical assistance under a State plan, the individual shall apply for medical assistance by not later than the last day of the month following the month during which the determination is made.CommentsClose CommentsPermalink
`(d) Payment- Notwithstanding any other provision of this title, medical assistance that--CommentsClose CommentsPermalink
`(1) is furnished to an individual described in subsection (a)--CommentsClose CommentsPermalink
`(A) during a presumptive eligibility period;CommentsClose CommentsPermalink
`(B) by a entity that is eligible for payments under the State plan; andCommentsClose CommentsPermalink
`(2) is included in the care and services covered by the State plan, shall be treated as medical assistance provided by such plan for purposes of clause (4) of the first sentence of section 1905(b).'.CommentsClose CommentsPermalink
(2) CONFORMING AMENDMENTS-CommentsClose CommentsPermalink
(A) Section 1902(a)(47) of the Social Security Act (
(B) Section 1903(u)(1)(D)(v) of such Act (
(i) by striking `or for' and inserting `for'; andCommentsClose CommentsPermalink
(ii) by inserting before the period the following: `, or for medical assistance provided to an individual described in subsection (a) of section 1920C during a presumptive eligibility period under such section'.CommentsClose CommentsPermalink
(e) Clarification of Coverage of Family Planning Services and Supplies- Section 1937(b) of the Social Security Act (
`(5) COVERAGE OF FAMILY PLANNING SERVICES AND SUPPLIES- Notwithstanding the previous provisions of this section, a State may not provide for medical assistance through enrollment of an individual with benchmark coverage or benchmark-equivalent coverage under this section unless such coverage includes for any individual described in section 1905(a)(4)(C), medical assistance for family planning services and supplies in accordance with such section.'.CommentsClose CommentsPermalink
(f) Effective Date- The amendments made by this section take effect on October 1, 2007.CommentsClose CommentsPermalink
SEC. 803. AUTHORITY TO CONTINUE PROVIDING ADULT DAY HEALTH SERVICES APPROVED UNDER A STATE MEDICAID PLAN.
(a) In General- During the period described in subsection (b), the Secretary of Health and Human Services shall not--CommentsClose CommentsPermalink
(1) withhold, suspend, disallow, or otherwise deny Federal financial participation under section 1903(a) of the Social Security Act (
(2) withdraw Federal approval of any such State plan or part thereof regarding the provision of such services (by regulation or otherwise).CommentsClose CommentsPermalink
(b) Period Described- The period described in this subsection is the period that begins on November 3, 2005, and ends on March 1, 2009.CommentsClose CommentsPermalink
SEC. 804. STATE OPTION TO PROTECT COMMUNITY SPOUSES OF INDIVIDUALS WITH DISABILITIES.
Section 1924(h)(1)(A) of the Social Security Act (
SEC. 805. COUNTY MEDICAID HEALTH INSURING ORGANIZATIONS .
(a) In General- Section 9517(c)(3) of the Consolidated Omnibus Budget Reconciliation Act of 1985 (
(1) in subparagraph (A), by inserting `, in the case of any health insuring organization described in such subparagraph that is operated by a public entity established by Ventura County, and in the case of any health insuring organization described in such subparagraph that is operated by a public entity established by Merced County' after `described in subparagraph (B)'; andCommentsClose CommentsPermalink
(2) in subparagraph (C), by striking `14 percent' and inserting `16 percent'.CommentsClose CommentsPermalink
(b) Effective Date- The amendments made by subsection (a) shall take effect on the date of the enactment of this Act.CommentsClose CommentsPermalink
Subtitle B--Payments
SEC. 811. PAYMENTS FOR PUERTO RICO AND TERRITORIES.
(a) Payment Ceiling- Section 1108(g) of the Social Security Act (
(1) in paragraph (2), by striking `paragraph (3)' and inserting `paragraphs (3) and (4)'; andCommentsClose CommentsPermalink
(2) by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(4) FISCAL YEARS 2009 THROUGH 2012 FOR CERTAIN INSULAR AREAS- The amounts otherwise determined under this subsection for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa for fiscal years 2009 through 2012 shall be increased by the following amounts:CommentsClose CommentsPermalink
`(A) PUERTO RICO- For Puerto Rico, $250,000,000 for fiscal year 2009, $350,000,000 for fiscal year 2010, $500,000,000 for fiscal year 2011, and $600,000,000 for fiscal year 2012.CommentsClose CommentsPermalink
`(B) VIRGIN ISLANDS- For the Virgin Islands, $5,000,000 for each of fiscal years 2009 through 2012.CommentsClose CommentsPermalink
`(C) GUAM - For Guam, $5,000,000 for each of fiscal years 2009 through 2012.CommentsClose CommentsPermalink
`(D) NORTHERN MARIANA ISLANDS- For the Northern Mariana Islands, $4,000,000 for each of fiscal years 2009 through 2012.CommentsClose CommentsPermalink
`(E) AMERICAN SAMOA- For American Samoa, $4,000,000 for each of fiscal years 2009 through 2012.CommentsClose CommentsPermalink
Such amounts shall not be taken into account in applying paragraph (2) for fiscal years 2009 through 2012 but shall be taken into account in applying such paragraph for fiscal year 2013 and subsequent fiscal years.'.CommentsClose CommentsPermalink
(b) Removal of Federal Matching Payments for Improving Data Reporting Systems From the Overall Limit on Payments to Territories Under Title XIX- Such section is further amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(5) EXCLUSION OF CERTAIN EXPENDITURES FROM PAYMENT LIMITS- With respect to fiscal year 2008 and each fiscal year thereafter, if Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa qualify for a payment under subparagraph (A)(i) or (B) of section 1903(a)(3) for a calendar quarter of such fiscal year with respect to expenditures for improvements in data reporting systems described in such subparagraph, the limitation on expenditures under title XIX for such commonwealth or territory otherwise determined under subsection (f) and this subsection for such fiscal year shall be determined without regard to payment for such expenditures.'.CommentsClose CommentsPermalink
SEC. 812. MEDICAID DRUG REBATE.
Paragraph (1)(B)(i) of section 1927(c) of the Social Security Act (
(1) by striking `and' at the end of subclause (IV);CommentsClose CommentsPermalink
(2) in subclause (V)--CommentsClose CommentsPermalink
(A) by inserting `and before January 1, 2008,' after `December 31, 1995,'; andCommentsClose CommentsPermalink
(B) by striking the period at the end and inserting `; and'; andCommentsClose CommentsPermalink
(3) by adding at the end the following new subclause:CommentsClose CommentsPermalink
`(VI) after December 31, 2007, is 22.1 percent.'.CommentsClose CommentsPermalink
SEC. 813. ADJUSTMENT IN COMPUTATION OF MEDICAID FMAP TO DISREGARD AN EXTRAORDINARY EMPLOYER PENSION CONTRIBUTION.
(a) In General- Only for purposes of computing the Federal medical assistance percentage under section 1905(b) of the Social Security Act (
(b) Significantly Disproportionate Employer Pension Contribution- For purposes of subsection (a), a significantly disproportionate employer pension contribution described in this subsection with respect to a State for a fiscal year is an employer contribution towards pensions that is allocated to such State for a period if the aggregate amount so allocated exceeds 25 percent of the total increase in personal income in that State for the period involved.CommentsClose CommentsPermalink
SEC. 814. MORATORIUM ON CERTAIN PAYMENT RESTRICTIONS.
Notwithstanding any other provision of law, the Secretary of Health and Human Services shall not, prior to the date that is 1 year after the date of enactment of this Act, take any action (through promulgation of regulation, issuance of regulatory guidance, use of federal payment audit procedures, or other administrative action, policy, or practice, including a Medical Assistance Manual transmittal or letter to State Medicaid directors) to restrict coverage or payment under title XIX of the Social Security Act for rehabilitation services, or school-based administration, transportation, or medical services if such restrictions are more restrictive in any aspect than those applied to such coverage or payment as of July 1, 2007.CommentsClose CommentsPermalink
SEC. 815. TENNESSEE DSH.
The DSH allotments for Tennessee for each fiscal year beginning with fiscal year 2008 under subsection (f)(3) of section 1923 of the Social Security Act (
SEC. 816. CLARIFICATION TREATMENT OF REGIONAL MEDICAL CENTER.
(a) In General- Nothing in section 1903(w) of the Social Security Act (
(b) Center Described- A center described in this subsection is a publicly-owned regional medical center that--CommentsClose CommentsPermalink
(1) provides level 1 trauma and burn care services;CommentsClose CommentsPermalink
(2) provides level 3 neonatal care services;CommentsClose CommentsPermalink
(3) is obligated to serve all patients, regardless of ability to pay;CommentsClose CommentsPermalink
(4) is located within a Standard Metropolitan Statistical Area (SMSA) that includes at least 3 States;CommentsClose CommentsPermalink
(5) provides services as a tertiary care provider for patients residing within a 125-mile radius; andCommentsClose CommentsPermalink
(6) meets the criteria for a disproportionate share hospital under section 1923 of such Act (
SEC. 817. EXTENSION OF SSI WEB-BASED ASSET DEMONSTRATION PROJECT TO THE MEDICAID PROGRAM.
(a) In General- The Secretary of Health and Human Services shall provide for the application to asset eligibility determinations under the Medicaid program under title XIX of the Social Security Act of the automated, secure, web-based asset verification request and response process being applied for determining eligibility for benefits under the Supplemental Security Income (SSI) program under title XVI of such Act under a demonstration project conducted under the authority of section 1631(e)(1)(B)(ii) of such Act (
(b) Limitation- Such application shall only extend to those States in which such demonstration project is operating and only for the period in which such project is otherwise provided.CommentsClose CommentsPermalink
(c) Rules of Application- For purposes of carrying out subsection (a), notwithstanding any other provision of law, information obtained from a financial institution that is used for purposes of eligibility determinations under such demonstration project with respect to the Secretary of Health and Human Services under the SSI program may also be shared and used by States for purposes of eligibility determinations under the Medicaid program. In applying section 1631(e)(1)(B)(ii) of the Social Security Act under this subsection, references to the Commissioner of Social Security and benefits under title XVI of such Act shall be treated as including a reference to a State described in subsection (b) and medical assistance under title XIX of such Act provided by such a State.CommentsClose CommentsPermalink
Subtitle C--Miscellaneous
SEC. 821. DEMONSTRATION PROJECT FOR EMPLOYER BUY-IN.
