prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 1.

Report 1: Beginning the summer 2013 through 2016, there were numerous reports in the media on sexual assault incidents in the U S  armed services  In many cases, such reports were followed by questions on what actions were taken by the Department of Defense (DOD), the Obama Administration, and Congress to address the issue  This report lists a comprehensive chronology of official activities in response to incidents of military sexual assault, as well as legislative action on the issue  The report is divided into three sections: the DOD and the Obama Administration's actions, congressional action, and legislation in the 113 th (2013-2014) and 114 th (2015-2016) Congresses  Also included is a resources section with related articles, hearings, and reports  Information in this report was compiled from the official government websites of DOD, the Obama White House and Congress gov for historical background and will not be updated  June 13, 2012 – DOD announced Army Major General Gary S  Patton as the new director of the Sexual Assault Prevention and Response Office (SAPRO)  September 25, 2012 – As part of the DOD's efforts to confront the crime of sexual assault in the military, then Secretary of Defense Leon Panetta announced improvements to prospective commander and senior enlisted training and a review of the initial military training environment in every service  December 21, 2012 – DOD released key findings from the Academic Program Year (APY) 2011-2012 Report on Sexual Harassment and Violence at the United States Military Service Academies  According to this report, the overall prevalence rate of unwanted sexual contact increased in all three military academies  From 2011 to 2012, the Air Force Academy in Colorado showed the largest increase in reported sexual assaults from 33 to 52 incidents  Sexual assaults at the Naval Academy in Annapolis, MD, increased from 11 to 15, and were up at the U S  Military Academy in West Point, NY, from 10 to 13  January 18, 2013 – DOD announced the release of the 2012 Workplace and Gender Relations Survey of Reserve Component Members   This report included rates of unwanted sexual contact, unwanted gender-related behaviors (i e , sexual harassment and sexist behavior), and gender discriminatory behaviors and sex discrimination reported by survey respondents during the past 12 months  March 7, 2013 – Defense Secretary Chuck Hagel, in a letter responding to Members of Congress, wrote that an internal review was being conducted of a decision by a senior Air Force commander, Lt  Gen  Craig Franklin, to overturn the sexual assault conviction of an Air Force fighter pilot, Lt  Col  James Wilkerson  Colonel Wilkerson was found guilty in November 2012 of aggravated sexual assault and was sentenced to one year in military prison  Lt  General Franklin's decision to overturn the findings of the court-martial freed Colonel Wilkerson, and allowed him to be reinstated in the Air Force  In his letter, Hagel said that while General Franklin's decision could not be overturned, he had asked Pentagon lawyers and the Secretary of the Air Force to review the way in which General Franklin decided the case  He also said he wanted a review of whether the military should change the way it handles sexual assault cases  April 2, 2013 – Secretary Chuck Hagel stated in a message to all DOD personnel on Sexual Assault Awareness and Prevention Month that, "Together, we must work every day to instill a climate that does not tolerate or ignore sexist behavior, sexual harassment, or sexual assault  These have no place in the United States military and violate everything we stand for and the values we defend " April 8, 2013 – Secretary Hagel announced that DOD's Office of General Counsel will review Article 60 of the Uniform Code of Military Justice (UCMJ) after an Air Force officer's court-martial conviction for sexual assault was dismissed using the authority provided by Article 60  May 6, 2013 – The Office of the Secretary of Defense released a 24-page memorandum from Secretary Hagel to all heads of the military services regarding DOD's 2013 Sexual Assault Prevention and Response Strategy, and the release of the Annual Report on Sexual Assault in the Military 2012 (2 volumes)  According to this report, in FY2012 (October 1, 2011, through September 30, 2012), the number of sexual assaults reported by members of the military rose 6% to 3,374  An anonymous survey of military personnel showed the number of service members who had experienced unwanted sexual contact could be as many as 26,000 but most never reported the incidents  That number is an increase over the 19,000 estimated assaults in 2011  These reports involved offenses ranging from abusive sexual contact to rape  May 7, 2013 – In a DOD press briefing, Defense Secretary Chuck Hagel and Major General Gary Patton, director of SAPRO, announced new series of actions to further DOD's sexual assault and prevention efforts  Hagel directed service chiefs to develop methods to hold all military commanders accountable for establishing command climates of dignity and respect in incorporating sexual assault prevention and victim care principles in their commands  May 7, 2013 – DOD announced the establishment of the Response Systems to Adult Sexual Assault Crimes Panel consisting of nine selected appointees  Secretary of Defense Hagel appointed five members to serve on the response systems panel, who joined four members appointed by the chairman and ranking member of the Senate Armed Services Committee, and the chairman and ranking member of the House Armed Services Committee  May 14, 2013 – The Army announced that an Army Sergeant First Class assigned to III Corps, Fort Hood, TX, was under investigation for pandering, abusive sexual contact, assault, and maltreatment of subordinates  May 15, 2013 – Returning from NATO meetings in Brussels, the Chairman of the Joint Chiefs of Staff, Army Gen  Martin E  Dempsey, told reporters that sexual assault in the Armed Forces constitutes a crisis in the military  He further stated that "We're losing the confidence of the women who serve that we can solve this problem, and that's a crisis " May 16, 2013 – At the White House, President Obama met with senior military leaders on the issue of sexual assault in the U S  Armed Forces  The President stated that not only is it "shameful and disgraceful" but also "dangerous to our national security " May 17, 2013 – During a press briefing, Defense Secretary Hagel and Chairman of the Joint Chiefs of Staff Army Gen  Martin Dempsey discussed their meeting with President Obama, Vice President Biden, and senior enlisted and officer leadership in the U S  military  Dempsey told the Armed Forces Press Service that he believes that the long wars in Iraq and Afghanistan may be factors in the growing incidents of sexual assault  He also stated that: "If a perpetrator shows up at a court-martial with a rack of ribbons and has four deployments and a Purple Heart, there is certainly a risk that we might be a little too forgiving of that particular crime " May 17, 2013 – In an interview, Air Force Chief of Staff, Gen  Mark Walsh, said that sexual assaults in his branch of the military typically involve alcohol use and can be traced to a lack of respect for women  "We have a problem with respect for women that leads to many of the situations that result in sexual assault in our Air Force," he told reporters in his Pentagon office  Walsh further stated that combatting the crisis is his top priority and that he reviews every reported case of sexual assault  May 22, 2013 – The Pentagon announced that DOD's sexual assault prevention staff would be exempt from furloughs  According to Pentagon spokeswoman, Cynthia O  Smith, "The full-time civilians working these programs and implementing policies will not be furloughed  This will ensure responsive victim care and ensure all the programs recently directed by Secretary Hagel are implemented swiftly and efficiently " May 24, 2013 – President Obama addressed graduates of the U S  Naval Academy in Annapolis, MD, and noted in his commencement speech that the misconduct of some in the military can endanger U S  forces and undermine U S  efforts to achieve security and peace worldwide  He further stated that those who commit sexual assault are not only committing a crime, they also "threaten the trust and discipline that make our military strong " May 25, 2013 – In a commencement speech at the U S  Military Academy at West Point, NY, Defense Secretary Chuck Hagel told graduates that they must be the generation of leaders that will commit to building a culture of respect for every member of the military  He stated that sexual harassment and sexual assault in the military "are a profound betrayal of sacred oaths and sacred trusts " He also quoted President Obama's remarks at the Naval Academy when he said, "these crimes have no place in the greatest military on earth " May 30, 2013 – Pentagon officials reaffirmed DOD's commitment to fighting sexual assault by launching the Safe HelpRoom at http://SafeHelpline org , a Sexual Assault Support Service for the DOD community  This new service allows victims to participate in moderated group chat sessions to connect with and support one another in a secure online environment  The Safe HelpRoom is in response to a need for peer support services identified by users of DOD's Safe Helpline for sexual assault victims  June 6, 2013 – In a speech at the 2013 Joint Women's Leadership Symposium, Navy Adm  James A  Winnefeld Jr , vice chairman of the Joint Chiefs of Staff, said plans to combat and eliminate sexual assault include a greater investment in specially trained sexual assault investigators and a push for more psychological, medical, and legal assistance for victims  The vice chairman also said officials will examine the scientific roots of behavioral factors associated with potential predators, which will assist sexual assault prevention efforts  June 7, 2013 – The Pentagon released a statement that Maj  Gen  Michael T  Harrison was suspended of his duties as the Commanding General of United States Army Japan and I Corps for failing in his duties as a commander to report or investigate an allegation of sexual assault  June 7, 2013 – Air Force officials announced Maj  Gen  Margaret H  Woodward has been assigned to direct the Air Force Sexual Assault Prevention and Response Office to replace Lt  Col  Jeffrey Krusinski, the former chief of the Air Force Sexual Assault Prevention and Response Program  He was arrested and charged by Arlington County, VA, police for allegedly being drunk and groping a woman in a parking lot one mile from the Pentagon  In the previous year, Maj  Gen  Woodward led the investigation of Air Force training in the wake of a sexual assault scandal centered at Lackland Air Force Base, Texas  June 27, 2013 – Defense Secretary Hagel met in person with the Sexual Assault Response Systems Review Panel for the first time  According to the Pentagon, "the panel will conduct an independent review and assessment of the systems used to investigate, prosecute, and adjudicate crimes involving sexual assault and related offenses under the Uniform Code of Military Justice, and will develop recommendations to improve the effectiveness of those systems " DOD established the panel in accordance with the National Defense Authorization Act (NDAA) for Fiscal Year 2013 ( P L  112-239 , Section 576 (a))  Previously, Hagel held a teleconference with panel members  July 3, 2013 – The Chief of the National Guard Bureau, Army Gen  Frank J  Grass, launched a comprehensive campaign designed to assist National Guard units in combating sexual assault as part of a military-wide effort to protect victims and eradicate the crime from the ranks  July 9, 2013 – DOD Inspector General (IG) released its report, Joint Warfighting and Readiness Evaluation of the Military Criminal Investigative Organizations Sexual Assault Investigations   The report evaluated the Military Criminal Investigative Organizations' (MCIOs') sexual assault investigations in 2010 to determine whether they were adequately investigated  The report found most MCIO investigations (89%) met or exceeded the investigative standards and returned only cases with significant deficiencies (11%) to the MCIOs for corrective action  July 18, 2013 – The Air Force adopted two new measures to eliminate sexual assault from within the ranks, including requiring mandatory discharge for airmen, officer or enlisted, who commit sexual assault, and requiring the Air Force's most senior commanders to review actions taken on these cases  In addition, the Air Force Academy is reviewing the results of a survey on sexual assault taken on June 24, 2013  Suggestions from survey respondents ranged from involving faculty with character coaching to a complete revamping of how the Air Force Academy trains its freshmen  July 18, 2013 – Secretary of the Navy Ray Mabus announced additional resources for investigators and a new initiative designed to enhance accountability and transparency across the Navy  Mabus approved nearly $10 million to hire more than 50 additional Naval Criminal Investigative Service (NCIS) Family and Sexual Violence Program personnel to shorten investigation times, and directed the Navy and Marine Corps to regularly publish online the results of each service's courts- martial  July 18, 2013 – The Air Force announced that airmen who commit sexual assaults will be discharged, and senior commanders must review actions taken on sexual assault cases under new Air Force initiatives as of July 2, 2013  August 15, 2013 – Defense Secretary Hagel announced seven new anti-sexual assault initiatives in a memo detailing "    absolute and sustained commitment to providing a safe environment in which every service member and DOD civilian is free from the threat of sexual harassment and assault," he wrote in a statement  "Our success depends on a dynamic and responsive approach  We, therefore, must continually assess and strive to improve our prevention and response programs " October 3, 2013 – Air Force Col  Alan R  Metzler, the deputy director for SAPRO, emphasized that the first step to stopping sexual assault in the military is through prevention but when prevention fails, new measures to improve victims' confidence and combat underreporting were needed  Metzler outlined the DOD Sexual Assault Advocate Certification Program (D-SAACP) and the Defense Sexual Assault Incident Database (DSAID), two initiatives set to improve the advocacy services provided to victims of sexual assault  November 9, 2013 – Army Maj  Gen  Gary S  Patton, director of DOD's SAPRO, reported on DOD's recent prevention and awareness successes before the Response Systems to Adult Sexual Assault Crimes Panel  He testified that new DOD initiatives to combat sexual assault helped create a 46% jump in victims reporting compared to the previous year  December 20, 2013 – President Obama instructed Defense Secretary Hagel and Chairman Dempsey to continue their efforts to make substantial improvements with respect to