A bill to amend title XVIII of the Social Security Act to reduce the incidence of diabetes among Medicare beneficiaries.

Summary: Medicare Diabetes Prevention Act of 2012 - Amends title XVIII (Medicare) of the Social Security Act to cover items and services furnished under a diabetes prevention program to an eligible individual.

Directs the Secretary of Health and Human Services (HHS) to establish criteria for a diabetes prevention program in accordance with the standards under the National Diabetes Prevention Program established by the Centers for Disease Control and Prevention (CDC).

Expresses the sense of the Senate that the CDC's National Diabetes Prevention Program presents an opportunity for states to reduce the incidence of diabetes among individuals enrolled in their Medicaid programs.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medicare Diabetes Prevention Act of 
2012''.

SEC. 2. DIABETES PREVENTION UNDER THE MEDICARE PROGRAM.

    (a) Coverage of Diabetes Prevention Program Services.--
            (1) Coverage of services.--
                    (A) In general.--Section 1861(s)(2) of the Social 
                Security Act (42 U.S.C. 1395x(s)(2)) is amended--
                            (i) in subparagraph (EE), by striking 
                        ``and'' after the semicolon at the end;
                            (ii) in subparagraph (FF), by inserting 
                        ``and'' after the semicolon at the end; and
                            (iii) by adding at the end the following 
                        new subparagraph:
            ``(GG) items and services furnished under a diabetes 
        prevention program (as defined in subsection (iii)(1)) to an 
        eligible diabetes prevention program individual (as defined in 
        subsection (iii)(2));''.
                    (B) Definitions.--Section 1861 of the Social 
                Security Act (42 U.S.C. 1395x) is amended by adding at 
                the end the following new subsection:

  ``Diabetes Prevention Program; Eligible Diabetes Prevention Program 
       Individual; Qualified Diabetes Prevention Program Provider

