A bill to amend title XVIII of the Social Security Act to improve Medicare benefits for individuals with kidney disease, and for other purposes.

Summary: Kidney Disease Equitable Access, Prevention, and Research Act of 2012 - Amends title XVIII (Medicare) of the Social Security Act to direct the Secretary of Health and Human Services (HHS), in specified circumstances, to accept the results of a state licensure survey for purposes of determining federal certification of the compliance of a renal dialysis facility (RDF) with the conditions of Medicare participation.

Allows the Secretary to assess and collect reasonable fees for the initial Medicare survey from an RDF.

Revises Medicare requirements for group health plans to extend from 12 to 42 months after an individual becomes eligible for Medicare part A (Hospital Insurance Benefits for the Aged and Disabled) benefits the period during which a group health plan is a primary payer (and Medicare the secondary payer) for ESRD patients. Requires such a plan to: (1) provide adequate, advanced, written notice to patients regarding changes to dialysis service benefits, new restrictions on out-of-network access, or reductions in rates paid for out-of-network benefits; (2) allow patients to continue using their existing provider or facility for dialysis services for at least 24 months after a plan or issuer notice of any change; (3) hold patients harmless from a provider network change if the change requires unreasonable drive time or disrupts the physician-patient relationship; (4) ensure that out-of-pocket payments for such services apply to the Medicare part C (Medicare+Choice Program) out-of-pocket maximums and are treated as non-routine for copayment purposes; and (5) meet minimum network adequacy standards. Prohibits such a plan from: (1) restricting the duration or number of dialysis sessions for patients to less than the number for which payment may be made; (2) requiring assignment of benefits for such services; or (3) denying or limiting coverage for patients for such services if premiums, copayments, or other payments are made by third parties on their behalf. Directs the Secretary to study: (1) the social, behavioral, and biological factors leading to kidney disease; and (2) efforts to slow the progression of kidney disease in minority populations that are disproportionately affected by it. Directs the Secretary to report to Congress on the research gaps with respect to the development of quality metrics and care management metrics for ESRD patients. Directs the Comptroller General to evaluate the transportation barriers facing dialysis patients that result in less than 100% compliance with their plan of care under the Medicare program. Includes as a person qualified to furnish kidney disease education services an RDF with a physician or a physician assistant, nurse practitioner, or clinical nurse specialist. Declares that the mandatory single payment to an RDF or other provider of renal dialysis services shall not take into account the amount of payment for kidney disease education services. Revises the definition of “kidney disease education services” to specify education services furnished to individuals: (1) with stage V (as well as those with stage IV) chronic kidney disease, and (2) who are not receiving dialysis services.

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Kidney Disease 
Equitable Access, Prevention, and Research Act of 2012''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
TITLE I--PROVIDING EQUITABLE ACCESS TO CARE FOR INDIVIDUALS WITH KIDNEY 
                                DISEASE

Sec. 101. Improving access to care through improvements in the initial 
                            survey process for renal dialysis 
                            facilities.
Sec. 102. Providing choice in primary insurer.
Sec. 103. Protecting individuals with kidney failure from unfair 
                            practices.
TITLE II--SUPPORTING RESEARCH TO IMPROVE ACCESS TO HIGH QUALITY KIDNEY 
                                  CARE

Sec. 201. Understanding the progression of kidney disease in minority 
                            populations.
Sec. 202. Recommendations on dialysis quality and care management 
                            research gaps.
Sec. 203. GAO study on transportation barriers to access kidney care.
  TITLE III--IMPROVING ACCESS TO PREVENTIVE CARE FOR INDIVIDUALS WITH 
                             KIDNEY DISEASE

Sec. 301. Improving access to medicare kidney disease education.

TITLE I--PROVIDING EQUITABLE ACCESS TO CARE FOR INDIVIDUALS WITH KIDNEY 
                                DISEASE

SEC. 101. IMPROVING ACCESS TO CARE THROUGH IMPROVEMENTS IN THE INITIAL 
              SURVEY PROCESS FOR RENAL DIALYSIS FACILITIES.

