Preventing and Reducing Improper Medicare and Medicaid Expenditures to Restore Integrity to Benefits Act of 2015

Summary: Preventing and Reducing Improper Medicare and Medicaid Expenditures to Restore Integrity to Benefits Act of 2015 This bill amends title XIX (Medicaid) of the Social Security Act to make several changes related to the prevention of Medicaid fraud. With respect to the Medicaid Integrity Program (MIP), the bill: (1) specifies that program appropriations&nbsp;may cover costs of equipment, travel, training, and salaries and benefits; and (2) allows the Department of Health and Human Services (HHS) flexibility in determining the number of additional staff necessary to carry out the program. (MIP is a federal program aimed at preventing and reducing provider fraud, waste, and abuse in the Medicaid program.) Under current law, HHS may contract with Medicare administrative contractors (MACs), which are&nbsp;private&nbsp;insurers that process Medicare claims within&nbsp;specified geographic jurisdictions. The bill&nbsp;requires HHS to provide specified incentives for MACs to reduce improper payment error rates within their jurisdictions. The bill establishes criminal penalties of up to 10 years imprisonment and up to $500,000 in fines for illegally purchasing or distributing Medicare, Medicaid, or Children's Health Insurance Program (CHIP) beneficiary identification or billing privileges. The bill increases the scope of the Medicare-Medicaid Data Match Program (Medi-Medi Program), an existing program through which contractors and participating&nbsp;governmental agencies collaboratively analyze&nbsp;Medicare and Medicaid billing trends. HHS must establish a plan to encourage states to participate in the Medi-Medi Program.  HHS shall develop and implement a plan to allow states to access relevant data on improper or fraudulent payments made under the Medicare program on behalf of individuals dually eligible for both Medicare and Medicaid.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Preventing and Reducing Improper 
Medicare and Medicaid Expenditures to Restore Integrity to Benefits Act 
of 2015''.

SEC. 2. STRENGTHENING MEDICAID PROGRAM INTEGRITY THROUGH FLEXIBILITY.

    Section 1936 of the Social Security Act (42 U.S.C. 1396u-6) is 
amended--
            (1) in subsection (a), by inserting ``, or otherwise,'' 
        after ``entities''; and
            (2) in subsection (e)--
                    (A) in paragraph (1), in the matter preceding 
                subparagraph (A), by inserting ``(including the costs 
                of equipment, salaries and benefits, and travel and 
                training)'' after ``Program under this section''; and
                    (B) in paragraph (3), by striking ``by 100'' and 
                inserting ``by 100, or such number as determined 
                necessary by the Secretary to carry out the Program,''.

SEC. 3. ESTABLISHING MEDICARE ADMINISTRATIVE CONTRACTOR ERROR REDUCTION 
              INCENTIVES.

    (a) In General.--Section 1874A(b)(1)(D) of the Social Security Act 
(42 U.S.C. 1395kk-1(b)(1)(D)) is amended--
            (1) by striking ``quality.--The Secretary'' and inserting 
        ``quality.--
                            ``(i) In general.--Subject to clauses (ii) 
                        and (iii), the Secretary''; and
            (2) by inserting after clause (i), as added by paragraph 
        (1), the following new clauses:
                            ``(ii) Improper payment rate reduction 
                        incentives.--The Secretary shall provide 
                        incentives for medicare administrative 
                        contractors to reduce the improper payment 
                        error rates in their jurisdictions.
                            ``(iii) Incentives.--The incentives 
                        provided for under clause (ii)--
                                    ``(I) may include a sliding scale 
                                of award fee payments and additional 
                                incentives to medicare administrative 
                                contractors that either reduce the 
                                improper payment rates in their 
                                jurisdictions to certain thresholds, as 
                                determined by the Secretary, or 
                                accomplish tasks, as determined by the 
                                Secretary, that further improve payment 
                                accuracy; and
                                    ``(II) may include substantial 
                                reductions in award fee payments under 
                                cost-plus-award-fee contracts, for 
                                medicare administrative contractors 
                                that reach an upper end improper 
                                payment rate threshold or other 
                                threshold as determined by the 
                                Secretary, or fail to accomplish tasks, 
                                as determined by the Secretary, that 
                                further improve payment accuracy.''.
    (b) Effective Date.--
            (1) In general.--The amendments made by subsection (a) 
        shall apply to contracts entered into or renewed on or after 
        the date that is 3 years after the date of enactment of this 
        Act.
            (2) Application to existing contracts.--In the case of 
        contracts in existence on or after the date of the enactment of 
        this Act and that are not subject to the effective date under 
        paragraph (1), the Secretary of Health and Human Services 
        shall, when appropriate and practicable, seek to apply the 
        incentives provided for in the amendments made by subsection 
        (a) through contract modifications.