sexual assault prevention and response, including to the military justice system  He also directed that they report back with a full-scale review of their progress, by December 1, 2014  January 10, 2014 – Army Maj  Gen  Jeffrey J  Snow, the new SAPRO chief announced the release of the Annual Report to Congress on Sexual Harassment and Violence at the Military Service Academies   The report covered the 2012-13 academic year, and found in 2013, reports of sexual assault decreased at the U S  Military Academy at West Point, New York and the U S  Air Force Academy in Colorado Springs, Colorado  The number of reported incidents went up at the U S  Naval Academy in Annapolis, Maryland  January 30, 2014 – The independent Response Systems to Adult Sexual Assault Crimes Panel accepted a subcommittee recommendation that senior military commanders retain authority for referring these crimes to courts-martial  May 1, 2014 – DOD released the 2013 Annual Report on Sexual Assault in the Military   The report covered the period from Oct  1, 2012, through Sept  30, 2013, and revealed 5,061 reports of sexual assault in the Defense Department, a 50 percent jump from the previous year  More than 70 percent of all cases that the military had jurisdiction resulted in criminal charges  July 17, 2014 – DOD collaborated with the Justice Department's Office for Victims of Crime to develop a curriculum that expands on the skills learned in initial sexual assault response coordinator and sexual assault prevention and response victim advocate training  December 4, 2014 – Secretary Hagel released DOD's Report to the President of the United States on Sexual Assault Prevention and Response on its progress in addressing sexual assault in the military, and announced four directives to further strengthen the department's prevention and response program  According to this report, based on survey data, servicemembers experienced fewer sexual assaults in FY2014 than in FY2012, an estimated 19,000, down from 26,000  January 16, 2015 – Secretary Hagel at the Air Force Sexual Assault Prevention and Response Summit remarked that the fight to end sexual assault in the military must be "personal " He cited "encouraging progress" over the last year, but acknowledged more can be done, notably in areas such as social retaliation, which he said stems from the overall environment  February 11, 2015 – The annual report on sexual harassment and violence at the military service academies estimated that overall rates of unwanted sexual contact at the military service academies declined in Academic Program Year (APY) 2013-2014, decreased for both men and women, indicating that fewer sexual assaults occurred at the academies in APY 13-14 than in APY 11-12  February 19, 2015 – Health and criminal investigation experts spoke at the Army's Sexual Harassment/Assault Response Program Summit on the underreporting of male victims of sexual assault in the military due to factors such as shame and fear of being ostracized  March 26, 2015 – SAPRO head Army Maj  Gen  Jeffrey Snow monitored 50 initiatives put in place by past Defense secretaries Leon Panetta and Chuck Hagel  According to Snow, the most recent data, gathered last year, shows the past-year prevalence of sexual assault is down significantly, Snow said  Estimates indicate there were 6,000 to 7,000 fewer sexual assaults in 2014 than in 2012  May 1, 2015 – According to the 2014 RAND Military Workplace Stud y, "the percentage of active duty women who experienced unwanted sexual contact over the past year declined from 6 1% in 2012 to an estimated 4 3% in 2014  For active duty men, the estimated prevalence rate dropped from 1 2% in 2012 to 0 9% in 2014  Based on these rates, an estimated 18,900 service members experienced unwanted sexual contact in 2014, down from around 26,000 in 2012 " May 22, 2015 – Defense Secretary Ash Carter announced Army Maj  Gen  Camille M  Nichols will assume duties as director of SAPRO effective June 8, 2015  January 8, 2016 – DOD announced the release of the Annual Report on Sexual Harassment and Violence at the Military Service Academies for A cademic P rogram Y ear 2014-2015   Data in the report indicated the academies received 91 sexual assault reports during the academic year, an increase of 32 reports over the previous year  April 2 8 , 2016 – Defense Secretary Ash Carter announced a sexual assault retaliation prevention and response strategy aimed at how the department supports servicemembers who experience retaliation, while aligning prevention and response efforts across the services  May 5, 2016 – The annual report of the Defense Department's Sexual Assault Prevention and Response Program indicated that DOD's efforts are having an impact  In FY2015, service members made 6,083 reports of sexual assault – the same rate as the previous fiscal year, with four in 1,000 servicemembers reporting sexual assault despite a smaller active force size  In addition, 21 percent of those making restricted reports in fiscal 2015 chose to convert to unrestricted reports, enabling them to participate in the military justice process  September 19 , 2016 – The Naval Academy in Annapolis, MD, hosted an all-day training event to strengthen how military and civilian communities work together to support servicemembers who report sexual assault in a joint program between DOD and the Justice Department  October 19, 2016 – DOD released the 2016 Military Investigation and Justice Experience Survey that allowed servicemembers who have experienced sexual assault and elected to participate in the military justice process the opportunity to provide DOD with direct feedback on their experiences; and to improve the services and support servicemembers reporting sexual assault  December 15, 2016 – Defense Department officials announced the release of the "DOD Plan to Prevent and Respond to Sexual Assault of Military Men," designed to enhance outreach to military men and increase efforts to help them recover  The following information was compiled using Congress gov, Congressional Quarterly (CQ com), House gov, Senate gov, and Roll Call  See the section "Resources" for a list of congressional hearings, reports and other documents  January 23, 2013 – The House Armed Services Committee held a hearing on sexual misconduct at Lackland Air Force Base in San Antonio, TX  January 25, 2013 – H R  430 , Protect Our Military Trainees Act, was introduced  This legislation would have amended the Uniform Code of Military Justice to protect new members of the Armed Forces who are undergoing basic training from the sexual advances of the members of the Armed Forces responsible for their instruction  It also requires that violators be punished as a court-martial may direct  March 5, 2013 – H R  975 , the Servicemember Mental Health Review Act, was introduced  This bill would have amended Title 10, United States Code, to extend the duration of the Physical Disability Board of Review and to the expand the authority of such Board to review the separation of members of the Armed Forces on the basis of a mental condition not amounting to disability, including separation on the basis of a personality or adjustment disorder  This would have included a review of those victims who have suffered military sexual trauma  March 13, 2013 – S  548 , Military Sexual Assault Prevention Act of 2013, was introduced, read twice, and referred to the Senate Armed Services Committee  This legislation aimed to amend Title 10, United States Code, and to improve capabilities of the Armed Forces to prevent and respond to sexual assault and sexual harassment in the Armed Forces  March 13, 2013 – Victims of sexual assault in the military testified before a Senate panel examining the military's handling of sexual assault cases and stated that the "military justice system is broken " They urged Congress to make changes in the law that would stem the rape, sexual assault, and sexual harassment that they said are pervasive in the service branches  Several male Navy veterans testified before the Senate Armed Service Committee's military personnel panel investigating sexual assaults in the military  One recounted that he was raped in 2000 by a higher-ranking petty officer aboard a submarine  He told the committee that he carries permanent shame not for the sexual assault but over how the Navy forced him to leave  He stated in his testimony, "I carry my discharge as an official and permanent symbol of shame, on top of the trauma of the physical attack, the retaliation and its aftermath " March 20, 2013 – S  628 , Servicemember Mental Health Review Act, was introduced, read twice and referred to the Committee on Armed Services  Related to H R  975 , this bill would have amended Title 10, United States Code, to extend the duration of the Physical Disability Board of Review and to the expand the authority of such board to review the separation of members of the Armed Forces on the basis of a mental condition not amounting to disability, including separation on the basis of a personality or adjustment disorder  This would have included a review of those victims who may have suffered military sexual trauma  April 17, 2013 – H R  1593 , Sexual Assault Training Oversight and Prevention (STOP) Act, was introduced  This bill seeks to amend Title 10, United States Code, by establishing a Sexual Assault Oversight and Response Council and an enhanced Sexual Assault Oversight and Response Office "to improve the prevention of and response to sexual assault in the Armed Forces, and by requiring the appointment of a Director of Military Prosecutions for sexual-related offenses committed by a member of the Armed Forces " April 26, 2013 – A U S  senator reportedly put a hold on the nomination of Air Force Lt  Gen  Susan Helms, nominated to serve as vice commander of the U S  Space Command  Earlier in February 2012, Gen  Helms rejected the recommendation of legal counsel and overturned the conviction of an Air Force captain who had been found guilty of aggravated sexual assault of a female lieutenant  May 7, 2013 – S  871 , Combating Military Sexual Assault Act of 2013, was introduced, read twice and referred to the Committee on Armed Services  This legislation would have aimed to provide any victim with a special military lawyer who would assist them throughout the process, prohibit sexual contact between instructors and trainees during and within 30 days of completion of basic training or its equivalent, and ensure that sexual assault response coordinators are available to help members of the National Guard and Reserve  May 7, 2013 – H R  1864 , to amend Title 10, United States Code, would have required an Inspector General investigation of allegations of retaliatory personnel actions taken in response to making protected communications regarding sexual assault, was introduced and referred to the House Armed Services Committee  This bill would have required the Inspector General of the Department of Defense (DOD), the Department of Homeland Security (DHS) with respect to the Coast Guard, or any of the military departments to investigate allegations of retaliatory personnel actions taken in response to making protected communications regarding alleged instances of rape, sexual assault, or other forms of sexual misconduct in violation of the Uniform Code of Military Justice  May 7, 2013 – At the Senate Armed Services Committee, Subcommittee on Personnel hearing Gen  Mark Welsh, the Air Force's Chief of Staff, told the committee that he and Air Force Secretary Michael Donley were "appalled" by the charges against Lt  Col  Jeffrey Krusinski, branch chief of the Air Force's Sexual Assault and Prevention Office  He was arrested and charged by Arlington County, VA, police for allegedly being drunk and groping a woman in a parking lot one mile from the Pentagon  "Sexual assault prevention and response efforts are critically important to us," Welsh said  "It is unacceptable that this occurs anywhere, at any time, in our Air Force " May 8, 2013 – H R  1867 , the Better Enforcement for Sexual Assault Free Environments (BE SAFE) Act of 2013, was introduced, read twice, and referred to the House Armed Services Committee  This bill would have amended Title 10, United States Code, "to require an Inspector General investigation of allegations of retaliatory personnel actions taken in response to making protected communications regarding sexual assault " This bill would ensure those found guilty of rape, sexual assault, sodomy, or an attempt to commit any of those crimes, are—at a minimum—dismissed or dishonorably discharged from the military  The five-year statute of limitations within the military's justice system for sexual assault cases would be eliminated, and legal assistance services available to victims would be expanded  May 8, 2013 – In a hearing of the Defense Subcommittee of the Senate Appropriations Committee, senators questioned the Air Force's top leaders over rising sexual assaults in the military  Some senators cited DOD statistics from the Annual Report on Sexual Assault in the Military 2012 on the number of incidents of sexual assaults the same week Lt  Col  Jeffrey Krusinski, Chief of the Air Force's Sexual Assault Prevention and Response Branch, was arrested and charged with sexual battery  May 9, 2013 – A hearing of the Defense Subcommittee of the House Appropriations Committee on the Air Force budget was held  Witnesses included Michael Donley, Secretary of the Air Force, and General Mark Welsh, Air Force Chief of Staff  Members of the committee questioned them on Defense Secretary Hagel's review of the decision by Lt  Gen  Craig Franklin to dismiss Lt  Col  James Wilkerson's sexual assault conviction  May 14, 2013 – H Res  213 , a resolution to establish the "Special Committee on Sexual Assault and Abuse in the Armed Forces" was introduced  A "Dear Colleague" memorandum urged support of this legislation referencing Gen  Martin Dempsey's denouncement of military sexual assault as a "crisis" and the need for Congress to address this problem in a "deeper, more comprehensive manner " This Special Committee would have included 19 members appointed by the Speaker and Minority Leader, as well as chairman and ranking members of the committees on Armed Services, Appropriations, Judiciary, and Oversight and Government Reform  May 14, 2013 – H R  1960 , a bill to authorize appropriations for FY2014 for military activities of the Department of Defense, for military construction, and for defense activities of the Department of Energy, to prescribe military personnel strengths for such fiscal year, and for other purposes, was introduced  The FY2014 NDAA addressed the issue of sexual assault in the military by establishing minimum sentencing guidelines for any service members found guilty of sexual assault as well as other provisions  May 15, 2013 – H R  1986 , Sexual Assault Nurse Examiner (SANE) Deployment Act, was introduced  This bill would have provided for the assignment of Sexual Assault Nurse Examiners-Adult/Adolescent to brigades and equivalent units of the Armed Forces  May 15, 2013 – H R  2002 , Combating Military Sexual Assault