    Section 1864 of the Social Security Act (42 U.S.C. 1395aa) is 
amended--
            (1) by redesignating subsection (e) as subsection (f);
            (2) by inserting after subsection (d) the following new 
        subsection:
    ``(e)(1) If the Secretary has entered into an agreement with any 
State under this section under which the appropriate State or local 
agency that performs any survey related to determining the compliance 
of a renal dialysis facility subject to the requirements of section 
1881(b) and the State licensure survey requirements are consistent with 
or exceed such Federal requirements, the Secretary must accept the 
results of the State licensure survey for purposes of determining 
Federal certification of compliance. In the case of such an initial 
survey of a renal dialysis facility, the Secretary may allow any State 
to waive the reimbursement for conducting the survey under this section 
if it requests such a waiver.
    ``(2) In the case of a renal dialysis facility that has waited for 
more than 6 months to receive the results of an initial survey under 
this section, the Secretary shall establish a specific timetable for 
completing and reporting the results of the survey.''; and
            (3) in subsection (f), as so redesignated--
                    (A) by striking ``Notwithstanding any other 
                provision of law,'' and inserting ``(1) Notwithstanding 
                any other provision of law and except as provided in 
                paragraph (2)''; and
                    (B) by adding at the end the following:
    ``(2) The Secretary may assess and collect fees for the initial 
Medicare survey from a renal dialysis facility subject to the 
requirements of section 1881(b) in an amount not to exceed a reasonable 
fee necessary to cover the costs of initial surveys conducted for 
purposes of determining the compliance of a renal dialysis facility 
with the requirements of section 1881(b). Fees may be assessed and 
collected under this paragraph only in such manner as would result in 
an aggregate amount of fees collected during any fiscal year being 
equal to the aggregate amount of costs for such fiscal year for initial 
surveys of such facilities under this section. A renal dialysis 
facility's liability for such fees shall be reasonably based on the 
proportion of the survey costs which relate to such facility. Any funds 
collected under this paragraph shall be used only to conduct the 
initial survey of the facilities providing the fees.
    ``(3) Fees authorized under paragraph (2) shall be collected by the 
Secretary and available only to the extent and in the amount provided 
in advance in appropriations Acts and upon request of the Secretary, 
subject to the amount and usage limitations of such paragraph. Such 
fees so collected are authorized to remain available until expended.''.

SEC. 102. PROVIDING CHOICE IN PRIMARY INSURER.

    (a) Providing for Patient Choice.--
            (1) In general.--Section 1862(b)(1)(C) of the Social 
        Security Act (42 U.S.C. 1395y(b)(1)(C)) is amended--
                    (A) in the last sentence, by inserting ``and before 
                January 1, 2013,'' after ``prior to such date)''; and
                    (B) by adding at the end the following new 
                sentence: ``Effective for items and services furnished 
                on or after January 1, 2013 (with respect to periods 
                beginning on or after the date that is 42 months prior 
                to such date), clauses (i) and (ii) shall be applied by 
                substituting `42-month' for `12-month' each place it 
                appears in the first sentence.''.
            (2) Effective date.--The amendments made by this subsection 
        shall take effect on the date of enactment of this Act. For 
        purposes of determining an individual's status under section 
        1862(b)(1)(C) of the Social Security Act (42 U.S.C. 
        1395y(b)(1)(C)), as amended by paragraph (1), an individual who 
        is within the coordinating period as of the date of enactment 
        of this Act shall have that period extended to the full 42 
        months described in the last sentence of such section, as added 
        by the amendment made by paragraph (1)(B).
    (b) Providing Equitable Access to Insurance for Individuals With 
Kidney Failure.--The Secretary of Health and Human Services shall 
clarify upon enactment of this Act that the Medicare Secondary Payer 
rules set forth in section 1862(b)(1)(C) of the Social Security Act (42 
U.S.C. 1395y(b)(1)(C)), as amended by this Act, apply to qualified 
health plans established under section 1311(b)(1)(B) of Public Law 111-
148 (42 U.S.C. 13031(b)(1)(B)).

SEC. 103. PROTECTING INDIVIDUALS WITH KIDNEY FAILURE FROM UNFAIR 
              PRACTICES.

    (a) In General.--Section 1862(b)(1)(C)(ii) of the Social Security 
Act (42 U.S.C. 1395y(b)(1)(C)(ii)) is amended to read as follows:
                            ``(ii) may not differentiate in the 
                        benefits it provides between individuals having 
                        end stage renal disease and other individuals 
                        covered by such plan or issuer on the basis of 
                        the existence of end stage renal disease, the 
                        need for renal dialysis, or in any other 
                        manner, and such plan--
                                    ``(I) shall provide adequate, 
                                advanced, written notification to 
                                patients regarding changes to dialysis 
                                service benefits, new restrictions on 
                                out-of-network access, or reductions in 
                                rates paid for out-of-network benefits 
                                for such services;
                                    ``(II) shall allow patients to 
                                continue using their existing provider 
                                or facility of such services for at 
                                least 24 months following the date of 
                                notice of any change by the plan or 
                                issuer in the dialysis services network 
                                of the plan or issuer;
                                    ``(III) shall hold patients 
                                harmless from provider network changes 
                                with respect to such services if such 
                                changes require unreasonable drive time 
                                or disrupt the physician-patient 
                                relationship;
                                    ``(IV) may not restrict the 
                                duration or number of dialysis sessions 
                                for patients, such as based on a fixed 
                                number of treatments per week, to less 
                                than the number for which payment may 
                                be made pursuant to section 1881(b)(1);
                                    ``(V) may not require assignment of 
                                benefits for such services;
                                    ``(VI) shall ensure that out-of-
                                pocket payments for such services apply 
                                to the medicare part C out-of-pocket 
                                maximums and not treated as routine for 
                                purposes of calculating beneficiary 
                                copayments;
                                    ``(VII) may not deny or limit 
                                coverage for patients for such services 
                                if premiums, copayments, or other 
                                payments are made by third parties on 
                                their behalf; and
                                    ``(VIII) shall meet minimum network 
                                adequacy standards specified by the 
                                Secretary with respect to such 
                                services;''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to group health plans as of January 1, 2014.