Title XXI of the Social Security Act, as amended by section 133(a)(1), is further amended by adding at the end the following new section:CommentsClose CommentsPermalink
`SEC. 2112. DEMONSTRATION PROJECT FOR EMPLOYER BUY-IN.
`(a) Authority-CommentsClose CommentsPermalink
`(1) IN GENERAL- The Secretary shall establish a demonstration project under which up to 10 States (each referred to in this section as a `participating State') that meets the conditions of paragraph (2) may provide, under its State child health plan (notwithstanding section 2102(b)(3)(C)) for a period of 5 years, for child health assistance in relation to family coverage described in subsection (d) for children who would be targeted low-income children but for coverage as beneficiaries under a group health plan as the children of participants by virtue of a qualifying employer's contribution under subsection (b)(2).CommentsClose CommentsPermalink
`(2) CONDITIONS- The conditions described in this paragraph for a State are as follows:CommentsClose CommentsPermalink
`(A) NO WAITING LISTS- The State does not impose any waiting list, enrollment cap, or similar limitation on enrollment of targeted low-income children under the State child health plan.CommentsClose CommentsPermalink
`(B) ELIGIBILITY OF ALL CHILDREN UNDER 200 PERCENT OF POVERTY LINE- The State is applying an income eligibility level under section 2110(b)(1)(B)(ii)(I) that is at least 200 percent of the poverty line.CommentsClose CommentsPermalink
`(3) QUALIFYING EMPLOYER DEFINED- In this section, the term `qualifying employer' means an employer that has a majority of its workforce composed of full-time workers with family incomes reasonably estimated by the employer (based on wage information available to the employer) at or below 200 percent of the poverty line. In applying the previous sentence, two part-time workers shall be treated as a single full-time worker.CommentsClose CommentsPermalink
`(b) Funding- A demonstration project under this section in a participating State shall be funded, with respect to assistance provided to children described in subsection (a)(1), consistent with the following:CommentsClose CommentsPermalink
`(1) LIMITED FAMILY CONTRIBUTION- The family involved shall be responsible for providing payment towards the premium for such assistance of such amount as the State may specify, except that the limitations on cost-sharing (including premiums) under paragraphs (2) and (3) of section 2103(e) shall apply to all cost-sharing of such family under this section.CommentsClose CommentsPermalink
`(2) MINIMUM EMPLOYER CONTRIBUTION- The qualifying employer involved shall be responsible for providing payment to the State child health plan in the State of at least 50 percent of the portion of the cost (as determined by the State) of the family coverage in which the employer is enrolling the family that exceeds the amount of the family contribution under paragraph (1) applied towards such coverage.CommentsClose CommentsPermalink
`(3) LIMITATION ON FEDERAL FINANCIAL PARTICIPATION- In no case shall the Federal financial participation under section 2105 with respect to a demonstration project under this section be made for any portion of the costs of family coverage described in subsection (d) (including the costs of administration of such coverage) that are not attributable to children described in subsection (a)(1).CommentsClose CommentsPermalink
`(c) Uniform Eligibility Rules- In providing assistance under a demonstration project under this section--CommentsClose CommentsPermalink
`(1) a State shall establish uniform rules of eligibility for families to participate; andCommentsClose CommentsPermalink
`(2) a State shall not permit a qualifying employer to select, within those families that meet such eligibility rules, which families may participate.CommentsClose CommentsPermalink
`(d) Terms and Conditions- The family coverage offered to families of qualifying employers under a demonstration project under this section in a State shall be the same as the coverage and benefits provided under the State child health plan in the State for targeted low-income children with the highest family income level permitted.'.CommentsClose CommentsPermalink
SEC. 822. DIABETES GRANTS.
Section 2104 of the Social Security Act (
(1) in subsection (a)(11), by inserting before the period at the end the following: `plus for fiscal year 2009 the total of the amount specified in subsection (j)'; andCommentsClose CommentsPermalink
(2) by adding at the end the following new subsection:CommentsClose CommentsPermalink
`(j) Funding for Diabetes Grants- From the amounts appropriated under subsection (a)(11), for fiscal year 2009 from the amounts--CommentsClose CommentsPermalink
`(1) $150,000,000 is hereby transferred and made available in such fiscal year for grants under section 330B of the Public Health Service Act; andCommentsClose CommentsPermalink
`(2) $150,000,000 is hereby transferred and made available in such fiscal year for grants under section 330C of such Act.'.CommentsClose CommentsPermalink
SEC. 823. TECHNICAL CORRECTION.
(a) Correction of Reference to Children in Foster Care Receiving Child Welfare Services- Section 1937(a)(2)(B)(viii) of the Social Security Act (
(b) Effective Date- The amendment made by subsection (a) shall take effect as if included in the amendment made by section 6044(a) of the Deficit Reduction Act of 2005.CommentsClose CommentsPermalink
TITLE IX--MISCELLANEOUS
SEC. 901. MEDICARE PAYMENT ADVISORY COMMISSION STATUS.
Section 1805(a) of the Social Security Act (
SEC. 902. REPEAL OF TRIGGER PROVISION.
Subtitle A of title VIII of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (
SEC. 903. REPEAL OF COMPARATIVE COST ADJUSTMENT (CCA) PROGRAM.
Section 1860C-1 of the Social Security Act (
SEC. 904. COMPARATIVE EFFECTIVENESS RESEARCH.
(a) In General- Part A of title XVIII of the Social Security Act is amended by adding at the end the following new section:CommentsClose CommentsPermalink
`COMPARATIVE EFFECTIVENESS RESEARCH
`Sec. 1822. (a) Center for Comparative Effectiveness Research Established-CommentsClose CommentsPermalink
`(1) IN GENERAL- The Secretary shall establish within the Agency of Healthcare Research and Quality a Center for Comparative Effectiveness Research (in this section referred to as the `Center') to conduct, support, and synthesize research (including research conducted or supported under section 1013 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003) with respect to the outcomes, effectiveness, and appropriateness of health care services and procedures in order to identify the manner in which diseases, disorders, and other health conditions can most effectively and appropriately be prevented, diagnosed, treated, and managed clinically.CommentsClose CommentsPermalink
`(2) DUTIES- The Center shall--CommentsClose CommentsPermalink
`(A) conduct, support, and synthesize research relevant to the comparative clinical effectiveness of the full spectrum of health care treatments, including pharmaceuticals, medical devices, medical and surgical procedures, and other medical interventions;CommentsClose CommentsPermalink
`(B) conduct and support systematic reviews of clinical research, including original research conducted subsequent to the date of the enactment of this section;CommentsClose CommentsPermalink
`(C) use methodologies such as randomized controlled clinical trials as well as other various types of clinical research, such as observational studies;CommentsClose CommentsPermalink
`(D) submit to the Comparative Effectiveness Research Commission, the Secretary, and Congress appropriate relevant reports described in subsection (d)(2);CommentsClose CommentsPermalink
`(E) encourage, as appropriate, the development and use of clinical registries and the development of clinical effectiveness research data networks from electronic health records, post marketing drug and medical device surveillance efforts, and other forms of electronic health data; andCommentsClose CommentsPermalink
`(F) not later than 180 days after the date of the enactment of this section, develop methodological standards to be used when conducting studies of comparative clinical effectiveness and value (and procedures for use of such standards) in order to help ensure accurate and effective comparisons and update such standards at least biennially.CommentsClose CommentsPermalink
`(b) Oversight by Comparative Effectiveness Research Commission-CommentsClose CommentsPermalink
`(1) IN GENERAL- The Secretary shall establish an independent Comparative Effectiveness Research Commission (in this section referred to as the `Commission') to oversee and evaluate the activities carried out by the Center under subsection (a) to ensure such activities result in highly credible research and information resulting from such research.CommentsClose CommentsPermalink
`(2) DUTIES- The Commission shall--CommentsClose CommentsPermalink
`(A) determine national priorities for research described in subsection (a) and in making such determinations consult with patients and health care providers and payers;CommentsClose CommentsPermalink
`(B) monitor the appropriateness of use of the CERTF described in subsection (f) with respect to the timely production of comparative effectiveness research determined to be a national priority under subparagraph (A);CommentsClose CommentsPermalink
`(C) identify highly credible research methods and standards of evidence for such research to be considered by the Center;CommentsClose CommentsPermalink
`(D) review and approve the methodological standards (and updates to such standards) developed by the Center under subsection (a)(2)(F);CommentsClose CommentsPermalink
`(E) enter into an arrangement under which the Institute of Medicine of the National Academy of Sciences shall conduct an evaluation and report on standards of evidence for such research;CommentsClose CommentsPermalink
`(F) support forums to increase stakeholder awareness and permit stakeholder feedback on the efforts of the Agency of Healthcare Research and Quality to advance methods and standards that promote highly credible research;CommentsClose CommentsPermalink
`(G) make recommendations for public data access policies of the Center that would allow for access of such data by the public while ensuring the information produced from research involved is timely and credible;CommentsClose CommentsPermalink
`(H) appoint a clinical perspective advisory panel for each research priority determined under subparagraph (A), which shall frame the specific research inquiry to be examined with respect to such priority to ensure that the information produced from such research is clinically relevant to decisions made by clinicians and patients at the point of care;CommentsClose CommentsPermalink
`(I) make recommendations for the priority for periodic reviews of previous comparative effectiveness research and studies conducted by the Center under subsection (a);CommentsClose CommentsPermalink
`(J) routinely review processes of the Center with respect to such research to confirm that the information produced by such research is objective, credible, consistent with standards of evidence established under this section, and developed through a transparent process that includes consultations with appropriate stakeholders;CommentsClose CommentsPermalink
`(K) at least annually, provide guidance or recommendations to health care providers and consumers for the use of information on the comparative effectiveness of health care services by consumers, providers (as defined for purposes of regulations promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996) and public and private purchasers;CommentsClose CommentsPermalink