Act of 2013, was introduced and referred to the House Committee on Armed Services  This bill was related to S  871 , and would have provided any sexual assault victim with a special military lawyer who would assist them throughout the process, prohibit sexual contact between instructors and trainees during and within 30 days of completion of basic training or its equivalent, and ensure that sexual assault response coordinators (SARCs) are available to help members of the National Guard and Reserve  May 16, 2013 – H R  2016 , Military Justice Improvement Act of 2013, was introduced and referred to the Committee on Armed Services  This bill would have required "a commanding officer who receives a report of a sexual-related offense involving a member in such officer's chain of command to act immediately upon such report by way of referral to the appropriate criminal investigative office or service " This bill was related to S  538 , Military Sexual Assault Prevention Act of 2013, and S  967 , Military Justice Improvement Act of 2013  May 16, 2013 – S  967 , Military Justice Improvement Act of 2013, was introduced, read twice, and referred to the Committee on Armed Services  This bill would have required a commanding officer who receives a report of a sex-related offense involving a member in such officer's chain of command to act immediately upon such report by way of referral to the appropriate criminal investigative office or service  May 21, 2013 – S  992 , a bill to provide for offices on sexual assault prevention and response under the Chiefs of Staff of the Armed Forces, to require reports on additional offices and selection of sexual assault prevention and response personnel, and for other purposes  This bill was read twice and referred to the Committee on Armed Services  May 22, 2013 – A House panel passed a number of changes in sexual assault prevention programs that limited commander discretion in reducing or dismissing rape and assault charges and expanded support services for victims  The House Armed Services Subcommittee on Military Personnel approved the personnel issues as part of H R  1960 , the FY2014 NDAA bill  May 22, 2013 – The Senate Appropriations Subcommittee on Defense held a hearing on the Army's FY 2014 Budget Request  Witnesses included Secretary of the Army, John McHugh and Chief of Staff of the Army, General Raymond T  Odierno  Army Secretary McHugh announced at this hearing that the service will soon require soldiers being considered for sexual assault prevention jobs to undergo behavioral-health evaluations as a way of screening out potential sex offenders from these high-profile positions  This was in response to a senator's question about the criteria for sexual assault prevention jobs  McHugh said that service record and availability are the only criteria commanders are using to fill these jobs since sexual-assault prevention positions do not fall under any military occupational specialty and lack career incentives  May 23, 2013 – S  1032 , Better Enforcement for Sexual Assault Free Environments Act of 2013, was introduced, read twice and referred to the Committee on Armed Services  This bill would amend Title 10, United States Code, to make certain improvements in the Uniform Code of Military Justice related to sex-related offenses committed by members of the Armed Forces  June 4, 2013 – The uniformed chiefs of the Army, Navy, Air Force, Marine Corps, and Coast Guard appeared before a hearing of the Senate Armed Services Committee, Subcommittee on Military Personnel  These military leaders acknowledged that despite a "zero tolerance" for sexual abuse, they had neglected the "epidemic" in the ranks by not always monitoring subordinate commanders  Chairman of the Joint Chiefs of Staff, Army Gen  Martin Dempsey pointed to competing demands and pressures of fighting two wars in Iraq and Afghanistan, as a justification for lack of adequate monitoring  The Service Chiefs voiced support for legislative changes that would take tougher action against offenders and provide more support for victims of military sexual assault  They opposed a legislative proposal that would remove unit commanders' legal power to oversee major criminal cases and transfer that authority to uniformed prosecutors  The Army Chief of Staff, Gen  Ray Odierno, noted that taking away commanders' authority in matters of military justice would adversely impact discipline and that "we cannot, however, simply 'prosecute' our way out of this problem  At its heart, sexual assault is a discipline issue that requires a culture change " June 4, 2013 – S  1092 was introduced, read twice, and referred to the Senate Armed Services Committee  This bill would have amended Title 10, United States Code, to require an Inspector General investigation of allegations of retaliatory personnel actions taken in response to making protected communications regarding sexual assault  June 6, 2013 –would allow victims of sexual assault to apply for a permanent change The House Armed Services Committee passed H R  1960 , the NDAA for FY2014, by a vote of 59-2  According to the Committee's Fact Sheet, "the FY14 NDAA of station or unit transfer, while authorizing the Secretary of Defense to inform commanders of their authority to remove or temporarily reassign service members who are the alleged perpetrators of sexual assault  It also requires the provision of victims' counsels, qualified and specially trained lawyers in each of the services, to be made available to provide legal assistance to the victims of sex-related offenses  The FY14 NDAA adds rape, sexual assault, or other sexual misconduct to the protected communications of service members with a Member of Congress or an Inspector General " June 14, 2013 – The House passed H R  1960 , the NDAA for FY2014 by a vote of 315 to 108 (Roll no  244)  This bill includes a provision protecting victims of sexual assault in the Armed Forces as protected communications under military whistle-blower laws, to shield victims against retaliatory actions  The measure seeks to encourage more victims to report assaults, rape and other forms of sexual misconduct  June 17, 2013 – H R  2397 , "Department of Defense Appropriations Act, 2014," was introduced and referred to the House Committee on Appropriations  It was reported as an original measure, H Rept  113-113   Lawmakers wrote in this committee report that they were "outraged by the pervasive problem of sexual assault in the Armed Forces  Sexual assault is not just an issue in the military; it is an epidemic  To address it, the Committee believes that there must be a culture change at every level of the military, from the most senior leadership to the most junior ranks " Included was a measure that would provide $182 million for the Pentagon's Sexual Assault Prevention and Response Office (SAPRO) and for an expansion of a victim's counseling program  For FY2013, the programs received $95 million  The bill included $25 million that was not requested by the administration in a transfer account to expand assistance across the Defense Department  June 20, 2013 – S  1197 , NDAA for Fiscal Year 2014, was introduced in the Senate  This bill would have authorized "appropriations for fiscal year 2014 for military activities of the Department of Defense, for military construction, and for defense activities of the Department of Energy, to prescribe military personnel strengths for such fiscal year, and for other purposes," and referred to the Committee on Armed Services  The original measure was reported to the Senate in Report No  113-44 and placed on the Legislative Calendar under General Orders (Calendar No  91)  Included in this bill was Title V—Military Personnel Policy, Subtitle E—Sexual Assault Prevention and Response and Military Justice  June 27, 2013 – H R  1864 , a bill "To amend Title 10, United States Code, to require an Inspector General investigation of allegations of retaliatory personnel actions taken in response to making protected communications regarding sexual assault," was agreed to/passed in the House, 423-0 (Roll no  294)  July 18, 2013 – Army Gen  Martin E  Dempsey, the chairman of the Joint Chiefs of Staff, and Navy Adm  James A  Winnefeld Jr , the vice chairman, in a hearing before the Senate Armed Services Committee said that commanders should retain responsibility for prosecuting service members accused of sexual assault, and taking that authority away could harm good order and discipline  July 2 2 , 2013 – H R  2777 , Stop Pay for Violent Offenders Act, was introduced "to amend Title 10, United States Code, to authorize the Secretaries of the military departments to suspend the pay and allowances of a member of the Armed Forces who is held in confinement pending trial by court-martial or by civil authority for any sex-related offense or capital offense " July 24, 2013 – H Amdt  408 to H R  2397 , an amendment to provide funds to identify individuals who were separated from the military on the grounds of a disorder subsequent to reporting a sexual assault and, if appropriate, correcting their record  This amendment (A065) was agreed to by voice vote  July 24, 2013 – H R  2397 , "Department of Defense Appropriations Act, 2014," was passed/agreed to in House, 315 - 109 (Roll no  414)  October 22, 2013 – H R  3304 , the NDAA for FY2014, was introduced in the House  As introduced, the bill would have provided for a defense counsel interview of victim of an alleged sex-related offense in presence of trial counsel, counsel for the victim, or a Sexual Assault Victim Advocate, prohibition on service in the Armed Forces by individuals who have been convicted of certain sexual offenses, Coast Guard regulations regarding request for permanent change of station or unit transfer by victim of sexual assault, temporary administrative reassignment or removal of an active duty member accused of committing a sexual assault, Inspector General investigation of allegations of retaliatory personnel actions taken in response to making protected communications regarding sexual assault, compliance tracking of commanding officers in conducting organizational climate assessments for purposes of preventing and responding to sexual assaults, advancement of submittal deadline for report of independent panel on assessment of military response systems to sexual assault, retention of certain forms on sexual assault, timely access to Sexual Assault Response Coordinators by the National Guard and Reserves, and qualifications and selection of Department of Defense sexual assault prevention and response personnel and required availability of Sexual Assault Nurse Examiners  It also would establish commanding officer actions regarding sexual assault reports, an eight-day incident reporting requirement in response to unrestricted report of sexual assault in which the victim is a member of the Armed Forces, and curricula that addresses the prevention of sexual assault at the military service academies  December 26, 2013 – H R  3304 , the NDAA for FY2014 became P L  113-66   As enacted, the bill included more than two dozen provisions to address an epidemic of sexual assault in the military in Title XVII—Sexual Assault Prevention and Response and Related Reforms, Subtitle A—Reform of Uniform Code of Military Justice  February 26, 2014 – Dr  Karen S  Guice, principal deputy assistant secretary of defense for health affairs, and other Defense Department officials testified before the Senate Armed Services Committee's personnel subcommittee on the relationship between military sexual assault survivors and the subsequent development of suicide and post-traumatic stress disorder  April 9, 2014 – H R  4435 , the Howard P  "Buck" McKeon National Defense Authorization Act for Fiscal Year 2015, was introduced in the House  The bill would have applied Title XVII of the National Defense Authorization Act for Fiscal Year 2014 ( P L  113-66 ; 127 Stat  950) to the military service academies, consulted with victims of sexual assault regarding victims' preference for prosecution of offense by court-martial or civilian court, created a confidential review of characterization of terms of discharge for victims of sexual offenses, revised requirements relating to DOD policy on retention of evidence in a sexual assault case to allow return of personal property upon completion of related proceedings, required the DOD Inspector General to review separation of members who made unrestricted reports of sexual assault, and would have created a deadline for submission of report containing results of review of Office of Diversity Management and Equal Opportunity role in sexual harassment cases  Prior to passing in the House, the House Armed Services Committee rejected an amendment from Congresswoman Speier that would have removed the military chain of command from decisions to prosecute sexual assault cases and other major crimes, except offenses that are unique to the military  She offered an alternative proposal, which would have only removed commanding officers' prosecutorial discretion for instances of sexual assault, that was also rejected by a 28-34 vote  It was received in the Senate, read twice, and placed on Senate Legislative Calendar under General Orders  Calendar No  425  June 2, 2014 — S  2410 , the Carl Levin National Defense Authorization Act for Fiscal Year 2015, was introduced in the Senate  It was placed on Senate Legislative Calendar under General Orders  Calendar No  402  The bill included measures on military justice such as enhancing sexual assault prevention and response, the application of P L  113-66 , Title XVII to military academies, and the collaboration between the Departments of Justice and Defense  December 19 , 2014 — H R  3979 , the Carl Levin and Howard P  "Buck" McKeon National Defense Authorization Act for Fiscal Year 2015, was signed as P L  113-291   Subtitle D—Military Justice, Including Sexual Assault and Domestic Violence Prevention and Response addressed the following: modification of DOD policy on retention of evidence in a sexual assault cases to permit return of personal property upon completion of related proceedings; requirements relating to Sexual Assault Forensic Examiner; analysis and assessment of disposition of most serious offenses; a plan for limited use of certain information on sexual assaults in restricted reports by military criminal investigative organizations; the establishment of a Defense Advisory Committee on Investigation, Prosecution, and Defense of Sexual Assault in the Armed Forces; confidential review of the terms of discharge of sexual assault survivors; deadline for submission of report containing results of review of Office of Diversity Management and Equal Opportunity role in sexual harassment cases; and applied Title XVII of the NDAA for Fiscal Year 2014 ( P L  113-66 ; 127 Stat  950) to the military service academies  January 13, 2015 — S  178 , the Justice for Victims of Trafficking Act of 2015 was introduced in the Senate  Title V of this bill "Military Sex Offender Reporting" stipulates that the Secretary of Defense shall provide the Attorney General information about sex offenders