TITLE II--SUPPORTING RESEARCH TO IMPROVE ACCESS TO HIGH QUALITY KIDNEY 
                                  CARE

SEC. 201. UNDERSTANDING THE PROGRESSION OF KIDNEY DISEASE IN MINORITY 
              POPULATIONS.

    Not later than one year after the date of the enactment of this 
Act, the Secretary of Health and Human Services shall complete a study 
(and submit a report to Congress) on--
            (1) the social, behavioral, and biological factors leading 
        to kidney disease; and
            (2) efforts to slow the progression of kidney disease in 
        minority populations that are disproportionately affected by 
        such disease.

SEC. 202. RECOMMENDATIONS ON DIALYSIS QUALITY AND CARE MANAGEMENT 
              RESEARCH GAPS.

    Not later than 2 years after the date of the enactment of this Act, 
the Secretary of Health and Human Services shall submit to Congress a 
report regarding the research gaps with respect to the development of 
quality metrics and care management metrics for patients with end-stage 
renal disease, including pediatric and home dialysis patients. Such 
report shall include recommendations about undertaking research to fill 
such gaps and prioritizing such research.

SEC. 203. GAO STUDY ON TRANSPORTATION BARRIERS TO ACCESS KIDNEY CARE.

    (a) In General.--The Comptroller General of the United States shall 
conduct an evaluation of the transportation barriers facing dialysis 
patients that result in less than 100 percent compliance with their 
plan of care under the Medicare program.
    (b) Specific Matters Evaluated.--In conducting the evaluation under 
subsection (a), the Comptroller General shall examine--
            (1) the costs associated with providing dialysis services;
            (2) the number and characteristics of patients who miss at 
        least 2 dialysis treatments during a month or have shortened 
        treatments because of barriers to transportation; and
            (3) the potential sources of providing dialysis patients 
        with such transportation services.
    (c) Report.--Not later than the date that is 6 months after the 
date of the enactment of this Act, the Comptroller General shall submit 
to Congress a report on the study conducted under subsection (a) 
together with recommendations for such legislation and administrative 
action as the Comptroller General determines appropriate.

  TITLE III--IMPROVING ACCESS TO PREVENTIVE CARE FOR INDIVIDUALS WITH 
                             KIDNEY DISEASE

SEC. 301. IMPROVING ACCESS TO MEDICARE KIDNEY DISEASE EDUCATION.

    (a) In General.--Section 1861(ggg)(2) of the Social Security Act 
(42 U.S.C. 1395x(ggg)(2)) is amended--
            (1) by striking subparagraph (B); and
            (2) in subparagraph (A)--
                    (A) by striking ``(A)'' after ``(2)'';
                    (B) by striking ``and'' at the end of clause (i);
                    (C) by striking the period at the end of clause 
                (ii) and inserting ``; and'';
                    (D) by redesignating clauses (i) and (ii) as 
                subparagraphs (A) and (B), respectively; and
                    (E) by adding at the end the following:
                    ``(C) a renal dialysis facility subject to the 
                requirements of section 1881(b)(1) with personnel--
                            ``(i) who provide the services described in 
                        paragraph (1); and
                            ``(ii) that include a physician (as defined 
                        in subsection (r)(1)) or a physician assistant, 
                        nurse practitioner, or clinical nurse 
                        specialist (as defined in subsection 
                        (aa)(5)).''.
    (b) Payment to Renal Dialysis Facilities.--Section 1881(b) of such 
Act (42 U.S.C. 1395rr(b)) is amended by adding at the end the following 
new paragraph:
    ``(15) For purposes of paragraph (14), the single payment for renal 
dialysis services under such paragraph shall not take into account the 
amount of payment for kidney disease education services (as defined in 
section 1861(ggg)). Instead, payment for such services shall be made to 
the renal dialysis facility on an assignment-related basis under 
section 1848.''.
    (c) Providing Education Services to Individuals With Kidney 
Failure.--Section 1861(ggg)(1)(A) of the Social Security Act (42 U.S.C. 
1395x(ggg)(1)(A)) is amended--
            (1) by inserting ``or stage V'' after ``stage IV''; and
            (2) by inserting ``and who is not receiving dialysis 
        services'' after ``chronic kidney disease''.
    (d) Effective Date.--The amendments made by this section apply to 
kidney disease education services furnished on or after January 1, 
2013.