`(L) make recommendations for a strategy to disseminate the findings of research conducted and supported under this section that enables clinicians to improve performance, consumers to make more informed health care decisions, and payers to set medical policies that improve quality and value;CommentsClose CommentsPermalink
`(M) provide for the public disclosure of relevant reports described in subsection (d)(2); andCommentsClose CommentsPermalink
`(N) submit to Congress an annual report on the progress of the Center in achieving national priorities determined under subparagraph (A) for the provision of credible comparative effectiveness information produced from such research to all interested parties.CommentsClose CommentsPermalink
`(3) COMPOSITION OF COMMISSION-CommentsClose CommentsPermalink
`(A) IN GENERAL- The members of the Commission shall consist of--CommentsClose CommentsPermalink
`(i) the Director of the Agency for Healthcare Research and Quality;CommentsClose CommentsPermalink
`(ii) the Chief Medical Officer of the Centers for Medicare & Medicaid Services; andCommentsClose CommentsPermalink
`(iii) 15 additional members who shall represent broad constituencies of stakeholders including clinicians, patients, researchers, third-party payers, consumers of Federal and State beneficiary programs.CommentsClose CommentsPermalink
`(B) QUALIFICATIONS-CommentsClose CommentsPermalink
`(i) DIVERSE REPRESENTATION OF PERSPECTIVES- The members of the Commission shall represent a broad range of perspectives and shall collectively have experience in the following areas:CommentsClose CommentsPermalink
`(I) Epidemiology.CommentsClose CommentsPermalink
`(II) Health services research.CommentsClose CommentsPermalink
`(III) Bioethics.CommentsClose CommentsPermalink
`(IV) Decision sciences.CommentsClose CommentsPermalink
`(V) Economics.CommentsClose CommentsPermalink
`(ii) DIVERSE REPRESENTATION OF HEALTH CARE COMMUNITY- At least one member shall represent each of the following health care communities:CommentsClose CommentsPermalink
`(I) Consumers.CommentsClose CommentsPermalink
`(II) Practicing physicians, including surgeons.CommentsClose CommentsPermalink
`(III) Employers.CommentsClose CommentsPermalink
`(IV) Public payers.CommentsClose CommentsPermalink
`(V) Insurance plans.CommentsClose CommentsPermalink
`(VI) Clinical researchers who conduct research on behalf of pharmaceutical or device manufacturers.CommentsClose CommentsPermalink
`(4) APPOINTMENT- The Comptroller General of the United States, in consultation with the chairs of the committees of jurisdiction of the House of Representatives and the Senate, shall appoint the members of the Commission.CommentsClose CommentsPermalink
`(5) CHAIRMAN; VICE CHAIRMAN- The Comptroller General of the United States shall designate a member of the Commission, at the time of appointment of the member, as Chairman and a member as Vice Chairman for that term of appointment, except that in the case of vacancy of the Chairmanship or Vice Chairmanship, the Comptroller General may designate another member for the remainder of that member's term.CommentsClose CommentsPermalink
`(6) TERMS-CommentsClose CommentsPermalink
`(A) IN GENERAL- Except as provided in subparagraph (B), each member of the Commission shall be appointed for a term of 4 years.CommentsClose CommentsPermalink
`(B) TERMS OF INITIAL APPOINTEES- Of the members first appointed--CommentsClose CommentsPermalink
`(i) 8 shall be appointed for a term of 4 years; andCommentsClose CommentsPermalink
`(ii) 7 shall be appointed for a term of 3 years.CommentsClose CommentsPermalink
`(7) COORDINATION- To enhance effectiveness and coordination, the Comptroller General is encouraged, to the greatest extent possible, to seek coordination between the Commission and the National Advisory Council of the Agency for Healthcare Research and Quality.CommentsClose CommentsPermalink
`(8) CONFLICTS OF INTEREST- In appointing the members of the Commission or a clinical perspective advisory panel described in paragraph (2)(H), the Comptroller General of the United States or the Commission, respectively, shall take into consideration any financial conflicts of interest.CommentsClose CommentsPermalink
`(9) COMPENSATION- While serving on the business of the Commission (including travel time), a member of the Commission shall be entitled to compensation at the per diem equivalent of the rate provided for level IV of the Executive Schedule under
`(10) AVAILABILITY OF REPORTS- The Commission shall transmit to the Secretary a copy of each report submitted under this subsection and shall make such reports available to the public.CommentsClose CommentsPermalink
`(11) DIRECTOR AND STAFF; EXPERTS AND CONSULTANTS- Subject to such review as the Secretary, in consultation with the Comptroller General deems necessary to assure the efficient administration of the Commission, the Commission may--CommentsClose CommentsPermalink
`(A) employ and fix the compensation of an Executive Director (subject to the approval of the Secretary, in consultation with the Comptroller General) and such other personnel as may be necessary to carry out its duties (without regard to the provisions of title 5, United States Code, governing appointments in the competitive service);CommentsClose CommentsPermalink
`(B) seek such assistance and support as may be required in the performance of its duties from appropriate Federal departments and agencies;CommentsClose CommentsPermalink
`(C) enter into contracts or make other arrangements, as may be necessary for the conduct of the work of the Commission (without regard to section 3709 of the Revised Statutes (
`(D) make advance, progress, and other payments which relate to the work of the Commission;CommentsClose CommentsPermalink
`(E) provide transportation and subsistence for persons serving without compensation; andCommentsClose CommentsPermalink
`(F) prescribe such rules and regulations as it deems necessary with respect to the internal organization and operation of the Commission.CommentsClose CommentsPermalink
`(12) POWERS-CommentsClose CommentsPermalink
`(A) OBTAINING OFFICIAL DATA- The Commission may secure directly from any department or agency of the United States information necessary to enable it to carry out this section. Upon request of the Executive Director, the head of that department or agency shall furnish that information to the Commission on an agreed upon schedule.CommentsClose CommentsPermalink
`(B) DATA COLLECTION- In order to carry out its functions, the Commission shall--CommentsClose CommentsPermalink
`(i) utilize existing information, both published and unpublished, where possible, collected and assessed either by its own staff or under other arrangements made in accordance with this section,CommentsClose CommentsPermalink
`(ii) carry out, or award grants or contracts for, original research and experimentation, where existing information is inadequate, andCommentsClose CommentsPermalink
`(iii) adopt procedures allowing any interested party to submit information for the Commission's use in making reports and recommendations.CommentsClose CommentsPermalink
`(C) ACCESS OF GAO TO INFORMATION- The Comptroller General shall have unrestricted access to all deliberations, records, and nonproprietary data of the Commission, immediately upon request.CommentsClose CommentsPermalink
`(D) PERIODIC AUDIT- The Commission shall be subject to periodic audit by the Comptroller General.CommentsClose CommentsPermalink
`(c) Research Requirements- Any research conducted, supported, or synthesized under this section shall meet the following requirements:CommentsClose CommentsPermalink
`(1) ENSURING TRANSPARENCY, CREDIBILITY, AND ACCESS-CommentsClose CommentsPermalink
`(A) The establishment of the agenda and conduct of the research shall be insulated from inappropriate political or stakeholder influence.CommentsClose CommentsPermalink
`(B) Methods of conducting such research shall be scientifically based.CommentsClose CommentsPermalink
`(C) All aspects of the prioritization of research, conduct of the research, and development of conclusions based on the research shall be transparent to all stakeholders.CommentsClose CommentsPermalink
`(D) The process and methods for conducting such research shall be publicly documented and available to all stakeholders.CommentsClose CommentsPermalink
`(E) Throughout the process of such research, the Center shall provide opportunities for all stakeholders involved to review and provide comment on the methods and findings of such research.CommentsClose CommentsPermalink
`(2) USE OF CLINICAL PERSPECTIVE ADVISORY PANELS- The research shall meet a national research priority determined under subsection (b)(2)(A) and shall examine the specific research inquiry framed by the clinical perspective advisory panel for the national research priority.CommentsClose CommentsPermalink
`(3) STAKEHOLDER INPUT- The priorities of the research, the research, and the dissemination of the research shall involve the consultation of patients, health care providers, and health care consumer representatives through transparent mechanisms recommended by the Commission.CommentsClose CommentsPermalink
`(d) Public Access to Comparative Effectiveness Information-CommentsClose CommentsPermalink
`(1) IN GENERAL- Not later than 90 days after receipt by the Center or Commission, as applicable, of a relevant report described in paragraph (2) made by the Center, Commission, or clinical perspective advisory panel under this section, appropriate information contained in such report shall be posted on the official public Internet site of the Center and of the Commission, as applicable.CommentsClose CommentsPermalink
`(2) RELEVANT REPORTS DESCRIBED- For purposes of this section, a relevant report is each of the following submitted by a grantee or contractor of the Center:CommentsClose CommentsPermalink
`(A) An interim progress report.CommentsClose CommentsPermalink
`(B) A draft final comparative effectiveness review.CommentsClose CommentsPermalink
`(C) A final progress report on new research submitted for publication by a peer review journal.CommentsClose CommentsPermalink
`(D) Stakeholder comments.CommentsClose CommentsPermalink
`(E) A final report.CommentsClose CommentsPermalink
`(3) ACCESS BY CONGRESS AND THE COMMISSION TO THE CENTER'S INFORMATION- Congress and the Commission shall each have unrestricted access to all deliberations, records, and nonproprietary data of the Center, immediately upon request.CommentsClose CommentsPermalink
`(e) Dissemination and Incorporation of Comparative Effectiveness Information-CommentsClose CommentsPermalink
`(1) DISSEMINATION- The Center shall provide for the dissemination of appropriate findings produced by research supported, conducted, or synthesized under this section to health care providers, patients, vendors of health information technology focused on clinical decision support, appropriate professional associations, and Federal and private health plans.CommentsClose CommentsPermalink
`(2) INCORPORATION- The Center shall assist users of health information technology focused on clinical decision support to promote the timely incorporation of the findings described in paragraph (1) into clinical practices and to promote the ease of use of such incorporation.CommentsClose CommentsPermalink
`(f) Reports to Congress-CommentsClose CommentsPermalink