in the military to be included in the National Sex Offender Registry and the Dru Sjodin National Sex Offender Public Website  It became P L  114-22 on May 29, 2015  February 3, 2015 — H R  677 , American Heroes COLA Act of 2015, was introduced in the House, passed on February 9, and the next day was received in the Senate, read twice, and referred to the Committee on Veterans' Affairs  Section 6 proposed that veterans whose claims were being reviewed again in relation to a previously denied claim relating to military sexual trauma be given priority, among other claims  February 12, 2015 — H R  956 , the Military Track, Register and Alert Communities Act of 2015 (Military TRAC Act) was introduced in the House and referred to the House Armed Services Committee's Subcommittee on Military Personnel on November 23  This bill intended to require DOD to maintain a sex offender registry of individuals convicted of certain sex offenses under the Uniform Code of Military Justice or of other military offenses appropriate for sex offender registration purposes  April 13, 2015 — H R  1735 , the National Defense Authorization Act for Fiscal Year 2016, was introduced in the House  Subtitle D addressed military justice, including sexual assault and domestic violence prevention and response  April 24, 2015 — H R  2029 , the Consolidated Appropriations Act, 2016 was introduced in the House and later became P L  114-113   Section 8057 specified that "$25,000,000 shall be for continued implementation and expansion of the Sexual Assault Special Victims' Counsel Program " May 14, 2015 — S  1356 , the National Defense Authorization Act for Fiscal Year 2016 was introduced in the Senate and later became P L  114-92 on November 25, 2015  Subtitle D "Military Justice, Including Sexual Assault and Domestic Violence Prevention and Response" amended the Uniform Code of Military Justice, authorized Special Victims' Counsel for civilian DOD employees, required the DOD to develop a policy to standardize the training for Special Victims' Counsel, required the establishment of Defense Advisory Committee on Investigation, Prosecution, and Defense of Sexual Assault in the Armed Forces within 90 days, required the development of a plan to improve prevention and response to sexual assaults of male members of the Armed Forces, required the establishment of a strategy to prevent retaliation against Armed Forces members who report or intervene on behalf of sexual assault victims, and authorized the President to modify Rule 304(c) of the Military Rules of Evidence to conform to the rules governing the admissibility of the corroboration of admissions and confessions in the trial of criminal cases in the U S  district courts  June 11, 2015 — S  1558 , Department of Defense Appropriations Act, 2016, was introduced in the Senate  The bill would have required specified O&M funds to be used for continued implementation and expansion of the Sexual Assault Prevention and Response Program  June 11, 2015 — S  1567 , a bill to amend Title 10, United States Code, to provide for a review of the characterization or terms of discharge from the Armed Forces of individuals with mental health disorders alleged to affect terms of discharge, was introduced in the Senate  The bill proposed to address medical evidence reviews for former members applying for relief from the terms of their discharge due to military sexual trauma among other conditions  June 11, 2015 — S Amdt  1578 to S Amdt  1463 in H R  1735 , National Defense Authorization Act for Fiscal Year 2016, was proposed in the Senate and later considered and defeated on June 16  This bill was intended to reform procedures for determinations to proceed to trial by court-martial for certain offenses under the Uniform Code of Military Justice  It did not achieve 60 votes in the Senate by Yea-Nay Vote  The final vote was 50 - 49  April 12, 2016 — H R  4909 , the NDAA for FY2017, was introduced in the House where it passed on May 18  On May 26, it was received in the Senate, read twice, and placed on Senate Legislative Calendar under General Orders  Calendar No  502  April 18, 2016 — H R  4991 , the Prevent Retaliation and Open up Transparency to Expand Care for Troops (PROTECT) Act of 2016, was introduced in the House and later referred to the House Armed Services' Subcommittee on Military Personnel  The bill intended to amend the Uniform Code of Military Justice to establish the offense of retaliation with provisions that would permit any person intent on retaliating against anyone for reporting or planning to report a criminal offense to be punished as a court-martial may direct  May 18, 2016 — S  2943 , the National Defense Authorization Act for Fiscal Year 2017, was introduced in the Senate and became P L  114-328 on December 23  Subtitle D specified requirements for the review by a discharge review board of claims by former members asserting post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) in connection with combat or sexual trauma  Subtitle E "Military Justice and Legal Assistance Matters" required an annual report on sexual assault and response efforts, required Sexual Assault Prevention and Response Office to establish evaluation metrics and best practices in the prevention of and response to retaliation, and modified the definition of sexual harassment for the purposes of investigations of complaints of harassment by commanding officers  Title XXXV "Maritime Matters" established requirements for policies and training regarding sexual harassment and sexual assault prevention and response at the U S  Merchant Marine Academy and required the Inspector General of the Department of Transportation to submit a report to Congress about the sexual harassment and sexual assault prevention and response program at the U S  Merchant Marine Academy  Title LIV "Court-Martial Jurisdiction" specified the sexual offenses over which general courts-martial have exclusive jurisdiction  Title LX "Punitive Articles" created a new section of the Uniform Code of Military Justice addressing accountability for sexual misconduct committed by recruiters and trainers during the various phases within the recruiting and basic military training environments, revised the definition of ''sexual act'' with respect to the offenses of rape and sexual assault  May 19, 2016 — H R  5293 , Department of Defense Appropriations Act, 2017, was introduced in the House, passed on June 16, received in the Senate the next day, where it received a motion to proceed to consideration  The bill would have required O&M funds to be used for continued implementation and expansion of the Sexual Assault Prevention and Response (SAPR) Program  May 26, 2016 — S  3000 , Department of Defense Appropriations Act, 2017, was introduced in the Senate and placed on Senate Legislative Calendar under General Orders  Calendar No  500  The Senate Committee on Appropriations, Subcommittee on Department of Defense held several hearings prior from February-April  The bill would have required specified O&M funds to be used for continued implementation and expansion of the SAPR Program  DOD Directive No  6495 01  "Sexual Assault Prevention and Response (SAPR) Program," January 23, 2012, Incorporating Change 3, April 11, 2017, at http://www esd whs mil/Portals/54/Documents/DD/issuances/dodd/649501p pdf DOD Directive No  6495 02  "Sexual Assault Prevention and Response (SAPR) Program Procedures," March 28, 2013, Incorporating Change 3, May 24, 2017, at https://www esd whs mil/Portals/54/Documents/DD/issuances/dodi/649502p pdf DOD Inspector General (IG)  E valuation of the Military Criminal Investigative Organizations Sexual Assault Investigations, DODIG-2013-091, July 9, 2013, 104 p   at http://www dodig mil/reports html/Article/1118941/evaluation-of-the-military-criminal-investigative-organizations-sexual-assault/ Sexual Assault Prevention and Response Office (SAPRO) at https://www sapr mil/ Includes the full text of DOD Annual Reports, FY2004 - FY2016, and reports on Sexual Harassment and Violence at the U S  Military Service Academies, Academic Program Years (APY) 2005-2018  "Final 2014–2015 Academic Program Year Annual Report on Sexual Harassment and Sexual Assault at the United States Merchant Marine Academy," Maritime Administration, undetermined date, at https://www marad dot gov/wp-content/uploads/pdf/Final-2014-2015-SASH-Report pdf "Department of Transportation U S  Merchant Marine Academy Culture Audit, Deliverable 4  Final Report," U S  Merchant Marine Academy, December 2016, at https://cms dot gov/sites/dot gov/files/docs/mission/civil-rights/263966/dot-usmma-report pdf "Sexual Assault Prevention and Response (SAPR) Program," United States Coast Guard, LMI, December 2016, at https://media defense gov/2017/Mar/29/2001723560/-1/-1/0/CIM_1754_10E PDF "Preliminary 2015-2016 Academic Year Biennial Survey and Report on Sexual Harassment and Sexual Assault at the United States Merchant Marine Academy," Maritime Administration, January 12, 2017, at https://www marad dot gov/wp-content/uploads/pdf/Preliminary-2015-2016-SASH-Report pdf Military Justice: Oversight and Better Collaboration Needed for Sexual Assault Investigations and Adjudications , GAO-11-579, Jun 22, 2011, 42 p  http://www gao gov/products/GAO-11-579 Preventing Sexual Harassment: DOD Needs Greater Leadership Commitment and an Oversight Framework , GAO-11-809, Sep 21, 2011, 47 p  http://www gao gov/assets/590/585344 pdf Prior GAO Work on DOD's Actions to Prevent and Respond to Sexual Assault in the Military , GAO-12-571R, Mar 30, 2012, 40 p  http://www gao gov/assets/590/589780 pdf DOD Has Taken Steps to Meet the Health Needs of Deployed Servicewomen, but Actions Are Needed to Enhance Care for Sexual Assault Victims, GAO-13-182, January 29, 2013, 40 p  http://www gao gov/assets/660/651624 pdf Military Personnel: Actions Needed to Address Sexual Assaults of Male Servicemembers, Report to the Committee on Armed Services , GAO-15-284, March 19, 2015, 86 p  http://www gao gov/products/GAO-15-284 Sexual Assault: Actions Needed to Improve DOD's Prevention Strategy and to Help Ensure It Is Effectively Implemented, GAO-16-61, November 4, 2015, 59 p  http://www gao gov/products/GAO-16-61 DOD and Coast Guard: Actions Needed to Increase Oversight and Management Information on Hazing Incidents Involving Servicemembers, GAO-16-226, Feb 9, 2016, 74 p  http://www gao gov/products/GAO-16-226 The following news sources are listed in chronological order to make it easier to follow the numerous incidents of wide-spread misconduct reported in the media  Military com has ongoing news on military sexual assault at http://www military com/topics/sexual-assault   Montgomery, Nancy  "Johnson Found Guilty of Last Two Counts; Awaits Sentencing " Stars and Stripes , June 13, 2012, at http://www stripes com/news/johnson-found-guilty-of-last-two-counts-awaits-sentencing-1 180204 Carroll, Chris  "Air Force has Identified 31 Alleged Victims in Lackland Sex Abuse Scandal," Stars and Stripes, June 28, 2012, at http://www stripes com/news/air-force-has-identified-31-alleged-victims-in-lackland-sex-abuse-scandal-1 181597 Dao, James  "Instructor for Air Force Is Convicted in Sex Assaults," New York Times , July 20, 2012, at http://www nytimes com/2012/07/21/us/lackland-air-force-base-instructor-guilty-of-sex-assaults html?pagewanted=all&_r=0 Blansett, Susan and Hoffman, Michael  "Sexual Assault Cases Flood Military Courts," Military com, August 13, 2012, at http://www military com/daily-news/2012/08/13/sex-assault-cases-flood-military-courts html Risen, James  "Honor Betrayed: Attacked at 19 by an Air Force Trainer, and Speaking Out," New York Times , February 26, 2013, at http://www nytimes com/2013/02/27/us/former-air-force-recruit-speaks-out-about-rape-by-her-sergeant-at-lackland html?pagewanted=all Mulrine, Anne  "Seeking the Sex-Assault Solution," Air Force Magazine , April 2013, at http://www airforcemag com/MagazineArchive/Pages/2013/April%202013/0413solution aspx "5 Former Lackland Commanders Disciplined," Military com, May 2, 2013, at http://www military com/daily-news/2013/05/02/5-former-lackland-commanders-disciplined html Kime, Patricia  "Lawmakers Act Fast with New Legislation on Military Sexual Assault " Army Times , May 7, 2013  Shapira, Ian  "July Trial Set for Jeffrey Krusinski, Air Force Officer Accused of Sexual Battery " Washington Post , May 9, 2013, at https://www washingtonpost com/local/july-trial-set-for-air-force-officer-accused-of-sexual-battery/2013/05/09/8a21eb92-b8d9-11e2-92f3-f291801936b8_story html?utm_term= e0d4951e6573 Steinhauer, Jennifer  "Lawmakers, at White House, Discuss Sex Abuse in Military " New York Times , May 9, 2013, at http://www nytimes com/2013/05/10/us/politics/lawmakers-huddle-at-white-house-on-sex-abuse-in-military html?_r=0 Whitlock, Craig  "Pentagon Grapples with Sex Crimes by Military Recruiters," Washington Post , May 12, 2013, at http://articles washingtonpost com/2013-05-12/world/39210853_1_military-recruiters-sexual-abuse-army-reserve Sisk, Richard  "Assault Prevention NCO Investigated for Sex Crimes " Military com, May 15, 2013, at http://www military com/daily-news/2013/05/15/assault-prevention-nco-investigated-for-sex-crimes html Whitlock, Craig  "Some in Congress want Changes in Military Law as a Result of Sex Crimes," Washington Post , May 15, 2013, at http://www washingtonpost com/world/national-security/some-in-congress-want-changes-in-military-law-as-result-of-sex-crimes/2013/05/15/672a2a8a-bd8b-11e2-a31d-a41b2414d001_story html Sisk, Richard  "Sex Assault Crisis Pushes Senate to Overhaul UCMJ," Military com, May 16, 2013, at http://www military com/daily-news/2013/05/16/sex-assault-crisis-pushes-senate-to-overhaul-ucmj html Tilghman, Andrew  "Dempsey: DOD May Have Become 'Too Forgiving' of Sexual Assault," Army Times , May 17, 2013  Brady, Gen  Roger Brady (ret )  "Commentary: Telling Truths about Sexual Assault is Risky," Air Force Times , May  21, 2013  Salcedo, Michele  "Senator: Fire Commanders Allowing Sex Assault," Army Times, May 26, 2013  Tucker, Eric  "More Details Released on Annapolis Sex Assault Investigation: Allegations Made Against Three Football Players," Navy Times , May 30, 2013  Lardner, Richard  "Brass Seeks to Temper Military Justice Overhaul," Associated Press, June 3, 2013, at http://www military com/daily-news/2013/06/03/brass-seeks-to-temper-military-justice-overhaul html Cassata, Donna and Richard Lardner  "Sexual Assaults Force Changes to Military Justice," Associated Press, June 4, 2013, at http://www military


