Value-Based Insurance Design Seniors Copayment Reduction Act of 2015

Summary: Value Based Insurance Design Seniors Copayment Reduction Act of 2015 Directs the Department of Health and Human Services (HHS) to establish a demonstration program to test Value-Based Insurance Design methodologies in Medicare Advantage plans under part C (Medicare+Choice) of title XVIII (Medicare) of the Social Security Act for beneficiaries with chronic clinical conditions. Defines "value-based insurance design methodology" as one for identifying specific prescription medications and clinical services for which copayments or coinsurance should be reduced or eliminated due to the high-value and effectiveness of such medications and services for specific clinical conditions. Directs HHS to expand the demonstration program, except in certain circumstances, by issuing regulations to implement, on a permanent basis, those components that are beneficial to Medicare beneficiaries and the Medicare program.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Value-Based Insurance Design Seniors 
Copayment Reduction Act of 2015''.

SEC. 2. FINDINGS.

    Congress makes the following findings:
            (1) A growing body of evidence demonstrates that increases 
        in patient-level financial barriers (including deductibles, 
        copayments, and coinsurance) for high-value medical services 
        (such as prescription medications, clinician visits, diagnostic 
        tests, and procedures) systematically reduces the use of such 
        services. Savings attributable to cost-related, decreased 
        utilization of specific services may lead to an increase in 
        total medical expenditures due to increased use of other 
        related clinical services, such as hospitalizations and 
        emergency room visits.
            (2) Empirical research studies demonstrate that reductions 
        in beneficiary out-of-pocket expenses for high-value 
        prescription medications and clinical services can mitigate the 
        adverse health and financial consequences attributable to cost-
        related decreased utilization of high-value services.
            (3) Financial barriers to prescription medications and 
        clinical services that are deemed to be high-value should be 
        reduced or eliminated to increase their use.
            (4) Value-Based Insurance Design is a methodology that 
        adjusts patient out-of-pocket costs for prescription 
        medications and clinical services according to the clinical 
        value, not exclusively the cost. Value-Based Insurance Design 
        is based on the concept of clinical nuance that recognizes--
                    (A) prescription medications and clinical services 
                differ in the clinical benefit provided; and
                    (B) the clinical benefit derived from a specific 
                prescription medication or clinical service depends on 
                the clinical situation, the provider, and where the 
                care is delivered.
            (5) The current ``one-size-fits-all'' copayment or 
        coinsurance design for prescription medications and clinical 
        services provided under the Medicare program does not recognize 
        the well-established value differences in health outcomes 
        produced by various medical interventions.
            (6) The establishment by Medicare of copayment and 
        coinsurance requirements using Value-Based Insurance Design 
        methodologies will improve patient-centered health outcomes, 
        enhance personal responsibility, and afford a more efficient 
        use of taxpayer dollars.

SEC. 3. DEMONSTRATION PROGRAM.