`(1) ANNUAL REPORTS- Beginning not later than one year after the date of the enactment of this section, the Director of the Agency of Healthcare Research and Quality and the Commission shall submit to Congress an annual report on the activities of the Center and the Commission, as well as the research, conducted under this section.CommentsClose CommentsPermalink
`(2) RECOMMENDATION FOR FAIR SHARE PER CAPITA AMOUNT FOR ALL-PAYER FINANCING- Beginning not later than December 31, 2009, the Secretary shall submit to Congress an annual recommendation for a fair share per capita amount described in subsection (c)(1) of section 9511 of the Internal Revenue Code of 1986 for purposes of funding the CERTF under such section.CommentsClose CommentsPermalink
`(3) ANALYSIS AND REVIEW- Not later than December 31, 2011, the Secretary, in consultation with the Commission, shall submit to Congress a report on all activities conducted or supported under this section as of such date. Such report shall include an evaluation of the return on investment resulting from such activities, the overall costs of such activities, and an analysis of the backlog of any research proposals approved by the Commission but not funded. Such report shall also address whether Congress should expand the responsibilities of the Center and of the Commission to include studies of the effectiveness of various aspects of the health care delivery system, including health plans and delivery models, such as health plan features, benefit designs and performance, and the ways in which health services are organized, managed, and delivered.CommentsClose CommentsPermalink
`(g) Coordinating Council for Health Services Research-CommentsClose CommentsPermalink
`(1) ESTABLISHMENT- The Secretary shall establish a permanent council (in this section referred to as the `Council') for the purpose of--CommentsClose CommentsPermalink
`(A) assisting the offices and agencies of the Department of Health and Human Services, the Department of Veterans Affairs, the Department of Defense, and any other Federal department or agency to coordinate the conduct or support of health services research; andCommentsClose CommentsPermalink
`(B) advising the President and Congress on--CommentsClose CommentsPermalink
`(i) the national health services research agenda;CommentsClose CommentsPermalink
`(ii) strategies with respect to infrastructure needs of health services research; andCommentsClose CommentsPermalink
`(iii) appropriate organizational expenditures in health services research by relevant Federal departments and agencies.CommentsClose CommentsPermalink
`(2) MEMBERSHIP-CommentsClose CommentsPermalink
`(A) NUMBER AND APPOINTMENT- The Council shall be composed of 20 members. One member shall be the Director of the Agency for Healthcare Research and Quality. The Director shall appoint the other members not later than 30 days after the enactment of this Act.CommentsClose CommentsPermalink
`(B) TERMS-CommentsClose CommentsPermalink
`(i) IN GENERAL- Except as provided in clause (ii), each member of the Council shall be appointed for a term of 4 years.CommentsClose CommentsPermalink
`(ii) TERMS OF INITIAL APPOINTEES- Of the members first appointed--CommentsClose CommentsPermalink
`(I) 10 shall be appointed for a term of 4 years; andCommentsClose CommentsPermalink
`(II) 9 shall be appointed for a term of 3 years.CommentsClose CommentsPermalink
`(iii) VACANCIES- Any vacancies shall not affect the power and duties of the Council and shall be filled in the same manner as the original appointment.CommentsClose CommentsPermalink
`(C) QUALIFICATIONS-CommentsClose CommentsPermalink
`(i) IN GENERAL- The members of the Council shall include one senior official from each of the following agencies:CommentsClose CommentsPermalink
`(I) The Veterans Health Administration.CommentsClose CommentsPermalink
`(II) The Department of Defense Military Health Care System.CommentsClose CommentsPermalink
`(III) The Centers for Disease Control and Prevention.CommentsClose CommentsPermalink
`(IV) The National Center for Health Statistics.CommentsClose CommentsPermalink
`(V) The National Institutes of Health.CommentsClose CommentsPermalink
`(VI) The Center for Medicare & Medicaid Services.CommentsClose CommentsPermalink
`(VII) The Federal Employees Health Benefits Program.CommentsClose CommentsPermalink
`(ii) NATIONAL, PHILANTHROPIC FOUNDATIONS- The members of the Council shall include 4 senior leaders from major national, philanthropic foundations that fund and use health services research.CommentsClose CommentsPermalink
`(iii) STAKEHOLDERS- The remaining members of the Council shall be representatives of other stakeholders in health services research, including private purchasers, health plans, hospitals and other health facilities, and health consumer groups.CommentsClose CommentsPermalink
`(3) ANNUAL REPORT- The Council shall submit to Congress an annual report on the progress of the implementation of the national health services research agenda.CommentsClose CommentsPermalink
`(h) Funding of Comparative Effectiveness Research- For fiscal year 2008 and each subsequent fiscal year, amounts in the Comparative Effectiveness Research Trust Fund (referred to in this section as the `CERTF') under section 9511 of the Internal Revenue Code of 1986 shall be available to the Secretary to carry out this section.'.CommentsClose CommentsPermalink
(b) Comparative Effectiveness Research Trust Fund; Financing for Trust Fund-CommentsClose CommentsPermalink
(1) ESTABLISHMENT OF TRUST FUND-CommentsClose CommentsPermalink
(A) IN GENERAL- Subchapter A of chapter 98 of the Internal Revenue Code of 1986 (relating to trust fund code) is amended by adding at the end the following new section:CommentsClose CommentsPermalink
`SEC. 9511. HEALTH CARE COMPARATIVE EFFECTIVENESS RESEARCH TRUST FUND.
`(a) Creation of Trust Fund- There is established in the Treasury of the United States a trust fund to be known as the `Health Care Comparative Effectiveness Research Trust Fund' (hereinafter in this section referred to as the `CERTF'), consisting of such amounts as may be appropriated or credited to such Trust Fund as provided in this section and section 9602(b).CommentsClose CommentsPermalink
`(b) Transfers to Fund- There are hereby appropriated to the Trust Fund the following:CommentsClose CommentsPermalink
`(1) For fiscal year 2008, $90,000,000.CommentsClose CommentsPermalink
`(2) For fiscal year 2009, $100,000,000.CommentsClose CommentsPermalink
`(3) For fiscal year 2010, $110,000,000.CommentsClose CommentsPermalink
`(4) For each fiscal year beginning with fiscal year 2011--CommentsClose CommentsPermalink
`(A) an amount equivalent to the net revenues received in the Treasury from the fees imposed under subchapter B of chapter 34 (relating to fees on health insurance and self-insured plans) for such fiscal year; andCommentsClose CommentsPermalink
`(B) subject to subsection (c)(2), amounts determined by the Secretary of Health and Human Services to be equivalent to the fair share per capita amount computed under subsection (c)(1) for the fiscal year multiplied by the average number of individuals entitled to benefits under part A, or enrolled under part B, of title XVIII of the Social Security Act during such fiscal year.CommentsClose CommentsPermalink
The amounts appropriated under paragraphs (1), (2), (3), and (4)(B) shall be transferred from the Federal Hospital Insurance Trust Fund and from the Federal Supplementary Medical Insurance Trust Fund (established under section 1841 of such Act), and from the Medicare Prescription Drug Account within such Trust Fund, in proportion (as estimated by the Secretary) to the total expenditures during such fiscal year that are made under title XVIII of such Act from the respective trust fund or account.CommentsClose CommentsPermalink
`(c) Fair Share Per Capita Amount-CommentsClose CommentsPermalink
`(1) COMPUTATION-CommentsClose CommentsPermalink
`(A) IN GENERAL- Subject to subparagraph (B), the fair share per capita amount under this paragraph for a fiscal year (beginning with fiscal year 2011) is an amount computed by the Secretary of Health and Human Services for such fiscal year that, when applied under this section and subchapter B of chapter 34 of the Internal Revenue Code of 1986, will result in revenues to the CERTF of $375,000,000 for the fiscal year.CommentsClose CommentsPermalink
`(B) ALTERNATIVE COMPUTATION-CommentsClose CommentsPermalink
`(i) IN GENERAL- If the Secretary is unable to compute the fair share per capita amount under subparagraph (A) for a fiscal year, the fair share per capita amount under this paragraph for the fiscal year shall be the default amount determined under clause (ii) for the fiscal year.CommentsClose CommentsPermalink
`(ii) DEFAULT AMOUNT- The default amount under this clause for--CommentsClose CommentsPermalink
`(I) fiscal year 2011 is equal to $2; orCommentsClose CommentsPermalink
`(II) a subsequent year is equal to the default amount under this clause for the preceding fiscal year increased by the annual percentage increase in the medical care component of the consumer price index (United States city average) for the 12-month period ending with April of the preceding fiscal year.CommentsClose CommentsPermalink
Any amount determined under subclause (II) shall be rounded to the nearest penny.CommentsClose CommentsPermalink
`(2) LIMITATION ON MEDICARE FUNDING- In no case shall the amount transferred under subsection (b)(4)(B) for any fiscal year exceed $90,000,000.CommentsClose CommentsPermalink
`(d) Expenditures From Fund-CommentsClose CommentsPermalink
`(1) IN GENERAL- Subject to paragraph (2), amounts in the CERTF are available to the Secretary of Health and Human Services for carrying out section 1822 of the Social Security Act.CommentsClose CommentsPermalink
`(2) ALLOCATION FOR COMMISSION- Not less than the following amounts in the CERTF for a fiscal year shall be available to carry out the activities of the Comparative Effectiveness Research Commission established under section 1822(b) of the Social Security Act for such fiscal year:CommentsClose CommentsPermalink
`(A) For fiscal year 2008, $7,000,000.CommentsClose CommentsPermalink
`(B) For fiscal year 2009, $9,000,000.CommentsClose CommentsPermalink
`(C) For each fiscal year beginning with 2010, $10,000,000.CommentsClose CommentsPermalink
Nothing in this paragraph shall be construed as preventing additional amounts in the CERTF from being made available to the Comparative Effectiveness Research Commission for such activities.CommentsClose CommentsPermalink
`(e) Net Revenues- For purposes of this section, the term `net revenues' means the amount estimated by the Secretary based on the excess of--CommentsClose CommentsPermalink
`(1) the fees received in the Treasury under subchapter B of chapter 34, overCommentsClose CommentsPermalink
`(2) the decrease in the tax imposed by chapter 1 resulting from the fees imposed by such subchapter.'.CommentsClose CommentsPermalink
(B) CLERICAL AMENDMENT- The table of sections for such subchapter A is amended by adding at the end thereof the following new item:CommentsClose CommentsPermalink
`Sec. 9511. Health Care Comparative Effectiveness Research Trust Fund.'.CommentsClose CommentsPermalink
(2) FINANCING FOR FUND FROM FEES ON INSURED AND SELF-INSURED HEALTH PLANS-CommentsClose CommentsPermalink
(A) GENERAL RULE- Chapter 34 of the Internal Revenue Code of 1986 is amended by adding at the end the following new subchapter:CommentsClose CommentsPermalink
`Subchapter B--Insured and Self-Insured Health Plans
`Sec. 4375. Health insurance.CommentsClose CommentsPermalink
`Sec. 4376. Self-insured health plans.CommentsClose CommentsPermalink
`Sec. 4377. Definitions and special rules.CommentsClose CommentsPermalink
`SEC. 4375. HEALTH INSURANCE.