Report 2: com/daily-news/2013/06/04/sexual-assaults-force-changes-to-military-justice html Zengerle, Patricia  "U S  Lawmakers Act to Limit Military Authority in Sex Assault Cases," Reuters, June 5, 2013, at http://www reuters com/article/2013/06/05/us-usa-military-sexassault-congress-idUSBRE9541IG20130605 Cassata, Donna and Richard Lardner  " House OKs 2-Yr Jail Term for Military Sex Assault ," Associated Press, June 14, 2013, at http://www military com/daily-news/2013/06/14/house-oks-2-year-jail-term-for-military-sex-assault html Montgomery, Nancy  " After 2 decades of sexual assault in military, no real change in message ," Stars and Stripes , July 7, 2013, at https://www stripes com/news/after-2-decades-of-sexual-assault-in-military-no-real-change-in-message-1 229091 Steinhauer, Jennifer  "Complex Fight in Senate over Curbing Military Sex Assaults," New York Times , June 14, 2013, at http://www nytimes com/2013/06/15/us/politics/in-senate-complex-fight-over-curbing-sexual-military-assaults html?pagewanted=all Dao, James  "In Debate over Military Sexual Assault, Men Are Overlooked Victims," New York Times , June 23, 2013, at http://www nytimes com/2013/06/24/us/in-debate-over-military-sexual-assault-men-are-overlooked-victims html?pagewanted=all&_r=0 Sisk, Richard  "Military Tries to Sever Booze, Sex Assault Link," Military com, July 8, 2013, at http://www military com/daily-news/2013/07/08/military-tries-to-sever-booze-sex-assault-link html Watson, Julie  "Military Works to Change Culture to Combat Rape," Associated Press, July 15, 2013, at http://www military com/daily-news/2013/07/15/military-works-to-change-culture-to-combat-rape html Olson, Wyatt  "IG Review Finds Deficiencies in Sex Assault Cases," Stars and Stripes, July 16, 2013, at http://www military com/daily-news/2013/07/16/ig-review-finds-deficiencies-in-sex-assault-cases html Shanker, Thom  "New Support for Military in Sex Cases," New York Times , July 24, 2013, at http://www nytimes com/2013/07/25/us/politics/new-support-for-military-in-sex-cases html Taranto, James  "A Strange Sort of Justice at West Point," The Wall Street Journal, July 26, 2013, at https://www wsj com/articles/a-strange-sort-of-justice-at-west-point-1376453937 Cassata, Donna, "Senator Targets Military Law over Sexual Assault," Associated Press, July 29, 2013, at http://www military com/daily-news/2013/07/29/senator-targets-military-law-over-sexual-assault html?comp=7000023317843&rank=3 Groer, Annie  " Military brass claim progress in pursuing sexual assault cases ," Washington Post, August 1, 2013, at https://www washingtonpost com/blogs/she-the-people/wp/2013/08/01/military-brass-claim-progress-in-pursing-sexual-assault-cases/?utm_term= 72e55e7e218c Jennifer Koons  "Sexual Assault in the Military: Can the Pentagon stem the rise in incidents?" CQ Researcher , vol  23, no  29 (A ugust 9, 2013 ), p p  693-716   Laird, Lorelei  " Military lawyers confront changes as sexual assault becomes big news ," ABA (American Bar Association) Journal , September 2013, at http://www abajournal com/magazine/article/military_lawyers_confront_changes_as_sexual_assault_becomes_big_news/ Jelinek, Pauline  " Pentagon: Reports of Sexual Assault Up 46 Percent ," Associated Press, November 8, 2013, at http://www military com/daily-news/2013/11/08/pentagon-reports-of-sexual-assault-up-46-percent html Matthews, Michael F  " The Untold Story of Military Sexual Assault ," The New York Times, November 24, 2013, at http://www nytimes com/2013/11/25/opinion/the-untold-story-of-military-sexual-assault html " Men Sexually Assaulted in the Military Speak Out ," Baltimore Sun, December 20, 2013, at http://www military com/daily-news/2013/12/20/men-sexually-assaulted-in-the-military-speak-out html Kageyama, Yuri and Richard Lardner  "Documents Reveal Chaotic Military Sex-Abuse Record," Associated Press, February 10, 2014, at http://www military com/daily-news/2014/02/10/documents-reveal-chaotic-military-sex-abuse-record html Montgomery, Nancy  "AF Program Rare Bright Spot in Sex Assault Fight," Stars and Stripes , February 27, 2014, at http://www military com/daily-news/2014/02/27/air-force-program-rare-bright-spot-in-sex-assault-fight html Cox, Matthew  "Alcohol Policies Reviewed as Sex Assault Rises," Military com, May 1, 2014, at http://www military com/daily-news/2014/05/01/alcohol-policies-reviewed-as-sex-assault-rises html Burns, Robert  "Army Knocks 2-Star Down to 1-Star Rank," Associated Press, August 27, 2014, at http://www military com/daily-news/2014/08/27/army-knocks-2-star-down-to-1-star-rank html Milham, Matt  "Army: It's Good News That Sexual Assault Reports Are Up," Stars and Stripes , September 26, 2014, at http://www military com/daily-news/2014/09/26/army-its-good-news-that-sexual-assault-reports-are-up html Draper, Robert  The Military's Rough Justice on Sexual Assault," New York Times , November 26, 2014, at https://www nytimes com/2014/11/30/magazine/the-militarys-rough-justice-on-sexual-assault html Sisk, Richard  "Sexual Assault Reports Increase 8%, Pentagon Cites Progress," Military com, December 4, 2014, at http://www military com/daily-news/2014/12/04/sexual-assault-reports-increase-8-pentagon-cites-progress html Baldor, Lolita C  "Male Military Sex Assault Victims Slow to Complain," Associated Press, December 9, 2014, at http://www military com/daily-news/2014/12/09/male-military-sex-assault-victims-slow-to-complain html Roulo, Claudette  "Sexual Assault Rates Decrease at Military Service Academies," DOD News, Defense Media Activity, February 11, 2015, at http://archive defense gov/news/newsarticle aspx?id=128158 Pellerin, Cheryl  "DOD Honors Sexual Assault Response Coordinators," DOD News, April 23, 2015, at https://www defense gov/News/Article/Article/604510/ Rowe, Major Derek  "General courts-martial for sexual assault: How do they work?" Air Force News , April 28, 2015, at http://www af mil/News/Commentaries/Display/Article/586763/general-courts-martial-for-sexual-assault-how-do-they-work/ Sisk, Richard  "Military Sexual Assault Reports Increased 11 Percent Last Year," Military com, May 1, 2015, at http://www military com/daily-news/2015/05/01/military-sexual-assault-reports-increased-11-percent-last-year html Johnson, Lieutenant General Michelle D , U S  Air Force Academy superintendent; Vice Admiral Walter E  "Ted" Carter Jr , superintendent, U S  Naval Academy; Lieutenant General Robert L  Caslen, superintendent, U S  Military Academy; Rear Admiral James A  Helis, superintendent, U S  Merchant Marine Academy; Rear Admiral Sandra L  Stosz, superintendent, U S  Coast Guard Academy  "Lessons to Share: The five superintendents of federal service academies discuss how their institutions -- which faced scrutiny over sexual assault before many other colleges attracted such attention -- have responded to the issue," Inside Higher Ed, May 7, 2015, at https://www insidehighered com/views/2015/05/07/essay-how-federal-service-academics-prevent-and-punish-sexual-assault Tilghman, Andrew  "Military sexual assault claims: 1 in 20 lead to jail time," Military Times, May 13, 2015, at https://www militarytimes com/2015/05/13/military-sexual-assault-claims-1-in-20-lead-to-jail-time/ Schogol, Jeff  "Defense seeks dismissal of sexual assault case transferred to Washington," Air Force Times, October 17, 2015, at https://www airforcetimes com/news/your-air-force/2015/10/17/defense-seeks-dismissal-of-sexual-assault-case-transferred-to-washington/ Whitlock, Craig  "In the war against sexual assault, the Army keeps shooting itself in the foot," Washington Post, December 19, 2015, at https://www washingtonpost com/news/checkpoint/wp/2015/12/19/in-the-war-against-sexual-assault-the-army-keeps-shooting-itself-in-the-foot/?utm_term= d856136e939b Defense Media Activity  "Defense Department Proposes UCMJ Changes," DOD News, December 28, 2015, at https://www defense gov/News/Article/Article/638108/defense-department-proposes-ucmj-changes/ Losey, Stephen  "USAF launches new strategy to curb sexual assault," Air Force Times, December 30, 2015, at https://www airforcetimes com/news/your-air-force/2015/12/30/usaf-launches-new-strategy-to-curb-sexual-assault/ Kime, Patricia  "Sexual assault reporting rises at U S  service academies," Military Times , January 8, 2016, at https://www militarytimes com/news/your-military/2016/01/08/sexual-assault-reporting-rises-at-u-s-service-academies/ Larter, David B  "Navy sex assault victims may be eligible for early separation," Navy Times, January 20, 2016, at https://www navytimes com/news/your-navy/2016/01/20/navy-sex-assault-victims-may-be-eligible-for-early-separation/ Cox, John Woodrow  "Why sex assault reports have spiked at the Naval Academy, West Point and the Air Force Academy, Washington Post , March 11, 2016, at https://www washingtonpost com/news/checkpoint/wp/2016/03/11/why-sex-assault-reports-have-spiked-at-the-naval-academy-west-point-and-the-air-force-academy/?utm_term= a5e15f2f16f1 Whitlock, Craig, Thomas Gibbons-Neff  "Military bringing more charges against ofﬁcers for sexual assault," Washington Post, March 20, 2016, at https://www stripes com/news/us/military-bringing-more-charges-against-of%EF%AC%81cers-for-sexual-assault-1 400140# WeTFNOFRXUc Lardner, Richard  "Pentagon misled lawmakers on military sexual assault cases," Associated Press , April 18, 2016, at https://apnews com/23aed8a571f64a9d9c81271f0c6ae2fa/pentagon-misled-lawmakers-military-sexual-assault-cases Kheel, Rebecca  "Senators ask Obama to investigate whether Pentagon misled Congress," The Hill, April 19, 2016, at http://thehill com/policy/defense/276832-senators-ask-obama-to-investigate-pentagons-sexual-assault-comments Secretary of the Air Force Public Affairs  "Air Force report on sexual assault highlights program's progress," Air Force News , May 05, 2016, at http://www af mil/News/Article-Display/Article/752653/air-force-report-on-sexual-assault-highlights-programs-progress/ Tilghman, Andrew  "Military sex assault: Just 4 percent of complaints result in convictions," Military Times , May 5, 2016, at https://www militarytimes com/veterans/2016/05/05/military-sex-assault-just-4-percent-of-complaints-result-in-convictions/ Montgomery, Nancy  "US Military Court Addresses 'Incapable of Consent' to Sex Issue," Stars and Stripes , May 18, 2016, at http://www military com/daily-news/2016/05/18/us-military-court-addresses-incapable-of-consent-to-sex-issue html Losey, Stephen  "Military must do right by wrongly-discharged sexual assault victims, advocates say," Air Force Times , May 19, 2016, at https://www airforcetimes com/news/your-air-force/2016/05/19/military-must-do-right-by-wrongly-discharged-sexual-assault-victims-advocates-say/ Lyle, Amaani  "DoD Safe Helpline Offers Specialized Support to Sexual Assault Victims," DOD News, July 15, 2016, at https://dod defense gov/News/Article/Article/841166/dod-safe-helpline-offers-specialized-support-to-sexual-assault-victims/ Rein, Lisa  "Merchant Marine Academy under fire for sexual assault allegations," Stars and Stripes, August 12, 2016, at https://www stripes com/news/us/merchant-marine-academy-under-fire-for-sexual-assault-allegations-1 423595 Lyle, Amaani  "DoD Unveils Plan to Broaden Sexual Assault Support to Men," DOD News, Defense Media Activity, December 15, 2016, at https://www defense gov/News/Article/Article/1030795/dod-unveils-plan-to-broaden-sexual-assault-support-to-men/ The following sources are listed in alphabetical order by author  Burgess, Ann W , Donna M  Slattery, and Patricia A  Herlihy  "Military Sexual Trauma: A Silent Syndrome " Journal of Psychosocial Nursing & Mental Health Services 51, no  2 (2013): 20-6  D'Ambrosio-Woodward, Tricia  "Military Sexual Assault: A Comparative Legal Analysis of the 2012 Department of Defense Report on Sexual Assault in the Military: What It Tells Us, What It Doesn't Tell Us, and How Inconsistent Statistic Gathering Inhibits Winning the 'Invisible War '" Wisconsin Journal of Law, Gender & Society 29, no  2 (2014): 173-211  Farris, Coreen, Terry L  Schell and Terri Tanielian  Physical and Psychological Health Following Military Sexual Assault: Recommendations for Care, Research, and Policy   Santa Monica, CA: RAND Corporation, 2013  http://www rand org/pubs/occasional_papers/OP382 Firestone, Juanita M , J  M  Miller, and Richard Harris  "Implications for Criminal Justice from the 2002 and 2006 Department of Defense Gender Relations and Sexual Harassment Surveys " American Journal of Criminal Justice : AJCJ 37, no  3 (2012): 432-451  Gibson, Carolyn J , Kristen E  Gray, Jodie G  Katon, Tracy L  Simpson, and Keren Lehavot  "Sexual Assault, Sexual Harassment, and Physical Victimization during Military Service across Age Cohorts of Women Veterans " Women's Health Issues 26, no  2 (2016): 225-231  Harrell, Margaret C , Laura Werber, Marisa Adelson, Sarah J  Gaillot, Charlotte Lynch and Amanda Pomeroy  A Compendium of Sexual Assault Research   Santa Monica, CA: RAND Corporation, 2009  http://www rand org/pubs/technical_reports/TR617 Holland, Kathryn, Rabelo, Verónica, and Cortina, Lilia  Sexual Assault Training in the Military: Evaluating Efforts to End the 'Invisible War ' American Journal of Community Psychology 54, no  3/4 (2014): 289-303  Morral, Andrew R , Kristie Gore, and Terry L  Schell  Sexual Assault and Sexual Harassment in the U S  Military, Volume 1  Design of the 2014 RAND Military Workplace Study   Santa Monica, CA: RAND Corporation, National Defense Research Institute, 2014  https://www rand org/pubs/research_briefs/RB9841 html Morral, Andrew R , Kristie Gore, and Terry L  Schell  Sexual Assault and Sexual Harassment in the U S  military: Volume 2  Estimates for Department of Defense Service members from the 2014 RAND Military Workplace Study   Santa Monica, CA: RAND Corporation, National Defense Research Institute, 2015  https://www rand org/pubs/research_reports/RR870z2-1 html O'Brien, Carol, Jessica Keith, and Lisa Shoemaker  "Don't Tell: Military Culture and Male Rape " Psychological Services 12, no  4 (2015): 357-365  Stander, Valeria A  and Cynthia J  Thomsen  "Sexual Harassment and Assault in the U S  Military: A Review of Policy and Research Trends " AMSUS Military Medicine (Association of Military Surgeons of the United States) 181, no  1S (2016): 20-27  This chronological list of hearings was compiled from Congress gov and CQ com  U S  Congress, House Armed Services Committee, A Review of Sexual Misconduct by Basic Training Instructors at Lackland Air Force Base , 113 th Cong , 1 st sess , January 23, 2013, H A S C  No  113-2 (Washington, DC: GPO, 2013)  U S  Congress, House Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for 2014 , Part 1, 113th Cong , 1 st sess , February 26, 2013 (Washington, DC: GPO, 2013)  U S  Congress, Senate Armed Services Committee, Subcommittee on Personnel, Testimony on Sexual Assault in the Military, 113 th Cong , 1 st sess , March 13, 2013, S  Hrg  113-303 (Washington, DC: GPO, 2013)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for Fiscal Year 2014 , 113th Cong , 1 st sess , April 17, 2013 (Washington, DC: GPO, 2013)  U S  Congress, House Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for 2014, Part 2 , 113th Cong , 1 st sess , April 24, 2013 (Washington, DC: GPO, 2013)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for Fiscal Year 2014 , 113th Cong , 1 st sess , April 24, 2013 (Washington, DC: GPO, 2013)  U S  Congress, House Appropriations Committee, Subcommittee on Defense, President Obama's Fiscal 2014 Budget Proposal for the U S  Navy and Marine Corps , 113 th Cong , 1 st sess , May 7, 2013 (Washington, DC: GPO, 2013)  U S  Congress, Senate Armed Services Committee, D epartment of Defense Authorization for Appropriations for Fiscal Year 2014 and the