    (a) In General.--Not later than 1 year after the date of enactment 
of this Act, the Secretary of Health and Human Services (in this 
section referred to as the ``Secretary'') shall establish a 
demonstration program to test Value-Based Insurance Design 
methodologies in Medicare Advantage plans under part C of title XVIII 
of the Social Security Act for beneficiaries with chronic clinical 
conditions.
    (b) Demonstration Program Design.--
            (1) In general.--The Secretary shall select not less than 2 
        Medicare Advantage plans to participate in the demonstration 
        program under this section.
            (2) Requirements.--A Medicare Advantage plan selected to 
        participate in the demonstration program under paragraph (1) 
        shall meet the following requirements:
                    (A) The plan offers a coordinated Medicare Part D 
                drug benefit.
                    (B) The plan and the Medicare Advantage 
                organization offering the plan meet such other criteria 
                as the Secretary determines appropriate.
    (c) Expansion of Demonstration Program.--The Secretary shall expand 
the demonstration program by issuing regulations to implement, on a 
permanent basis, the components of the demonstration program that are 
beneficial to Medicare beneficiaries and the Medicare program, unless 
the report under subsection (e) or (f)(3) contains an evaluation that 
the demonstration program under this section--
            (1) increases Medicare program expenditures for 
        beneficiaries participating in the demonstration program; or
            (2) decreases the quality of health care services provided 
        to Medicare beneficiaries participating in the demonstration 
        program.
    (d) Value-Based Insurance Design Methodology.--
            (1) Value-based insurance design.--For purposes of this 
        section, ``Value-Based Insurance Design'' is a methodology for 
        identifying specific prescription medications and clinical 
        services for which copayments or coinsurance should be reduced 
        or eliminated due to the high-value and effectiveness of such 
        medications and services for specific clinical conditions.
            (2) Reduction of copayments and coinsurance.--Under the 
        demonstration program, a Medicare Advantage organization, using 
        Value-Based Insurance Design methodologies, shall identify each 
        prescription medication and clinical service for which the 
        amount of the copayment or coinsurance payable should be 
        reduced or eliminated.
            (3) Reduction of copayments and coinsurance to encourage 
        use of specific clinical services.--Under the demonstration 
        program, the Medicare Advantage organization, using Value-Based 
        Insurance Design, may lower cost-sharing under the plan for the 
        purpose of encouraging enrollees to use prescription 
        medications and clinical services (such as preventive care, 
        primary care, specialty visits, diagnostic tests, procedures, 
        and durable medical equipment) that such organization has 
        identified as high-value for the management of specified 
        clinical conditions in paragraph (5). Any such variation on 
        copayment or coinsurance by a Medicare Advantage organization 
        must occur on an annual basis and be evidence-based.
            (4) Reduction of copayments and coinsurance to encourage 
        use of specific high-performing providers.--Under the 
        demonstration program, the Medicare Advantage organization, 
        using Value-Based Insurance Design, may lower cost-sharing 
        under the plan for the purpose of encouraging enrollees to use 
        providers that such organization has identified as high-
        performing based on quality metrics. Any such variation on 
        copayment or coinsurance by a Medicare Advantage organization 
        must occur on an annual basis.
            (5) Specific clinical conditions.--In identifying clinical 
        conditions for purposes of paragraph (3), the Medicare 
        Advantage organization shall, at a minimum, consider the 
        services utilized across the spectrum of care in the management 
        of the following clinical conditions:
                    (A) Asthma.
                    (B) Atrial fibrillation.
                    (C) Deep venous thrombosis.
                    (D) Cancer.
                    (E) Chronic obstructive pulmonary disease.
                    (F) Chronic renal failure/End stage renal disease.
                    (G) Congestive heart failure.
                    (H) Ischemic heart disease/Myocardial infarction.
                    (I) Depression.
                    (J) Diabetes mellitus.
                    (K) Hyperlipidemia.
                    (L) Hypertension.
                    (M) Osteoporosis.
                    (N) Stroke.
                    (O) Tobacco abuse disorder.
            (6) Prohibition of increases of copayments and 
        coinsurance.--A Medicare Advantage plan selected to participate 
        in the demonstration program under paragraph (1) may not raise 
        cost-sharing on any item or service to discourage its use.
    (e) Report on Implementation.--
            (1) In general.--Not later than 1 year after the date of 
        the enactment of this Act, the Secretary shall submit to 
        Congress a report on the implementation by the Secretary of the 
        demonstration program under this section.
            (2) Elements.--The report required by paragraph (1) shall 
        include the following:
                    (A) A statement setting forth each medication and 
                clinical service identified pursuant to subsection 
                (d)(3).
                    (B) For each such medication or clinical service 
                identified pursuant to subsection (d)(3), a statement 
                of the amount of the copayment or coinsurance required 
                to be paid for such service and the amount of the 
                reduction from previous cost-sharing levels.
                    (C) For each such high-performing provider 
                identified pursuant to subsection (d)(4), a statement 
                of the amount of the copayment or coinsurance required 
                to be paid for such clinician visit and the amount of 
                the reduction from previous cost-sharing levels.
    (f) Review and Assessment of Utilization of Value-Based Insurance 
Design Methodologies.--
            (1) In general.--The Secretary shall enter into a contract 
        or agreement with an independent, nonbiased entity having 
        expertise in Value-Based Insurance Design to review and assess 
        the implementation of the demonstration program under this 
        section. The review and assessment shall include the following:
                    (A) An assessment of the utilization of Value-Based 
                Insurance Design methodologies referred to in 
                subsection (d).
                    (B) An analysis of whether reducing or eliminating 
                the copayment or coinsurance for each medication and 
                clinical service identified pursuant to subsection 
                (d)(3) resulted in increased adherence to medication 
                regimens, increased service utilization, improvement in 
                quality metrics, better health outcomes, or enhanced 
                beneficiary experience.
                    (C) An analysis of the cost-savings resulting from 
                reducing or eliminating the copayment or coinsurance 
                for each medication or clinical service so identified.
                    (D) An analysis of whether reducing or eliminating 
                the copayment or coinsurance for each high-performing 
                provider identified pursuant to subsection (d)(4) 
                resulted in improvement in quality metrics, better 
                health outcomes, or enhanced beneficiary experience.
                    (E) An analysis of the cost-savings resulting from 
                reducing or eliminating the copayment or coinsurance 
                for each high-performing provider so identified.
                    (F) Such other matters as the Secretary considers 
                appropriate.
            (2) Report.--The contract or agreement entered into under 
        paragraph (1) shall require the entity concerned to submit to 
        the Secretary a report on the review and assessment conducted 
        by the entity under that paragraph in time for the inclusion of 
        the results of such report in the report required by paragraph 
        (3).
            (3) Report to congress.--Not later than 3 years after the 
        date of the enactment of this Act, the Secretary shall submit 
        to Congress a report on the review and assessment conducted 
        under this subsection. The report shall include the following:
                    (A) A description of the results of the review and 
                assessment.
                    (B) Such recommendations as the Secretary considers 
                appropriate for enhancing the utilization of the 
                methodologies referred to in subsection (d)(1) so as to 
                reduce copayments and coinsurance paid by Medicare 
                beneficiaries for high-value prescription medications 
                and clinical services furnished under the Medicare 
                program and to otherwise improve the quality of health 
                care provided under such Medicare program.
    (g) Waiver.--The Secretary may waive such provisions of titles XI 
and XVIII of the Social Security Act as may be necessary to carry out 
the demonstration program under this section.
    (h) Implementation Funding.--For purposes of carrying out the 
demonstration program under this section, the Secretary shall provide 
for the transfer from the Federal Hospital Insurance Trust Fund under 
section 1817 of the Social Security Act (42 U.S.C. 1395i) and the 
Federal Supplementary Insurance Trust Fund under section 1841 of the 
Social Security Act (42 U.S.C. 1395t), including the Medicare 
Prescription Drug Account in such Trust Fund, in such proportion as 
determined appropriate by the Secretary, of such sums as may be 
necessary.