`(a) Imposition of Fee- There is hereby imposed on each specified health insurance policy for each policy year a fee equal to the fair share per capita amount determined under section 9511(c)(1) multiplied by the average number of lives covered under the policy.CommentsClose CommentsPermalink
`(b) Liability for Fee- The fee imposed by subsection (a) shall be paid by the issuer of the policy.CommentsClose CommentsPermalink
`(c) Specified Health Insurance Policy- For purposes of this section:CommentsClose CommentsPermalink
`(1) IN GENERAL- Except as otherwise provided in this section, the term `specified health insurance policy' means any accident or health insurance policy issued with respect to individuals residing in the United States.CommentsClose CommentsPermalink
`(2) EXEMPTION FOR CERTAIN POLICIES- The term `specified health insurance policy' does not include any insurance if substantially all of its coverage is of excepted benefits described in section 9832(c).CommentsClose CommentsPermalink
`(3) TREATMENT OF PREPAID HEALTH COVERAGE ARRANGEMENTS-CommentsClose CommentsPermalink
`(A) IN GENERAL- In the case of any arrangement described in subparagraph (B)--CommentsClose CommentsPermalink
`(i) such arrangement shall be treated as a specified health insurance policy, andCommentsClose CommentsPermalink
`(ii) the person referred to in such subparagraph shall be treated as the issuer.CommentsClose CommentsPermalink
`(B) DESCRIPTION OF ARRANGEMENTS- An arrangement is described in this subparagraph if under such arrangement fixed payments or premiums are received as consideration for any person's agreement to provide or arrange for the provision of accident or health coverage to residents of the United States, regardless of how such coverage is provided or arranged to be provided.CommentsClose CommentsPermalink
`SEC. 4376. SELF-INSURED HEALTH PLANS.
`(a) Imposition of Fee- In the case of any applicable self-insured health plan for each plan year, there is hereby imposed a fee equal to the fair share per capita amount determined under section 9511(c)(1) multiplied by the average number of lives covered under the plan.CommentsClose CommentsPermalink
`(b) Liability for Fee-CommentsClose CommentsPermalink
`(1) IN GENERAL- The fee imposed by subsection (a) shall be paid by the plan sponsor.CommentsClose CommentsPermalink
`(2) PLAN SPONSOR- For purposes of paragraph (1) the term `plan sponsor' means--CommentsClose CommentsPermalink
`(A) the employer in the case of a plan established or maintained by a single employer,CommentsClose CommentsPermalink
`(B) the employee organization in the case of a plan established or maintained by an employee organization,CommentsClose CommentsPermalink
`(C) in the case of--CommentsClose CommentsPermalink
`(i) a plan established or maintained by 2 or more employers or jointly by 1 or more employers and 1 or more employee organizations,CommentsClose CommentsPermalink
`(ii) a multiple employer welfare arrangement, orCommentsClose CommentsPermalink
`(iii) a voluntary employees' beneficiary association described in section 501(c)(9),CommentsClose CommentsPermalink
the association, committee, joint board of trustees, or other similar group of representatives of the parties who establish or maintain the plan, orCommentsClose CommentsPermalink
`(D) the cooperative or association described in subsection (c)(2)(F) in the case of a plan established or maintained by such a cooperative or association.CommentsClose CommentsPermalink
`(c) Applicable Self-Insured Health Plan- For purposes of this section, the term `applicable self-insured health plan' means any plan for providing accident or health coverage if--CommentsClose CommentsPermalink
`(1) any portion of such coverage is provided other than through an insurance policy, andCommentsClose CommentsPermalink
`(2) such plan is established or maintained--CommentsClose CommentsPermalink
`(A) by one or more employers for the benefit of their employees or former employees,CommentsClose CommentsPermalink
`(B) by one or more employee organizations for the benefit of their members or former members,CommentsClose CommentsPermalink
`(C) jointly by 1 or more employers and 1 or more employee organizations for the benefit of employees or former employees,CommentsClose CommentsPermalink
`(D) by a voluntary employees' beneficiary association described in section 501(c)(9),CommentsClose CommentsPermalink
`(E) by any organization described in section 501(c)(6), orCommentsClose CommentsPermalink
`(F) in the case of a plan not described in the preceding subparagraphs, by a multiple employer welfare arrangement (as defined in section 3(40) of Employee Retirement Income Security Act of 1974), a rural electric cooperative (as defined in section 3(40)(B)(iv) of such Act), or a rural telephone cooperative association (as defined in section 3(40)(B)(v) of such Act).CommentsClose CommentsPermalink
`SEC. 4377. DEFINITIONS AND SPECIAL RULES.
`(a) Definitions- For purposes of this subchapter--CommentsClose CommentsPermalink
`(1) ACCIDENT AND HEALTH COVERAGE- The term `accident and health coverage' means any coverage which, if provided by an insurance policy, would cause such policy to be a specified health insurance policy (as defined in section 4375(c)).CommentsClose CommentsPermalink
`(2) INSURANCE POLICY- The term `insurance policy' means any policy or other instrument whereby a contract of insurance is issued, renewed, or extended.CommentsClose CommentsPermalink
`(3) UNITED STATES- The term `United States' includes any possession of the United States.CommentsClose CommentsPermalink
`(b) Treatment of Governmental Entities-CommentsClose CommentsPermalink
`(1) IN GENERAL- For purposes of this subchapter--CommentsClose CommentsPermalink
`(A) the term `person' includes any governmental entity, andCommentsClose CommentsPermalink
`(B) notwithstanding any other law or rule of law, governmental entities shall not be exempt from the fees imposed by this subchapter except as provided in paragraph (2).CommentsClose CommentsPermalink
`(2) TREATMENT OF EXEMPT GOVERNMENTAL PROGRAMS- In the case of an exempt governmental program, no fee shall be imposed under section 4375 or section 4376 on any covered life under such program.CommentsClose CommentsPermalink
`(3) EXEMPT GOVERNMENTAL PROGRAM DEFINED- For purposes of this subchapter, the term `exempt governmental program' means--CommentsClose CommentsPermalink
`(A) any insurance program established under title XVIII of the Social Security Act,CommentsClose CommentsPermalink
`(B) the medical assistance program established by title XIX or XXI of the Social Security Act,CommentsClose CommentsPermalink
`(C) any program established by Federal law for providing medical care (other than through insurance policies) to individuals (or the spouses and dependents thereof) by reason of such individuals being--CommentsClose CommentsPermalink
`(i) members of the Armed Forces of the United States, orCommentsClose CommentsPermalink
`(ii) veterans, andCommentsClose CommentsPermalink
`(D) any program established by Federal law for providing medical care (other than through insurance policies) to members of Indian tribes (as defined in section 4(d) of the Indian Health Care Improvement Act).CommentsClose CommentsPermalink
`(c) Treatment as Tax- For purposes of subtitle F, the fees imposed by this subchapter shall be treated as if they were taxes.CommentsClose CommentsPermalink
`(d) No Cover Over to Possessions- Notwithstanding any other provision of law, no amount collected under this subchapter shall be covered over to any possession of the United States.'.CommentsClose CommentsPermalink
(B) CLERICAL AMENDMENTS-CommentsClose CommentsPermalink
(i) Chapter 34 of such Code is amended by striking the chapter heading and inserting the following:CommentsClose CommentsPermalink
`CHAPTER 34--TAXES ON CERTAIN INSURANCE POLICIES
`subchapter a. policies issued by foreign insurers
`subchapter b. insured and self-insured health plans
`Subchapter A--Policies Issued By Foreign Insurers'.
(ii) The table of chapters for subtitle D of such Code is amended by striking the item relating to chapter 34 and inserting the following new item:CommentsClose CommentsPermalink
`Chapter 34--Taxes on Certain Insurance Policies'.
(C) EFFECTIVE DATE- The amendments made by this subsection shall apply with respect to policies and plans for portions of policy or plan years beginning on or after October 1, 2010.CommentsClose CommentsPermalink
SEC. 905. IMPLEMENTATION OF HEALTH INFORMATION TECHNOLOGY (IT) UNDER MEDICARE.