Future Years Defense Program , 113 th Cong , 1 st sess , May 7, 2013 (Washington, DC: GPO, 2013)  U S  Congress, House Appropriations Committee, Subcommittee on Defense, President Obama's Fiscal 2014 Budget Proposal for the U S  Army , 113 th Cong , 1 st sess , May 8, 2013  (Washington, DC: GPO, 2013)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense, President Obama's Fiscal 2014 Budget Proposal for the U S  Air Force , 113 th Cong , 1 st sess , May 8, 2013 (Washington, DC: GPO, 2013)  U S  Congress, House Appropriations Committee, Subcommittee on Defense, President Obama's Fiscal 2014 Budget Proposal for the U S  Air Force , 113 th Cong , 1 st sess , May 9, 2013 (Washington, DC: GPO, 2013)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for Fiscal Year 2014 , 113th Cong , 1 st sess , May 22, 2013 (Washington, DC: GPO, 2013)  U S  Congress, Senate Armed Services Committee, Pending Legislation Regarding Sexual Assaults in the Military , 113 th Cong , 1 st sess , June 4, 2013, S  Hrg  113–320 (Washington, DC: GPO, 2013)  U S  Congress, Senate Armed Services Committee, Subcommittee on Personnel, Markup of the National Defense Authorization Act for Fiscal Year 2014 , 113 th Cong , 1 st sess , June 11, 2013 (Washington, DC: GPO, 2013)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for Fiscal Year 2014 , 113th Cong , 1 st sess , June 11, 2013 (Washington, DC: GPO, 2013)  U S  Congress, House Armed Services Committee, Subcommittee on Military Personnel, Women in Service Review s , 113 th Cong , 1 st sess , July 24, 2013, H A S C  No  113–50 (Washington, DC: GPO, 2013)  U S  Congress , Senate Armed Services Committee, Subcommittee on Personnel, The Relationships Between Military Sexual Assault, Post-Traumatic Stress Disorder and Suicide, and on Department of Defense and Department of Veterans Affairs Medical Treatment and Management of Victims of Sexual Trauma , 113 th Cong , 2 nd sess , February 26, 2014, S  Hrg  113-480 (Washington, DC: GPO, 2013)   U S  Congress, Armed Services Committee , Fiscal Year 2015 National Defense Authorization Budget Request from the Department of Defense , 113 th Cong , 2 nd sess , March 6 , 2014 (Washington, DC: GPO, 2014)  U S  Congress, House Armed Services Committee, Fiscal Year 2015 National Defense Authorization Budget Request from the Department of the Navy , 113 th Cong , 2 nd sess , March 12 , 2014 (Washington, DC: GPO, 2014)  U S  Congress, House Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for 2015, Part 1 , 113 th Cong , 2 nd sess , March 13, 2014 (Washington, DC: GPO, 2014)  U S  Congress, House Armed Services Committee , Fiscal Year 2015 National Defense Authorization Budget Request from the Department of the Air Force , 113 th Cong  , 2 nd sess , March 14, 2014 (Washington, DC: GPO, 2014)  U S  Congress, House Armed Services Committee , Fiscal Year 2015 National Defense Authorization Budget Request from the Department of the Army , 113 th Cong , 2 nd sess , March 25 , 2014 (Washington, DC: GPO, 2014)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense , Department of Defense Appropriations for 2015 , 113th Cong , 2 nd sess , March 26 , 2014 (Washington, DC: GPO, 2014)  U S  Congress, House Appropriations Committee, Subcommittee , Department of Defense Appropriations for 2015 , Part 2, 113 th Cong , 2 nd sess , April 2, 2014, (Washington, DC: GPO, 2014)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense , Department of Defense Appropriations for 2015 , 113th Cong , 2 nd sess , April 2 , 2014 (Washington, DC: GPO, 2014)  U S  Congress, House Armed Services Committee , National Defense Priorities from the Members for the Fiscal Year 2015 National Defense Authorization Act , 113 th Cong  , 2 nd sess , April 9 , 2014 (Washington, DC: GPO, 2014)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for Fiscal Year 2015 , 113th Cong , 2 nd sess , April 9, 2014 (Washington, DC: GPO, 2014)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for Fiscal Year 2015 , 113th Cong , 2 nd sess , April 30, 2014 (Washington, DC: GPO, 2014)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense , Department of Defense Appropriations for 2015 , 113th Cong , 2 nd sess , June 18 , 2014 (Washington, DC: GPO, 2014)  U S  Congress, Senate Armed Services Committee , Department of Defense Authorization for Appropriations for Fiscal Year 2016 and the Future Years Defense Program , Part 1 , 114th Cong , 1 st sess , March 3 , 10 , 12 , 18 , 19, 26, April 4, 30 , 2015 (Washington, DC: GPO, 2015)  U S  Congress, Senate Armed Services , Department of Defense Authorization for Appropriations for Fiscal Year 2016 and the Future Years Defense Program , Part 7 Strategic Forces, 114 th Cong , 1 st sess , March 4, 25, April 15, 22, 29 , 2015 (Washington, DC: GPO, 2015)  U S  Congress, Senate Armed Services Committee, Department of Defense Authorization for Appropriations for Fiscal Year 2016 and the Future Years Defense Program , Part 3 Readiness and Management Support, 114 th Cong , 1 st sess , March 11, 25, April 22, 2015 (Washington, DC: GPO, 2015)  U S  Congress, Senate Armed Services Committee, The Current State of Readiness of U S  Forces in Review of the Defense Authorization Request for Fiscal Year 2016 and the Future Years Defense Program , 114 th Cong , 1 st sess , March 25, 2015 (Washington, DC: GPO, 2015)  U S  Congress, Senate Armed Services Committee, Department of Defense Authorization for Appropriations for Fiscal Year 2017 and the Future Years Defense Program , Part 1 , 114 th Cong , 2 nd sess , February 11, 23, March 3, 10, 15, 17, April 5, 7, 26, 2016 (Washington, DC: GPO, 2016)  U S  Congress, House Armed Services Committee, The Fiscal Year 2017 Na tional Defense Authorization Budget Request from the Department of Defense , 114 th Cong , 2 nd sess , March 22, 2016 (Washington, DC: GPO, 2016)  U S  Congress, Senate Armed Services Committee, Subcommittee on Strategic Forces, The Current State of Research, Diagnosis, and Treatment for Post-Traumatic Stress Disorder and Traumatic Brain Injury , 114 th Cong , 2 nd sess , April 20, 2016 (Washington, DC: GPO, 2016)  U S  Congress, House Committee on Armed Services, National Defense Authorization Act for Fiscal Year 2014 on H R 1960 with Additional and Dissenting Views, 113 th Cong , 1 st sess , H  Rept  113-102 (Washington, DC: GPO, 2013)  U S  Congress, House Committee on Appropriations, Department of Defense Appropriations Bill, 2014 to Accompany H R  2397 together with Additional Views, 113 th Cong , 1 st sess , H  Rept  113-113 (Washington, DC: GPO, 2013)  U S  Congress, Senate Committee on Armed Services, National Defense Authorization Act for Fiscal Year 2014 to accompany S  1197, 113 th Cong , 1 st sess , S  Rept  113-44 (Washington, DC: GPO, 2013)  U S  Congress, Senate Committee on Appropriations, Department of Defense Appropriations Bill, 2014 to accompany S 1429, 113 th Cong , 1 st sess , S  Rept  113-85 (Washington, DC: GPO, 2013)  U S  Congress, House Committee on Armed Services, First Annual Report on the Activities of the Committee on Armed Services for the One Hundred Thirteenth Congress , 113 th Cong , 1 st sess , H  Rept  113-309 (Washington, DC: GPO, 2013)  U S  Congress, House Committee on Armed Services, Howard P  "Buck" McKeon National Defense Authorization Act for Fiscal Year 2015 to accompany H R 4435, 113 th Cong, 2 nd sess , H  Rept  113-446 (Washington, DC: GPO, 2014)  U S  Congress, House Committee on Armed Services, Howard P  "Buck" McKeon National Defense Authorization Act for Fiscal Year 2015 supplemental report to accompany H R 4435, 113 th Cong  2 nd sess , H  Rept  113-446 part 2 (Washington, DC: GPO, 2014)  U S  Congress, Senate Committee on Armed Services, Carl Levin National Defense Authorization Act for Fiscal Year 2015 to accompany S 2410, 113 th Cong, 2 nd sess , S  Rept  113-176 (Washington, DC: GPO, 2014)  U S  Congress, House Committee on Appropriations, Department of Defense Appropriations Bill, 2015 to accompany H R 4870, 113 th Cong , 2 nd sess , H  Rept  113-473 (Washington, DC: GPO, 2014)  U S  Congress, Senate Committee on Appropriations, Department of Defense Appropriations Bill, 2015 to accompany H R 4870, 113 th Cong , 2 nd sess , S  Rept  113-211 (Washington, DC: GPO, 2014)  U S  Congress, House Committee on Armed Service, National Defense Authorization Act for Fiscal Year 2016 to accompany H R 1735, 114 th Cong , 1 st sess , H  Rept  114-102 (Washington, DC: GPO, 2015)  U S  Congress, Senate Committee on Armed Services, National Defense Authorization Act for Fiscal Year 2016 to accompany S 1376, 114 th Cong , 1 st sess , S  Rept  114-49 (Washington, DC: GPO, 2015)  U S  Congress, House Committee on Appropriations, Department of Defense Appropriations Bill, 2016 to accompany H R 2685, 114 th Cong , 1 st sess , H  Rept  114-139 (Washington, DC: GPO, 2015)  U S  Congress, Senate Committee on Appropriations, Department of Defense Appropriations Bill, 2016 to accompany S 1558, 114 th Cong , 1 st sess , S  Rept  114-63 (Washington, DC: GPO, 2015)  U S  Congress, House Conference Report, National Defense Authorization Act for Fiscal Year 2016 to accompany H R 1735, 114 th Cong , 1 st sess , H  Rept  114-270 (Washington, DC: GPO, 2015)  U S  Congress, House Committee on Armed Services, National Defense Authorization Act for Fiscal Year 2017 on H R 4909, 114 th Cong , 2 nd sess , H  Rept  114-537 (Washington, DC: GPO, 2016)  U S  Congress, Committee on Armed Services, National Defense Authorization Act for Fiscal Year 2017 to accompany S 2943, 114 th Cong, 2 nd sess , S  Rept  114-255 (Washington, DC: GPO, 2016)  U S  Congress, House Committee on Appropriations, Department of Defense Appropriations Bill, 2017 to accompany H R 5293, 114 th Cong , 2 nd sess , H  Rept  114-577 (Washington, DC: GPO, 2016)  U S  Congress, Senate Committee on Appropriations, Department of Defense Appropriations Bill, 2017 to accompany S 3000, 114 th Cong , 2 nd sess , S  Rept  114-263 (Washington, DC: GPO, 2016)  U S  Congress, House Conference Report, National Defense Authorization Act for Fiscal Year 2017 to accompany S  2943, 114 th Cong, 2 nd sess , H  Rept  114-840 (Washington, DC: GPO, 2016) 

ground_truth: Under CAPTA, states perform a range of prevention activities, including addressing the needs of infants born with prenatal drug exposure. The number of children under the age of 1 entering foster care increased by about 15 percent from fiscal years 2012 through 2015. Child welfare professionals attribute the increase to the opioid epidemic. GAO was asked to examine the steps states are taking to implement CAPTA requirements on substance-affected infants and related amendments enacted in 2016. This report examines (1) the extent to which states have adopted policies and procedures to notify CPS of substance-affected infants; (2) state efforts to develop plans of safe care, and associated challenges; and (3) steps HHS has taken to help states implement the provisions. To obtain this information, GAO surveyed state CPS directors in all 50 states and the District of Columbia and reached a 100 percent response rate. GAO also visited 3 states (Kentucky, Massachusetts, and Pennsylvania); reviewed relevant documents such as federal laws and regulations, and HHS guidance; and interviewed HHS officials. GAO did not assess states' compliance with CAPTA requirements. All states reported adopting, to varying degrees, policies and procedures regarding health care providers notifying child protective services (CPS) about infants affected by opioids or other substances. Under the Child Abuse Prevention and Treatment Act (CAPTA), as amended, governors are required to provide assurances that the states have laws or programs that include policies and procedures to address the needs of infants affected by prenatal substance use. This is to include health care providers notifying CPS of substance-affected infants. In response to GAO's survey, 42 states reported having policies and procedures that require health care providers to notify CPS about substance-affected infants and 8 states reported having policies that encourage notification. The remaining 1 state has a policy requiring health care providers to assess the needs of mothers and infants and if they conclude that infants are at risk for abuse or neglect, CPS is notified. In response to GAO's survey, 49 states reported that their CPS agency has policies to develop a plan of safe care; 2 reported not having such a requirement. Under CAPTA, states are required to develop a plan of safe care for substance-affected infants. Although not defined in law, a plan of safe care generally entails an assessment of the family's situation and a plan for connecting families to appropriate services to stabilize the family and ensure the child's safety and well-being. States reported that plans typically address the infant's safety needs, immediate medical needs, and the caregiver's substance use treatment needs. However, officials in the 3 states GAO visited noted challenges, including uncertainty about what to include in plans and the level of intervention needed for infants at low risk of abuse or neglect. The Department of Health and Human Services (HHS) has provided technical assistance and guidance to states to implement these CAPTA requirements. Most states reported in GAO's survey that additional guidance and assistance would be very or extremely helpful for addressing their challenges. Nevertheless, HHS officials told GAO that the agency does not anticipate issuing additional written guidance, but that states can access technical assistance through their regional offices and the National Center on Substance Abuse and Child Welfare—a resource center funded by HHS. However, of the 37 states that reported on the helpfulness of the assistance they have received, 19 said it was only moderately helpful to not helpful. States offered suggestions for improving the assistance, such as developing substance abuse training materials for staff and holding video conferences with other states to share information. In October 2017, HHS officials explained that some states have submitted plans that include details on how they are addressing the CAPTA requirements. HHS officials reported that some of the plans submitted to date indicated that states are not meeting the requirements and those states have been asked to develop program improvement plans. Without more specific guidance and assistance to enhance states' understanding of CAPTA requirements and better address known challenges such as the ones described in this report, states may miss an opportunity to provide more effective protections and services for the children and families most in need. GAO recommends that HHS provide additional guidance and technical assistance to states to address known challenges and enhance their understanding of requirements. HHS did not concur with the recommendation. As discussed in the report, GAO continues to believe that added guidance would benefit states.

prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 2.