    ``(iii)(1)(A) The term `diabetes prevention program' means a 
program that--
            ``(i) meets the criteria described in subparagraph (B); and
            ``(ii) is furnished by a qualified diabetes prevention 
        program provider (as defined in paragraph (3)(A)).
    ``(B) The Secretary shall establish the criteria for a diabetes 
prevention program. Such criteria shall be in accordance with the 
standards under the National Diabetes Prevention Program, as 
established by the Centers for Disease Control and Prevention, and 
shall require that the program complies with 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. In establishing such 
criteria, the Secretary may also consider other factors or clinical 
evidence as the Secretary determines appropriate.
    ``(C) Items and services furnished under a diabetes prevention 
program may be furnished in a community setting, as defined by the 
Secretary.
    ``(D) The Secretary shall establish procedures under which a 
qualified diabetes prevention program provider may contract with a 
diabetes prevention program delivery partner to furnish the items and 
services under a diabetes prevention program. For purposes of this 
subsection, the term `diabetes prevention program delivery partner' 
means an entity, including non-profit organizations, public and private 
hospitals, State and local departments of public health, and Federally 
qualified health centers, that meets criteria established by the 
Secretary. Such criteria shall be in accordance with the standards 
under the National Diabetes Prevention Program, as established by the 
Centers for Disease Control and Prevention. In establishing such 
criteria, the Secretary may also consider other factors or clinical 
evidence as the Secretary determines appropriate.
    ``(2)(A) The term `eligible diabetes prevention program individual' 
means an individual at risk for diabetes (as defined in subsection 
(yy)(2)) who would benefit from items and services under a diabetes 
prevention program, as determined based on criteria established by the 
Secretary.
    ``(B) The criteria established under subparagraph (A) shall be in 
accordance with the standards under the National Diabetes Prevention 
Program, as established by the Centers for Disease Control and 
Prevention. In establishing such criteria, the Secretary may also 
consider other factors or clinical evidence as the Secretary determines 
appropriate.
    ``(3)(A)(i) The term `qualified diabetes prevention program 
provider' means any entity, including a Federally qualified health 
center, that the Secretary determines--
            ``(I) is appropriate to furnish items and services under a 
        diabetes prevention program; and
            ``(II) meets criteria established by the Secretary, in 
        consultation with the Centers for Disease Control and 
        Prevention.
    ``(ii) A qualified diabetes prevention program provider may be, as 
determined appropriate by the Secretary, a supplier (as defined in 
subsection (d)), a provider of services (as defined in subsection (u)), 
a health insurance or services company, a community-based organization, 
or any other appropriate entity.
    ``(B) A qualified diabetes prevention program provider shall--
            ``(i) furnish the items and services under the diabetes 
        prevention program through a delivery partner (pursuant to 
        paragraph (1)(D)) unless no such delivery partner is available;
            ``(ii) manage and track the outcomes of a diabetes 
        prevention program (including attendance and weight loss of 
        participating individuals) through defined systems, including 
        outcomes of programs furnished under contract with a diabetes 
        prevention program delivery partner as defined in paragraph 
        (1)(D);
            ``(iii) implement business processes to manage program 
        workflow, such as eligibility, reporting, claims billing, class 
        scheduling, and enrollment;
            ``(iv) manage and verify billing accuracy and beneficiary 
        eligibility (as described in paragraph (2));
            ``(v) comply with applicable laws and regulations and 
        ensure such compliance by a diabetes prevention program 
        delivery partner;
            ``(vi) perform various forms of engagement with, and 
        outreach to, eligible diabetes prevention program individuals, 
        including those participating in programs furnished under 
        contract with a diabetes prevention program delivery partner;
            ``(vii) comply with all program integrity requirements as 
        established by the Secretary; and
            ``(viii) perform such other functions as established by the 
        Secretary.''.
            (2) Amount of payment.--Section 1833(a)(1) of the Social 
        Security Act (42 U.S.C. 1395l(a)(1)) is amended--
                    (A) by striking ``and (Z)'' and inserting ``(Z)''; 
                and
                    (B) by inserting before the semicolon at the end 
                the following: ``, and (AA) with respect to items and 
                services furnished under a diabetes prevention program 
                (as defined in section 1861(iii)(1)), the amount paid 
                shall be 100 percent of (i) except as provided in 
                clause (ii), the lesser of the actual charge for the 
                items and services or the amount determined under the 
                fee schedule that applies to such items and services 
                under this part, as determined by the Secretary, and 
                (ii) in the case of such items and services that are 
                covered OPD services (as defined in subsection 
                (t)(1)(B)), the amount determined under subsection 
                (t)''.
            (3) Waiver of application of deductible.--The first 
        sentence of section 1833(b) of the Social Security Act (42 
        U.S.C. 1395l(b)) is amended--
                    (A) by striking ``and'' before ``(10)''; and
                    (B) by inserting before the period the following: 
                ``, and (11) such deductible shall not apply with 
                respect to items and services under a diabetes 
                prevention program (as defined in section 
                1861(iii)(1))''.
            (4) Assignment of claims.--Section 1842(b)(18)(C) of the 
        Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is amended by 