(a) In General- Not later than January 1, 2010, the Secretary of Health and Human Services shall submit to Congress a report that includes--CommentsClose CommentsPermalink
(1) a plan to develop and implement a health information technology (health IT) system for all health care providers under the Medicare program that meets the specifications described in subsection (b); andCommentsClose CommentsPermalink
(2) an analysis of the impact, feasibility, and costs associated with the use of health information technology in medically underserved communities.CommentsClose CommentsPermalink
(b) Plan Specification- The specifications described in this subsection, with respect to a health information technology system described in subsection (a), are the following:CommentsClose CommentsPermalink
(1) The system protects the privacy and security of individually identifiable health information.CommentsClose CommentsPermalink
(2) The system maintains and provides permitted access to health information in an electronic format (such as through computerized patient records or a clinical data repository).CommentsClose CommentsPermalink
(3) The system utilizes interface software that allows for interoperability.CommentsClose CommentsPermalink
(4) The system includes clinical decision support.CommentsClose CommentsPermalink
(5) The system incorporates e-prescribing and computerized physician order entry.CommentsClose CommentsPermalink
(6) The system incorporates patient tracking and reminders.CommentsClose CommentsPermalink
(7) The system utilizes technology that is open source (if available) or technology that has been developed by the government.CommentsClose CommentsPermalink
The report shall include an analysis of the financial and administrative resources necessary to develop such system and recommendations regarding the level of subsidies needed for all such health care providers to adopt the system.CommentsClose CommentsPermalink
SEC. 906. DEVELOPMENT, REPORTING, AND USE OF HEALTH CARE MEASURES.
(a) In General- Part E of title XVIII of the Social Security Act (
`DEVELOPMENT, REPORTING, AND USE OF HEALTH CARE MEASURES
`Sec. 1890. (a) Fostering Development of Health Care Measures- The Secretary shall designate, and have in effect an arrangement with, a single organization (such as the National Quality Forum) that meets the requirements described in subsection (c), under which such organization provides the Secretary with advice on, and recommendations with respect to, the key elements and priorities of a national system for establishing health care measures. The arrangement shall be effective beginning no sooner than January 1, 2008, and no later than September 30, 2008.CommentsClose CommentsPermalink
`(b) Duties- The duties of the organization designated under subsection (a) (in this title referred to as the `designated organization') shall, in accordance with subsection (d), include--CommentsClose CommentsPermalink
`(1) establishing and managing an integrated national strategy and process for setting priorities and goals in establishing health care measures;CommentsClose CommentsPermalink
`(2) coordinating the development and specifications of such measures;CommentsClose CommentsPermalink
`(3) establishing standards for the development and testing of such measures;CommentsClose CommentsPermalink
`(4) endorsing national consensus health care measures; andCommentsClose CommentsPermalink
`(5) advancing the use of electronic health records for automating the collection, aggregation, and transmission of measurement information.CommentsClose CommentsPermalink
`(c) Requirements Described- For purposes of subsection (a), the requirements described in this subsection, with respect to an organization, are the following:CommentsClose CommentsPermalink
`(1) PRIVATE NONPROFIT- The organization is a private nonprofit entity governed by a board and an individual designated as president and chief executive officer.CommentsClose CommentsPermalink
`(2) BOARD MEMBERSHIP- The members of the board of the organization include representatives of--CommentsClose CommentsPermalink
`(A) health care providers or groups representing such providers;CommentsClose CommentsPermalink
`(B) health plans or groups representing health plans;CommentsClose CommentsPermalink
`(C) groups representing health care consumers;CommentsClose CommentsPermalink
`(D) health care purchasers and employers or groups representing such purchasers or employers; andCommentsClose CommentsPermalink
`(E) health care practitioners or groups representing practitioners.CommentsClose CommentsPermalink
`(3) OTHER MEMBERSHIP REQUIREMENTS- The membership of the organization is representative of individuals with experience with--CommentsClose CommentsPermalink
`(A) urban health care issues;CommentsClose CommentsPermalink
`(B) safety net health care issues;CommentsClose CommentsPermalink
`(C) rural and frontier health care issues; andCommentsClose CommentsPermalink
`(D) health care quality and safety issues.CommentsClose CommentsPermalink
`(4) OPEN AND TRANSPARENT- With respect to matters related to the arrangement described in subsection (a), the organization conducts its business in an open and transparent manner and provides the opportunity for public comment.CommentsClose CommentsPermalink
`(5) VOLUNTARY CONSENSUS STANDARDS SETTING ORGANIZATION- The organization operates as a voluntary consensus standards setting organization as defined for purposes of section 12(d) of the National Technology Transfer and Advancement Act of 1995 (
`(6) EXPERIENCE- The organization has at least 7 years experience in establishing national consensus standards.CommentsClose CommentsPermalink
`(d) Requirements for Health Care Measures- In carrying out its duties under subsection (b), the designated organization shall ensure the following:CommentsClose CommentsPermalink
`(1) MEASURES- The designated organization shall ensure that the measures established or endorsed under subsection (b) are evidence-based, reliable, and valid; and include--CommentsClose CommentsPermalink
`(A) measures of clinical processes and outcomes, patient experience, efficiency, and equity;CommentsClose CommentsPermalink
`(B) measures to assess effectiveness, timeliness, patient self-management, patient centeredness, and safety; andCommentsClose CommentsPermalink
`(C) measures of under use and over use.CommentsClose CommentsPermalink
`(2) PRIORITIES-CommentsClose CommentsPermalink
`(A) IN GENERAL- The designated organization shall ensure that priority is given to establishing and endorsing--CommentsClose CommentsPermalink
`(i) measures with the greatest potential impact for improving the effectiveness and efficiency of health care;CommentsClose CommentsPermalink
`(ii) measures that may be rapidly implemented by group health plans, health insurance issuers, physicians, hospitals, nursing homes, long-term care providers, and other providers;CommentsClose CommentsPermalink
`(iii) measures which may inform health care decisions made by consumers and patients; andCommentsClose CommentsPermalink
`(iv) measures that apply to multiple services furnished by different providers during an episode of care.CommentsClose CommentsPermalink
`(B) ANNUAL REPORT ON PRIORITIES; SECRETARIAL PUBLICATION AND COMMENT-CommentsClose CommentsPermalink
`(i) ANNUAL REPORT- The designated organization shall issue and submit to the Secretary a report by March 31 of each year (beginning with 2009) on the organization's recommendations for priorities and goals in establishing and endorsing health care measures under this section over the next five years.CommentsClose CommentsPermalink
`(ii) SECRETARIAL REVIEW AND COMMENT- After receipt of the report under clause (i) for a year, the Secretary shall publish the report in the Federal Register, including any comments of the Secretary on the priorities and goals set forth in the report.CommentsClose CommentsPermalink
`(3) RISK ADJUSTMENT- The designated organization, in consultation with health care measure developers and other stakeholders, shall establish procedures to assure that health care measures established and endorsed under this section account for differences in patient health status, patient characteristics, and geographic location, as appropriate.CommentsClose CommentsPermalink
`(4) MAINTENANCE- The designated organization, in consultation with owners and developers of health care measures, shall require the owners or developers of such measures to update and enhance such measures, including the development of more accurate and precise specifications, and retire existing outdated measures. Such updating shall occur not more often than once during each 12-month period, except in the case of emergent circumstances requiring a more immediate update to a measure.CommentsClose CommentsPermalink
`(e) Use of Health Care Measures; Reporting-CommentsClose CommentsPermalink
`(1) USE OF MEASURES- For purposes of activities authorized or required under this title, the Secretary shall select from health care measures--CommentsClose CommentsPermalink
`(A) recommended by multi-stakeholder groups; andCommentsClose CommentsPermalink
`(B) endorsed by the designated organization under subsection (b)(4).CommentsClose CommentsPermalink
`(2) REPORTING- The Secretary shall implement procedures, consistent with generally accepted standards, to enable the Department of Health and Human Services to accept the electronic submission of data for purposes of--CommentsClose CommentsPermalink
`(A) effectiveness measurement using the health care measures developed pursuant to this section; andCommentsClose CommentsPermalink
`(B) reporting to the Secretary measures used to make value-based payments under this title.CommentsClose CommentsPermalink
`(f) Contracts- The Secretary, acting through the Agency for Healthcare Research and Quality, may contract with organizations to support the development and testing of health care measures meeting the standards established by the designated organization.CommentsClose CommentsPermalink
`(g) Dissemination of Information- In order to make information on health care measures available to health care consumers, health professionals, public health officials, oversight organizations, researchers, and other appropriate individuals and entities, the Secretary shall work with multi-stakeholder groups to provide for the dissemination of information developed pursuant to this title.CommentsClose CommentsPermalink
`(h) Funding- For purposes of carrying out subsections (a), (b), (c), and (d), including for expenses incurred for the arrangement under subsection (a) with the designated organization, there is payable from the Federal Hospital Insurance Trust Fund (established under section 1817) and the Federal Supplementary Medical Insurance Trust Fund (established under section 1841)--CommentsClose CommentsPermalink
`(1) for fiscal year 2008, $15,000,000, multiplied by the ratio of the total number of months in the year to the number of months (and portions of months) of such year during which the arrangement under subsection (a) is effective; andCommentsClose CommentsPermalink
`(2) for each of the fiscal years, 2009 through 2012, $15,000,000.'.CommentsClose CommentsPermalink
SEC. 907. IMPROVEMENTS TO THE MEDIGAP PROGRAM.