Report 1: CAPTA, originally enacted in 1974, provides formula grants to states to improve child protective service systems  ACF administers the CAPTA state grant program and provides guidance and oversight to states  In fiscal year 2017, Congress provided about $25 million for the program  As part of the CAPTA state grant program, states are required to submit to the Secretary of HHS plans outlining how they intend to use CAPTA funds to improve their child protective service systems, among other things  State plans remain in effect for the duration of states’ participation in the grant program; if modifications are needed, these must be submitted  In addition to state plans, states are required to submit to HHS an annual data report providing information on agency decisions made in response to referrals of child abuse and neglect, as well as preventive services provided to families, among other things  CAPTA requires state governors to provide a series of assurances in their state plans  Since 2003, governors have had to provide an assurance that states have in effect and are enforcing a state law or program that includes policies and procedures to address the needs of infants affected by prenatal substance abuse or displaying withdrawal symptoms at birth  Under states’ policies and procedures, health care providers are required to notify CPS of such infants  Governors must also assure that a plan of safe care is developed for these infants  Although CAPTA does not define “plans of safe care,” for the purposes of this report we define them as plans to ensure the safety and well-being of infants who are born substance-affected  The Comprehensive Addiction and Recovery Act of 2016 (CARA) amended certain provisions of CAPTA that relate to substance-affected infants (see table 1)  In addition to provisions related to substance-affected infants, CAPTA also requires governors to provide an assurance to the Secretary of HHS that they have provisions or procedures for certain individuals to report known and suspected instances of child abuse and neglect, which are generally referred to as mandated reporter laws  All states have statutes identifying persons who are required to report suspected child maltreatment to an appropriate agency, such as child protective services, a law enforcement agency, or a state’s toll-free child abuse reporting hotline, according to a 2016 HHS report  Mandatory reporters often include social workers; teachers, principals, and other school personnel; physicians, nurses, and other health care workers; and counselors, therapists, and other mental health professionals  The circumstances under which a mandatory reporter must make a report vary from state to state, according to HHS  Typically, a report must be made when the reporter, in his or her official capacity, suspects or has reason to believe that a child has been abused or neglected  State laws require mandatory reporters to report the facts and circumstances that led them to suspect that a child has been abused or neglected; they do not have the burden of providing proof that abuse or neglect has occurred  CPS, a division within state and local social services, is generally the agency that conducts an initial assessment or investigation of reports of child abuse and neglect  It also offers services to families and children where maltreatment has occurred or is likely to occur  Typically, when CPS agencies receive a notification about suspected child abuse, including a substance-affected infant, social workers review the referral to determine if it should be accepted for investigation  During an investigation, social workers determine, among other things, the nature, extent, and cause of abuse or neglect, and identify the person responsible for the maltreatment  An investigation may include the following: a visit to the hospital and/or infant’s home; observation of the infant; risk and safety assessments; evaluation of the home environment; background checks, including criminal record checks of adults that reside with the family; as well as mental health evaluations  If social workers determine that there is enough evidence to suggest that an infant is at risk for harm or neglect, or that abuse or neglect occurred, the case is substantiated  Once a case is substantiated, CPS develops a case plan with the family outlining objectives and tasks for the family  Among other things, CPS may refer the family to services in the community, such as early intervention services, parenting classes, and substance abuse treatment  Generally, CPS attempts to strengthen the family and alleviate the problems which led to maltreatment  If the case is not substantiated, but there is genuine concern about the child’s situation and the family may benefit from services in the community, the case may be closed and/or the family may be referred for voluntary services (see figure 1)  Prenatal maternal opioid use has increased considerably in recent years  This increase has contributed to a significant rise in the rate of NAS  According to a recent study, the rate of NAS has increased from 1 2 per 1,000 hospital births in 2000 to 5 8 per 1,000 hospital births in 2012, reaching a total of 21,732 infants diagnosed with NAS  NAS occurs with considerable variability  According to a recent HHS report, various studies indicate that anywhere from 55 to 94 percent of infants exposed to opioids in-utero exhibit some degree of symptoms  Typically, infants with NAS develop symptoms within 72 hours of birth, but may develop symptoms within the first 2 weeks of life, including after hospital discharge  For the purpose of this report, infants exposed to opioids ingested by mothers in utero are considered substance-exposed, and those born negatively affected by exposure or experiencing withdrawal symptoms are considered substance-affected  According to experts, NAS is considered an expected and treatable result of women’s prenatal opioid use  Opioid exposure during pregnancy may occur for the following reasons: Women receiving pain medication with a prescription under the care of a physician  Medications can include fentanyl and oxycodone  Women under the care of a physician and undergoing treatment for an opioid use disorder with medications, such as methadone or buprenorphine  This type of treatment is generally referred to as medication-assisted treatment (MAT)  Women misusing opioid pain medications with or without a prescription (such as using without a prescription, using a different dosage than prescribed, or continuing to use a drug when no longer needed for pain)  Women using or abusing illicit opioid, such as heroin  In response to our survey, 42 states reported that state policies and procedures require health care providers to notify CPS about substance- affected infants  Some states reported that they explicitly require health care providers to notify CPS of substance-affected infants  For example, Wisconsin reported that under its state law if tests indicate that infants have controlled substances or controlled substance analogs in their bodily fluids, the health care provider shall report the occurrence of that condition to CPS  Others reported that the requirement is met by their states’ mandated reporter law—whereby people in certain positions, including health care providers, are required to notify CPS about substance-affected infants, similar to the manner in which other mandatory reporters, like school teachers, day care personnel, and social workers are required to report other instances of child abuse and neglect  For example, Kentucky statute requires that “any person who knows or has reasonable cause to believe that a child is dependent, neglected, or abused shall immediately” make a report to the police or CPS  The statutory definition for an abused or neglected child in Kentucky includes situations where a child’s health or welfare is harmed or threatened with harm because of parental incapacity due to alcohol and other drug abuse  Of the 42 states that require health care providers to notify CPS of substance-affected infants, 21 reported that notification is required for infants affected by both illegal and legal use of opioids  For example, in Massachusetts health care providers are required to notify CPS orally and, in writing within 48 hours, about substance-affected infants physically dependent on drugs, even if the drugs were legally obtained and the mother is under the care of a prescribing medical professional  Sixteen of the 42 states reported that health care providers are required to notify CPS of infants affected only by the illegal use of opioids, and five of the 42 states reported that they did not know if health care providers were required to notify CPS of infants affected by the illegal and legal use of opioids  The other eight states reported that although they did not have policies and procedures that require health care providers to notify CPS about substance-affected infants, they have laws or policies that encourage notification  Specifically, in written responses to our survey: Two states reported that under their state mandated reporter laws health care providers are encouraged, but not required, to notify CPS about substance-affected infants  Four states reported that they are working to amend their states’ policies and procedures to require that health care providers refer substance-affected infants to CPS  Another state reported that it encourages the notification from health care providers, but has not sought legislation to require health care providers to report substance-affected infants to CPS because of concerns that any laws that criminalize prenatal substance use would further deter substance-using pregnant women from seeking prenatal care  The state’s law requires all hospital personnel who suspect abuse and neglect or observe conditions that are likely to result in abuse or neglect to notify CPS  One state reported that all persons, including health care providers, are required to report child abuse and neglect, but reporting depends on whether a hospital’s policy indicates substance abuse is child abuse or neglect  Further, the state CPS director reported collaboration with the health care community on reporting substance exposed infants to its child abuse hotline  Although one state reported in our survey that it does not require or encourage health care providers to notify CPS about substance-affected infants, in an interview, state officials explained that its policy requires that health care providers notify CPS if, through an assessment, they conclude that infants are at risk for abuse and neglect  Under the state’s law, health care providers in each county are required to assess the needs of mothers and substance-affected infants using a protocol established by county health departments, CPS agencies, and hospitals  State officials told us that under the state’s law, the birth of a substance- affected infant is not in and of itself a sufficient basis for reporting child abuse or neglect  In addition to having policies and procedures regarding the reporting of substance-affected infants, in written responses to our survey some states reported providing training and guidance to support the efforts of health care providers to notify CPS about these infants  Three states reported that they offer mandatory reporter training to inform health care providers that they are obligated to notify CPS about substance-affected infants  Another state reported that its Department of Human Services developed a guide for mandated reporters that discusses what needs to be reported and where to make reports  Also, one state reported that it sent a formal letter to its state hospital association about how to report substance-affected infants to CPS  This state also sent a memo to its CPS county directors instructing them to contact their local health care providers on the importance of reporting substance-affected infants to CPS and the process for doing so  In addition, during our Massachusetts site visit, officials shared with us a memo that was sent to mandated reporters, community partners, and other stakeholders that offered guidance on when to file a report about substance-exposed infants  Further, local CPS staff at one Massachusetts field office told us that upon request they provide mandated reporter training to health care providers  Despite these policies, procedures, and guidance, in written responses to our survey, a few states reported concerns about requiring health care providers to notify CPS about substance-affected infants and the definition of substance-affected  All of the hospitals that we visited have policies consistent with their state’s law that require that health care providers, primarily hospital social workers, to notify CPS about substance-affected infants  However, one state reported that some medical personnel have been reluctant to report some infants that are positive for illegal and legal substances due to fears of mothers being arrested  Another state reported that stakeholders are concerned that having to notify CPS about substance-affected infants will have a chilling effect on the willingness of pregnant women who use substances to be honest with providers and seek the help and support they need and deserve  According to one state, there is often an inherent resistance to contacting CPS in these cases as health care providers tend to view child welfare involvement as punitive rather than a potential resource for the family  In addition, three states reported in written responses to our survey challenges understanding how to define terms, such as substance- affected, under CAPTA  For example, the Pennsylvania CPS director expressed concerns during our site visit, suggesting that CAPTA raises many unanswered questions, such as (1) if “affected by substances” means at-risk of being or physically affected by substances, (2) what policies relating to substance-affected infants should look like and include, and (3) whether “affected by substances” should include women who are under the care of health care or treatment providers and taking their medications as prescribed  A Kentucky public health official told us that a drug test, or whether the infant is affected by legal or illegal substances, should not be the sole factor in determining CPS’ involvement with a family  Rather, a holistic view of the family, whether the substance prohibits the mother’s ability to care for her child, and any risk factors present that places the infant at risk should also be considered  According to officials, an infant that is exposed to substances, but has not been affected by the substance, can still be at risk for child abuse and neglect  In response to our survey, 46 states reported that they have policies and procedures for deciding which notifications about substance-affected infants are accepted for investigation  Seventeen of those states reported that all notifications of substance-affected infants are accepted for investigation, regardless of the circumstances  The remaining 29 states reported that they apply specific criteria to determine if children who present as substance-affected are accepted for investigation by CPS  Several states reported in written responses