        adding at the end the following new clause:
            ``(vii) A qualified diabetes prevention program provider 
        (as defined in section 1861(iii)(3)(A)).''.
            (5) Exclusion of items and services under a diabetes 
        prevention program from skilled nursing facility prospective 
        payment system.--Section 1888(e)(2)(A)(ii) of the Social 
        Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by 
        inserting ``items and services under a diabetes prevention 
        program (as defined in section 1861(iii)(1)),'' after 
        ``qualified psychologist services,''.
            (6) Inclusion in federally qualified health center 
        services.--Section 1861(aa)(3) of the Social Security Act (42 
        U.S.C. 1395x(aa)(3)) is amended--
                    (A) in subparagraph (A), by striking ``and'' at the 
                end;
                    (B) in subparagraph (B), by striking the comma at 
                the end and inserting ``; and''; and
                    (C) by adding after subparagraph (B) the following 
                new subparagraph:
            ``(C) items and services under a diabetes prevention 
        program (as defined in section 1861(iii)(1)),''.
            (7) Special consideration for the dual eligible 
        population.--In implementing the amendments made by this 
        subsection, the Secretary of Health and Human Services shall 
        give special consideration to the needs of individuals who are 
        dually eligible for benefits under the Medicare and Medicaid 
        programs.
            (8) Evaluation and report to congress.--
                    (A) Evaluation.--The Secretary of Health and Human 
                Services shall conduct an evaluation on the coverage of 
                items and services under a diabetes prevention program 
                under the Medicare program, as added by the amendments 
                made by this subsection. Such evaluation shall include 
                an analysis of--
                            (i) the impact of the provision of such 
                        coverage on Medicare beneficiaries, including 
                        the impact on various populations, such as 
                        individuals who are dually eligible for 
                        benefits under the Medicare and Medicaid 
                        programs, and the impact of the provision of 
                        such coverage on health disparities;
                            (ii) the rate at which physicians refer 
                        eligible diabetes prevention program 
                        individuals to diabetes prevention programs 
                        under the Medicare program;
                            (iii) Medicare beneficiary participation 
                        levels in diabetes prevention programs under 
                        the Medicare program and the awareness of 
                        Medicare beneficiaries of the benefit;
                            (iv) the health outcomes resulting from 
                        completion of a diabetes prevention program 
                        under the Medicare program;
                            (v) program integrity protections important 
                        to diabetes prevention programs under the 
                        Medicare program; and
                            (vi) other areas determined appropriate by 
                        the Secretary.
                    (B) Report.--Not later than January 1, 2018, the 
                Secretary of Health and Human Services shall submit to 
                Congress a report on the evaluation conducted under 
                subparagraph (A), together with recommendations for 
                such legislation and administrative actions as the 
                Secretary determines appropriate.
            (9) Effective date.--The amendments made by paragraphs (1) 
        through (6) shall apply with respect to services furnished on 
        or after January 1, 2014.
    (b) Inclusion of Referral Rates to Diabetes Prevention Programs in 
the Medicare Physician Quality Reporting System.--Section 
1848(k)(2)(C)(i) of the Social Security Act (42 U.S.C. 1395w-
4(k)(2)(C)(i)) is amended by adding at the end the following new 
sentence: ``For purposes of reporting data on quality measures for 
covered professional services furnished during 2017 and each subsequent 
year, the quality measures specified under this paragraph shall include 
a measure with respect to referrals of eligible diabetes prevention 
program individuals (as defined in paragraph (2) of section 1861(iii)) 
to diabetes prevention programs (as defined in paragraph (1) of such 
section).''.
    (c) Inclusion of Diabetes Risk Assessment in Medicare Personalized 
Prevention Plan.--
            (1) In general.--Section 1861(hhh)(2)(C) of the Social 
        Security Act (42 U.S.C. 1395x(hhh)(2)(C)) is amended by 
        inserting before the period at the end the following: ``, and 
        an assessment of whether the individual is an individual at 
        risk for diabetes (as defined in subsection (yy)(2))''.
            (2) Effective date.--The amendments made by this subsection 
        shall apply to personalized prevention plans created or updated 
        on or after January 1, 2014.

SEC. 3. FINDINGS; SENSE OF THE SENATE REGARDING DIABETES PREVENTION 
              UNDER THE MEDICAID PROGRAM.

    (a) Findings.--Congress makes the following findings:
            (1) The prevalence and cost of diabetes is a significant 
        concern for State Medicaid programs. By 2020, the Medicaid 
        program is expected to cover 13,000,000 people with diabetes 
        and about 9,000,000 people who may have pre-diabetes. By 2020, 
        States will spend an estimated $83,000,000,000 on individuals 
        with diabetes or pre-diabetes.
            (2) The National Diabetes Prevention Program, as 
        established by the Centers for Disease Control and Prevention, 
        has been proven to reduce the onset of diabetes in at-risk 
        adults by 58 percent, using a cost-effective, community-based 
        intervention.
    (b) Sense of the Senate.--It is the sense of the Senate that the 
National Diabetes Prevention Program presents an opportunity for States 
to reduce the incidence of diabetes among individuals enrolled in their 
Medicaid programs.