(a) Implementation of NAIC Recommendations- The Secretary of Health and Human Services shall provide, under subsections (p)(1)(E) of section 1882 of the Social Security Act (
(b) Required Offering of a Range of Policies-CommentsClose CommentsPermalink
(1) IN GENERAL- Subsection (o) of such section is amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink
`(4) In addition to the requirement of paragraph (2), the issuer of the policy must make available to the individual at least medicare supplemental policies with benefit packages classified as `C' or `F'.'.CommentsClose CommentsPermalink
(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply to medicare supplemental policies issued on or after January 1, 2008.CommentsClose CommentsPermalink
(c) Removal of New Benefit Packages- Such section is further amended--CommentsClose CommentsPermalink
(1) in subsection (o)(1), by striking `(p), (v), and (w)' and inserting `(p) and (v)';CommentsClose CommentsPermalink
(2) in subsection (v)(3)(A)(i), by striking `or a benefit package described in subparagraph (A) or (B) of subsection (w)(2)'; andCommentsClose CommentsPermalink
(3) in subsection (w)--CommentsClose CommentsPermalink
(A) by striking `Policies' and all that follows through `The Secretary' and inserting `Policies- The Secretary';CommentsClose CommentsPermalink
(B) by striking the second sentence; andCommentsClose CommentsPermalink
(C) by striking paragraph (2).CommentsClose CommentsPermalink
SEC. 908. IMPLEMENTATION FUNDING.
For purposes of implementing the provisions of this Act (other than title X), the Secretary of Health and Human Services shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund established under section 1841 of the Social Security Act (
SEC. 909. ACCESS TO DATA ON PRESCRIPTION DRUG PLANS AND MEDICARE ADVANTAGE PLANS.
(a) In General- Section 1875 of the Social Security Act (
(1) in the heading, by inserting `TO CONGRESS; PROVIDING INFORMATION TO CONGRESSIONAL SUPPORT AGENCIES' after `AND RECOMMENDATIONS'; andCommentsClose CommentsPermalink
(2) by adding at the end the following new subsection:CommentsClose CommentsPermalink
`(c) Providing Information to Congressional Support Agencies-CommentsClose CommentsPermalink
`(1) IN GENERAL- Notwithstanding any provision under part D that limits the use of prescription drug data collected under such part, upon the request of a Congressional support agency, the Secretary shall provide such agency with information submitted to, or compiled by, the Secretary under part D (subject to the restriction on disclosure under paragraph (2)), including--CommentsClose CommentsPermalink
`(A) only with respect to Congressional support agencies that make official baseline spending projections, conduct oversight studies mandated by Congress, or make official recommendations on the program under this title to Congress--CommentsClose CommentsPermalink
`(i) aggregate negotiated prices for drugs covered under prescription drug plans and MA-PD plans;CommentsClose CommentsPermalink
`(ii) negotiated rebates, discounts, and other price concessions by drug and by contract or plan (as reported under section 1860D-2(d)(2));CommentsClose CommentsPermalink
`(iii) bid information (described in section 1860D-11(b)(2)(C)) submitted by such plans;CommentsClose CommentsPermalink
`(iv) data or a representative sample of data regarding drug claims and other data submitted under section 1860D-15(c)(1)(C) (as determined necessary and appropriate by the Congressional support agency to carry out the legislatively mandated duties of the agency);CommentsClose CommentsPermalink
`(v) the amount of reinsurance payments paid under section 1860D-15(a)(2), provided at the plan level; andCommentsClose CommentsPermalink
`(vi) the amount of any adjustments of payments made under subparagraph (B) or (C) of section 1860D-15(e)(2), provided at the plan level aggregate negotiated prices for drugs covered under prescription drug plans and MA-PD plans; andCommentsClose CommentsPermalink
`(B) access to drug event data submitted by such plans under section 1860D-15(d)(2)(A), except, with respect to data that reveals prices negotiated with drug manufacturers, such data shall only be available to Congressional support agencies that make official baseline spending projections, conduct oversight studies mandated by Congress, or make official recommendations on the program under this title to Congress.CommentsClose CommentsPermalink
`(2) RESTRICTION ON DATA DISCLOSURE-CommentsClose CommentsPermalink
`(A) IN GENERAL- Data provided to a Congressional support agency under this subsection shall not be disclosed, reported, or released in identifiable form.CommentsClose CommentsPermalink
`(B) IDENTIFIABLE FORM- For purposes of subparagraph (A), the term `identifiable form' means any representation of information that permits identification of a specific prescription drug plan, MA-PD plan, pharmacy benefit manager, drug manufacturer, drug wholesaler, or individual enrolled in a prescription drug plan or an MA-PD plan under part D.CommentsClose CommentsPermalink
`(3) TIMING- The Secretary shall release data under this subsection in a timeframe that enables Congressional support agencies to complete congressional requests.CommentsClose CommentsPermalink
`(4) USE OF THE DATA PROVIDED- Data provided to a Congressional support agency under this subsection shall only be used by such agency for carrying out the functions and activities of the agency mandated by Congress.CommentsClose CommentsPermalink
`(5) CONFIDENTIALITY- The Secretary shall establish safeguards to protect the confidentiality of data released under this subsection. Such safeguards shall not provide for greater disclosure than is permitted under any of the following:CommentsClose CommentsPermalink
`(A) The Federal regulations (concerning the privacy of individually identifiable health information) promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996.CommentsClose CommentsPermalink
`(B) Section 552 or 552a of title 5, United States Code, with regard to the privacy of individually identifiable beneficiary health information.CommentsClose CommentsPermalink
`(6) DEFINITIONS- In this subsection:CommentsClose CommentsPermalink
`(A) CONGRESSIONAL SUPPORT AGENCY- The term `Congressional support agency' means--CommentsClose CommentsPermalink
`(i) the Medicare Payment Advisory Commission;CommentsClose CommentsPermalink
`(ii) the Government Accountability Office; andCommentsClose CommentsPermalink
`(iii) the Congressional Budget Office.CommentsClose CommentsPermalink
`(B) MA-PD PLAN- The term `MA-PD plan' has the meaning given such term in section 1860D-1(a)(3)(C).CommentsClose CommentsPermalink
`(C) PRESCRIPTION DRUG PLAN- The term `prescription drug plan' has the meaning given such term in section 1860D-41(a)(14).'.CommentsClose CommentsPermalink
(b) Conforming Amendment- Section 1805(b)(2) of the Social Security Act (
`(D) PART D- Specifically, the Commission shall review payment policies with respect to the Voluntary Prescription Drug Benefit Program under part D, including--CommentsClose CommentsPermalink
`(i) the factors affecting expenditures;CommentsClose CommentsPermalink
`(ii) payment methodologies; andCommentsClose CommentsPermalink
`(iii) their relationship to access and quality of care for Medicare beneficiaries.'.CommentsClose CommentsPermalink
SEC. 910. ABSTINENCE EDUCATION.
Section 510 of the Social Security Act (
`SEC. 510. SEPARATE PROGRAM FOR ABSTINENCE EDUCATION.
`(a) In General- For the purpose described in subsection (b), the Secretary shall, for fiscal year 2008 and fiscal year 2009, allot to each State which has transmitted an application for the fiscal year under section 505(a) an amount equal to the product of--CommentsClose CommentsPermalink
`(1) the amount appropriated in subsection (d) for the fiscal year; andCommentsClose CommentsPermalink
`(2) the percentage determined for the State under section 502(c)(1)(B)(ii).CommentsClose CommentsPermalink
`(b) Purpose of Allotment-CommentsClose CommentsPermalink
`(1) PURPOSE- The purpose of an allotment under subsection (a) to a State is to enable the State to provide abstinence education, and where appropriate, mentoring, counseling, and adult supervision to promote abstinence from sexual activity, with a focus on those groups which are most likely to bear children out-of-wedlock.CommentsClose CommentsPermalink
`(2) DEFINITION; STATE OPTION- For purposes of this section, the term `abstinence education' has, at the option of each State receiving an allotment under subsection (a), the meaning given such term in subparagraph (A), or the meaning given such term in subparagraph (B), as follows:CommentsClose CommentsPermalink
`(A) Such term means a medically and scientifically accurate educational or motivational program which--CommentsClose CommentsPermalink
`(i) has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity;CommentsClose CommentsPermalink
`(ii) teaches abstinence from sexual activity outside marriage as the expected standard for all school age children;CommentsClose CommentsPermalink
`(iii) teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems;CommentsClose CommentsPermalink
`(iv) teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity;CommentsClose CommentsPermalink
`(v) teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects;CommentsClose CommentsPermalink
`(vi) teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child's parents, and society;CommentsClose CommentsPermalink
`(vii) teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; andCommentsClose CommentsPermalink
`(viii) teaches the importance of attaining self-sufficiency before engaging in sexual activity.CommentsClose CommentsPermalink
`(B) Such term means a medically and scientifically accurate educational or motivational program which promotes abstinence and educates those who are currently sexually active or at risk of sexual activity about additional methods to prevent unintended pregnancy or reduce other health risks.CommentsClose CommentsPermalink
`(3) CERTAIN REQUIREMENTS-CommentsClose CommentsPermalink
`(A) LIMITATION REGARDING INACCURATE INFORMATION- None of the funds made available under this section may be used to provide abstinence education that includes information that is medically and scientifically inaccurate. For purposes of this section, the term `medically and scientifically inaccurate' means information that is unsupported or contradicted by a preponderance of peer-reviewed research by leading medical, psychological, psychiatric, and public health publications, organizations and agencies.CommentsClose CommentsPermalink
`(B) EFFECTIVENESS REGARDING CERTAIN MATTERS- None of the funds made available under this section may be used for a program unless the program is based on a model that has been demonstrated to be effective in preventing unintended pregnancy, or in reducing the transmission of a sexually transmitted disease, including the human immunodeficiency virus. The preceding sentence does not apply to any program that was approved and funded under this section on or before September 30, 2007.CommentsClose CommentsPermalink
`(c) Applicability of Certain Sections-CommentsClose CommentsPermalink
`(1) REQUIREMENTS- Sections 503, 507, and 508 apply to allotments under subsection (a) to the same extent and in the same manner as such sections apply to allotments under section 502(c).CommentsClose CommentsPermalink
`(2) DISCRETION OF SECRETARY- Sections 505 and 506 apply to allotments under subsection (a) to the extent determined by the Secretary to be appropriate.CommentsClose CommentsPermalink
`(d) Authorization of Appropriations- For the purpose of allotments under subsection (a), there is authorized to be appropriated $50,000,000 for each of fiscal years 2008 and 2009.'.CommentsClose CommentsPermalink
TITLE X--REVENUES
SEC. 1001. INCREASE IN RATE OF EXCISE TAXES ON TOBACCO PRODUCTS AND CIGARETTE PAPERS AND TUBES.