SEC. 4. STRENGTHENING PENALTIES FOR THE ILLEGAL DISTRIBUTION OF A 
              MEDICARE, MEDICAID, OR CHIP BENEFICIARY IDENTIFICATION OR 
              BILLING PRIVILEGES.

    Section 1128B(b) of the Social Security Act (42 U.S.C. 1320a-7b(b)) 
is amended by adding at the end the following:
            ``(4) Whoever without lawful authority knowingly and 
        willfully purchases, sells or distributes, or arranges for the 
        purchase, sale, or distribution of a beneficiary identification 
        number or unique health identifier for a health care provider 
        under title XVIII, title XIX, or title XXI shall be imprisoned 
        for not more than 10 years or fined not more than $500,000 
        ($1,000,000 in the case of a corporation), or both.''.

SEC. 5. IMPROVING THE SHARING OF DATA BETWEEN THE FEDERAL GOVERNMENT 
              AND STATE MEDICAID PROGRAMS.

    (a) In General.--The Secretary of Health and Human Services (in 
this section referred to as the ``Secretary'') shall establish a plan 
to encourage and facilitate the participation of States in the 
Medicare-Medicaid Data Match Program (commonly referred to as the 
``Medi-Medi Program'') under section 1893(g) of the Social Security Act 
(42 U.S.C. 1395ddd(g)).
    (b) Program Revisions To Improve Medi-Medi Data Match Program 
Participation by States.--Section 1893(g)(1)(A) of the Social Security 
Act (42 U.S.C. 1395ddd(g)(1)(A)) is amended--
            (1) in the matter preceding clause (i), by inserting ``or 
        otherwise'' after ``eligible entities'';
            (2) in clause (i)--
                    (A) by inserting ``to review claims data'' after 
                ``algorithms''; and
                    (B) by striking ``service, time, or patient'' and 
                inserting ``provider, service, time, or patient'';
            (3) in clause (ii)--
                    (A) by inserting ``to investigate and recover 
                amounts with respect to suspect claims'' after 
                ``appropriate actions''; and
                    (B) by striking ``; and'' and inserting a 
                semicolon;
            (4) in clause (iii), by striking the period and inserting 
        ``; and''; and
            (5) by adding at the end the following new clause:
                            ``(iv) furthering the Secretary's design, 
                        development, installation, or enhancement of an 
                        automated data system architecture--
                                    ``(I) to collect, integrate, and 
                                assess data for purposes of program 
                                integrity, program oversight, and 
                                administration, including the Medi-Medi 
                                Program; and
                                    ``(II) that improves the 
                                coordination of requests for data from 
                                States.''.
    (c) Providing States With Data on Improper Payments Made for Items 
or Services Provided to Dual Eligible Individuals.--
            (1) In general.--The Secretary shall develop and implement 
        a plan that allows each State agency responsible for 
        administering a State plan for medical assistance under title 
        XIX of the Social Security Act access to relevant data on 
        improper or fraudulent payments made under the Medicare program 
        under title XVIII of the Social Security Act (42 U.S.C. 1395 et 
        seq.) for health care items or services provided to dual 
        eligible individuals.
            (2) Dual eligible individual defined.--In this section, the 
        term ``dual eligible individual'' means an individual who is 
        entitled to, or enrolled for, benefits under part A of title 
        XVIII of the Social Security Act (42 U.S.C. 1395c et seq.), or 
        enrolled for benefits under part B of title XVIII of such Act 
        (42 U.S.C. 1395j et seq.), and is eligible for medical 
        assistance under a State plan under title XIX of such Act (42 
        U.S.C. 1396 et seq.) or under a waiver of such plan.

SEC. 6. REPORT ON IMPLEMENTATION.

    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 implementation of the provisions of, and the 
amendments made by--
            (1) this Act; and
            (2) sections 506 and 507 of the Medicare Access and CHIP 
        Reauthorization Act of 2015 (Public Law 114-10).