(a) Small Cigarettes- Paragraph (1) of section 5701(b) of the Internal Revenue Code of 1986 is amended by striking `$19.50 per thousand ($17 per thousand on cigarettes removed during 2000 or 2001)' and inserting `$42 per thousand'.CommentsClose CommentsPermalink
(b) Large Cigarettes- Paragraph (2) of section 5701(b) of such Code is amended by striking `$40.95 per thousand ($35.70 per thousand on cigarettes removed during 2000 or 2001)' and inserting `$88.20 per thousand'.CommentsClose CommentsPermalink
(c) Small Cigars- Paragraph (1) of section 5701(a) of such Code is amended by striking `$1.828 cents per thousand ($1.594 cents per thousand on cigars removed during 2000 or 2001)' and inserting `$42 per thousand'.CommentsClose CommentsPermalink
(d) Large Cigars- Paragraph (2) of section 5701(a) of such Code is amended--CommentsClose CommentsPermalink
(1) by striking `20.719 percent (18.063 percent on cigars removed during 2000 or 2001)' and inserting `40 percent (33 percent on cigars removed after December 31, 2007, and before October 1, 2013)', andCommentsClose CommentsPermalink
(2) by striking `$48.75 per thousand ($42.50 per thousand on cigars removed during 2000 or 2001)' and inserting `$1 per cigar'.CommentsClose CommentsPermalink
(e) Cigarette Papers- Subsection (c) of section 5701 of such Code is amended by striking `1.22 cents (1.06 cents on cigarette papers removed during 2000 or 2001)' and inserting `2.63 cents'.CommentsClose CommentsPermalink
(f) Cigarette Tubes- Subsection (d) of section 5701 of such Code is amended by striking `2.44 cents (2.13 cents on cigarette tubes removed during 2000 or 2001)' and inserting `5.26 cents'.CommentsClose CommentsPermalink
(g) Snuff- Paragraph (1) of section 5701(e) of such Code is amended by striking `58.5 cents (51 cents on snuff removed during 2000 or 2001)' and inserting `$1.26'.CommentsClose CommentsPermalink
(h) Chewing Tobacco- Paragraph (2) of section 5701(e) of such Code is amended by striking `19.5 cents (17 cents on chewing tobacco removed during 2000 or 2001)' and inserting `42 cents'.CommentsClose CommentsPermalink
(i) Pipe Tobacco- Subsection (f) of section 5701 of such Code is amended by striking `$1.0969 cents (95.67 cents on pipe tobacco removed during 2000 or 2001)' and inserting `$2.36'.CommentsClose CommentsPermalink
(j) Roll-Your-Own Tobacco-CommentsClose CommentsPermalink
(1) IN GENERAL- Subsection (g) of section 5701 of such Code is amended by striking `$1.0969 cents (95.67 cents on roll-your-own tobacco removed during 2000 or 2001)' and inserting `$7.4667'.CommentsClose CommentsPermalink
(2) INCLUSION OF CIGAR TOBACCO- Subsection (o) of section 5702 of such Code is amended by inserting `or cigars, or for use as wrappers for making cigars' before the period at the end.CommentsClose CommentsPermalink
(k) Effective Date- The amendments made by this section shall apply to articles removed after December 31, 2007.CommentsClose CommentsPermalink
(l) Floor Stocks Taxes-CommentsClose CommentsPermalink
(1) IMPOSITION OF TAX- On cigarettes manufactured in or imported into the United States which are removed before January 1, 2008, and held on such date for sale by any person, there is hereby imposed a tax in an amount equal to the excess of--CommentsClose CommentsPermalink
(A) the tax which would be imposed under section 5701 of the Internal Revenue Code of 1986 on the article if the article had been removed on such date, overCommentsClose CommentsPermalink
(B) the prior tax (if any) imposed under section 5701 of such Code on such article.CommentsClose CommentsPermalink
(2) AUTHORITY TO EXEMPT CIGARETTES HELD IN VENDING MACHINES- To the extent provided in regulations prescribed by the Secretary, no tax shall be imposed by paragraph (1) on cigarettes held for retail sale on January 1, 2008, by any person in any vending machine. If the Secretary provides such a benefit with respect to any person, the Secretary may reduce the $500 amount in paragraph (3) with respect to such person.CommentsClose CommentsPermalink
(3) CREDIT AGAINST TAX- Each person shall be allowed as a credit against the taxes imposed by paragraph (1) an amount equal to $500. Such credit shall not exceed the amount of taxes imposed by paragraph (1) for which such person is liable.CommentsClose CommentsPermalink
(4) LIABILITY FOR TAX AND METHOD OF PAYMENT-CommentsClose CommentsPermalink
(A) LIABILITY FOR TAX- A person holding cigarettes on January 1, 2008, to which any tax imposed by paragraph (1) applies shall be liable for such tax.CommentsClose CommentsPermalink
(B) METHOD OF PAYMENT- The tax imposed by paragraph (1) shall be paid in such manner as the Secretary shall prescribe by regulations.CommentsClose CommentsPermalink
(C) TIME FOR PAYMENT- The tax imposed by paragraph (1) shall be paid on or before April 14, 2008.CommentsClose CommentsPermalink
(5) ARTICLES IN FOREIGN TRADE ZONES- - Notwithstanding the Act of June 18, 1934 (48 Stat. 998,
(A) internal revenue taxes have been determined, or customs duties liquidated, with respect to such article before such date pursuant to a request made under the 1st proviso of section 3(a) of such Act, orCommentsClose CommentsPermalink
(B) such article is held on such date under the supervision of a customs officer pursuant to the 2d proviso of such section 3(a).CommentsClose CommentsPermalink
(6) DEFINITIONS- For purposes of this subsection--CommentsClose CommentsPermalink
(A) IN GENERAL- Terms used in this subsection which are also used in section 5702 of the Internal Revenue Code of 1986 shall have the respective meanings such terms have in such section.CommentsClose CommentsPermalink
(B) SECRETARY- The term `Secretary' means the Secretary of the Treasury or the Secretary's delegate.CommentsClose CommentsPermalink
(7) CONTROLLED GROUPS- Rules similar to the rules of section 5061(e)(3) of such Code shall apply for purposes of this subsection.CommentsClose CommentsPermalink
(8) OTHER LAWS APPLICABLE- All provisions of law, including penalties, applicable with respect to the taxes imposed by section 5701 of such Code shall, insofar as applicable and not inconsistent with the provisions of this subsection, apply to the floor stocks taxes imposed by paragraph (1), to the same extent as if such taxes were imposed by such section 5701. The Secretary may treat any person who bore the ultimate burden of the tax imposed by paragraph (1) as the person to whom a credit or refund under such provisions may be allowed or made.CommentsClose CommentsPermalink
SEC. 1002. EXEMPTION FOR EMERGENCY MEDICAL SERVICES TRANSPORTATION.
(a) In General- Subsection (l) of section 4041 of the Internal Revenue Code of 1986 is amended to read as follows:CommentsClose CommentsPermalink
`(l) Exemption for Certain Uses-CommentsClose CommentsPermalink
`(1) CERTAIN AIRCRAFT- No tax shall be imposed under this section on any liquid sold for use in, or used in, a helicopter or a fixed-wing aircraft for purposes of providing transportation with respect to which the requirements of subsection (f) or (g) of section 4261 are met.CommentsClose CommentsPermalink
`(2) EMERGENCY MEDICAL SERVICES- No tax shall be imposed under this section on any liquid sold for use in, or used in, any ambulance for purposes of providing transportation for emergency medical services. The preceding sentence shall not apply to any liquid used after December 31, 2012.'.CommentsClose CommentsPermalink
(b) Fuels Not Used for Taxable Purposes- Section 6427 of such Code is amended by inserting after subsection (e) the following new subsection:CommentsClose CommentsPermalink
`(f) Use to Provide Emergency Medical Services- Except as provided in subsection (k), if any fuel on which tax was imposed by section 4081 or 4041 is used in an ambulance for a purpose described in section 4041(l)(2), the Secretary shall pay (without interest) to the ultimate purchaser of such fuel an amount equal to the aggregate amount of the tax imposed on such fuel. The preceding sentence shall not apply to any liquid used after December 31, 2012.'.CommentsClose CommentsPermalink
(c) Time for Filing Claims; Period Covered- Paragraphs (1) and (2)(A) of section 6427(i) of such Code are each amended by inserting `(f),' after `(d),'.CommentsClose CommentsPermalink
(d) Conforming Amendment- Section 6427(d) of such Code is amended by striking `4041(l)' and inserting `4041(l)(1)'.CommentsClose CommentsPermalink
(e) Effective Date- The amendments made by this section shall apply to fuel used in transportation provided in quarters beginning after the date of the enactment of this Act.CommentsClose CommentsPermalink
Passed the House of Representatives August 1, 2007.CommentsClose CommentsPermalink
Attest:CommentsClose CommentsPermalink
Clerk. LORRAINE C. MILLER, CommentsClose CommentsPermalink
Clerk.CommentsClose CommentsPermalink
By Jorge E. Sorensen,CommentsClose CommentsPermalink
Deputy Clerk.CommentsClose CommentsPermalink
Calendar No. 338CommentsClose CommentsPermalink
To amend titles XVIII, XIX, and XXI of the Social Security Act to extend and improve the children's health insurance program, to improve beneficiary protections under the Medicare, Medicaid, and the CHIP program, and for other purposes.CommentsClose CommentsPermalink
September 4, 2007
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