to our survey that they base their criteria for accepting notifications on the infant’s safety  For these states, drug exposure does not by itself indicate that an infant’s safety is at risk  For example, one state explained that in determining a child’s safety risk, staff evaluate a number of factors including the history of the family; the family’s presentation at the birthing hospital (appearance of chaotic behavior, suspected intoxication of adults, lack of appropriate concern or bonding with the infant); the presentation of the infant’s physical condition; the results of any testing of parent or child (blood, urine, etc ); discrepancies identified in the parent’s representation of their substance use or substance use treatment; and any other concerns noted by the reporting source  Other states reported that their criteria for accepting notifications for investigation are based on the degree or type of drug exposure in question  For example, one state reported that its policy directs CPS agencies to accept notifications for investigation when a parent has used illegal substances or non-medical use of prescribed medication during the last trimester of pregnancy  Another state reported that it will accept notifications for investigation if the infant is born with a positive toxicology or is experiencing drug withdrawal, or if the mother tests positive for substances  A few states reported using both risk to the safety of infants as well as degree or type of drug as their criteria for accepting notifications  For example, one state reported that it considers factors, such as the type of drug, the parent’s ability to care for the child, addiction history, and the parent’s readiness and preparation to care for the infant  In follow-up correspondences with states that reported that they do not have policies and procedures to decide whether to accept for investigation notices about substance-affected infants, one state reported that decisions are made on a case-by-case basis  A few states reported that after receiving notifications about substance- affected infants, CPS agencies may decide to opt out of investigating some families, referred to as “screening out” families  For example, in Massachusetts, CPS can “screen out” referrals of mothers if the only substance affecting the infants was used by the mothers as prescribed by their physician  In these instances, when CPS in Massachusetts is notified by the hospital about an infant, the screener gathers information from the caller and consults with a supervisor to determine whether the referral should be accepted for investigation or screened out  If the mother is on methadone, for example, but is involved with services and is in a treatment plan, CPS verifies with medical or other qualified providers that the mother used the drug as part of substance abuse or medical treatment as authorized  Additionally, CPS confirms that there are no other concerns of child abuse and/or neglect  If CPS officials in Massachusetts are unable to collect all the information that they need to screen out families, for example when a mother does not sign a release allowing CPS officials to speak with her health care providers, notifications about substance-affected infants are accepted for investigation  In response to our survey, 49 states reported that their CPS agency has policies to develop a plan to ensure the safety and well-being of substance-affected infants who meet the state’s criteria for investigation  Two states reported that CPS staff are not required to develop such a plan, even if a notification is accepted for an investigation or an assessment  For purposes of this report, we are defining a plan of safe care as a plan to ensure the safety and well-being of the infant  States’ approaches to identifying children and families who will receive a plan of safe care generally fall into two categories: 38 states reported that CPS is required to develop a plan of safe care for all notifications of substance-affected infants that are accepted for investigation, including those that are not substantiated  11 states reported that CPS staff are required to develop a plan of safe care only in those instances where an investigation substantiates the notification or uncovers an unmet need or present or emerging danger  For example, local Pennsylvania CPS officials told us that they only develop plans when there is a safety threat or other concern about the infant  Most states reported that after a notification of a substance-affected infant is accepted for investigation, CPS always conducts a needs assessment for the infant and caregivers  For example, one local CPS office that we visited told us that social workers assess risk to and safety of infants, their function (development, age appropriate behavior, etc ), and environment  In addition, workers assess the caregiver’s ability to parent and employment status, as well as housing  The assessments conducted as part of the investigation inform the development of plans of safe care, as well as decisions about the removal of infants from the home  Among the 49 states that reported that plans of safe care are developed for all or some substance-affected infants, 47 reported that these plans either always or sometimes address infants’ safety needs  Plans also address other needs, such as infants’ immediate medical and longer-term developmental needs, as well as caregiver’s substance use treatment needs  See figure 2 for the number of states whose plans of safe care address various issues facing the infant and parent  In written responses to our survey and during our site visits, officials reported that plans of safe care and referrals for services included in the plans are individualized based on the infant and family’s needs  For example, Massachusetts state CPS officials told us that plans of safe care are developed for each family based on the information that staff collect from the safety, risk, and family assessments, as well as information collected from individuals who may have knowledge that would inform the family assessments, such as medical and treatment providers, and family members  Kentucky state CPS officials told us that the local organizations and service providers that they collaborate with to develop the plan of safe care also vary based on the family’s needs  For example, Kentucky will only collaborate with substance use treatment providers to develop the plan of safe care when families have substance use disorders  Similarly, during our site visits, officials from two states told us that the decision to place an infant in foster care is based on the individualized needs of the infant and caregiver  For example, Massachusetts state officials told us that their decision to remove a baby from the home depends on a myriad of factors and is determined on a case-by-case basis  Officials explained that if a mother is discharged from the hospital and begins using drugs again and does not have adequate supports in place to care for her baby, CPS may decide to place the infant in foster care  However, if a mother has existing support systems in place to mitigate safety risks, CPS may decide to keep the baby in the home  In our survey, all 51 states reported that their agencies either always or sometimes refer parents or caregivers to substance use treatment programs, and most states reported that they always or sometimes refer parents or caregivers to parenting classes or programs (49), and other supportive services (49)  CPS officials in each of the three states that we visited told us that their plans of safe care include referrals to address not only the immediate needs of the infants, but also the needs of the parent or caregiver  For example, officials from a local Kentucky CPS agency told us that staff refer mothers of substance-exposed infants to a program called Sobriety Treatment and Recovery Team (START)  START is comprised of a social worker and a peer support mentor who has at least 3 years of sobriety, previous involvement with CPS, and was successfully able to regain or keep custody of her own children  According to officials, the START program has been able to provide participants with quick access to substance use disorder treatment  Officials from a Massachusetts local CPS agency told us that one of the services that they provide to parents of substance-affected infants is a parent aide who can help monitor how the parent is caring for the infant, such as administering the infant’s medications appropriately and ensuring the parent is not abusing the infant’s drugs  In addition, a parent aide can provide emotional support and help parents adjust after the infant is discharged from the hospital  Kentucky officials noted the effect that a healthy caregiver has on the outcome of the infant and emphasized that a baby cannot be healthy if the mother is not  Kentucky CPS officials said that they have found that the earlier caregivers enter treatment, the better the outcomes are for mothers and babies  According to Kentucky officials, parents who participate in the START program are less likely to have their child placed in foster care  Officials from the states that we visited told us that developing and monitoring plans of safe care under CAPTA’s new requirements for infants affected by their mother’s legal use of prescribed medications, as well as plans for these infants’ caregivers, present challenges  Specifically, officials reported concerns about increased caseloads, particularly if they are required to provide plans and services for infants at low risk of abuse or neglect, the content of plans, and confidentiality restrictions  Thirty-one of 50 states reported on our survey that staffing or resource limitations was very or extremely challenging, and CPS officials across the 3 states we visited said that the opioid epidemic has directly contributed to increased caseloads  According to a local Kentucky CPS office, the number of babies that met criteria for being accepted for investigation has increased about 55 percent from 2011 to 2016, while the number of staff has remained the same  Similarly, hospitals reported being impacted by this challenge  For example, staff at four hospitals we visited told us that they have delayed discharging infants from the hospital because CPS social workers did not identify caregivers to whom infants may be released or make plans for infants in a timely manner  In addition, staff from three hospitals told us that some CPS workers are difficult to contact and not especially responsive to their questions  One hospital social worker told us that she is concerned that the changes to CAPTA that require notifying CPS of all substance-affected newborns will inundate the agencies with cases  Officials from two of the three states we visited anticipated that providing services to infants affected by the legal use of prescribed medications, but not likely to be at risk for child abuse and neglect, will result in an increase in the number of families referred to CPS  This, in turn, will require a plan of safe care and further strain limited resources  Twenty- five states reported in our survey that the plan they develop for substance-affected infants is the same as for other children in CPS care, suggesting that states devote the same level of resources to these infants as other cases  The states we visited interpret CAPTA to require that plans of safe care be developed for all substance-affected infants who are referred to CPS, including those who may not meet usual criteria to be accepted for an investigation  Some state officials we interviewed questioned whether the new CAPTA requirements would allow for the best use of limited resources  For example, one senior state CPS official questioned whether it would be a good use of resources to develop plans of safe care for mothers in substance use disorder treatment or mothers using opioid medications due to chronic pain  A local CPS official we interviewed stated that drug exposure, in and of itself, is not necessarily a safety risk, and CPS should not intervene with families who are not at risk for child abuse or neglect  Instead, hospitals or treatment providers should intervene and refer families who do not meet criteria for CPS involvement, but could benefit from additional supports, to voluntary services  Kentucky public health officials told us that the period after a woman gives birth is a critical time for families as mothers may be stressed, sleep-deprived, exhausted, and may have other children in the home  This period may be especially challenging for mothers with substance use disorders, if adequate supports are not in place  According to officials women are typically covered for substance use treatment during pregnancy; however, this coverage ends roughly 60 days after the baby is born  In written responses to our survey, some states reported that they would rely on other agencies to develop plans of safe care  Similarly, in order to manage limited CPS resources, officials from two of the three states that we visited said they are considering having hospitals or other agencies assume responsibility for developing plans of safe care when there is no evidence of abuse or neglect and there appears to be minimal risk to the safety and well-being of the infant  Kentucky officials told us that they envision that CPS will be responsible for developing a plan of safe care for notifications that are accepted for investigation, while hospitals, or another agency, will be responsible for developing plans of safe care for referrals that are screened out by CPS  According to CPS state officials, the plan of safe care for the infant and the family can be part of the discharge plan prior to the family leaving the hospital  However, officials reported that obtaining cooperation from other agencies may be difficult  Some state officials reported being concerned that other agencies may not feel obligated to develop these plans, in part, because CAPTA provides funding to child welfare, and other agencies may therefore believe that child welfare should be responsible for developing the plan of safe care  CPS officials we interviewed in two of our site visit states, as well as one state we followed up with, told us that they were unsure of whether their current plans will meet new CAPTA requirements because CAPTA does not define a plan of safe care  For example, Massachusetts officials said that their plans include everything that a family might need to ensure the safety of the child, including resources to ensure stabilization and reunification of a family, but they are not sure whether the plans meet new CAPTA requirements, in part because they are not familiar with the term “plan of safe care ” An official in another state was also unsure about whether his state’s “safety plans” would meet CAPTA requirements  According to the official, safety plans may include a treatment plan for mothers, and referral services, such as early intervention for the child  In practice, plans of safe care generally address gaps that place an infant at risk for harm or neglect  However, state officials we interviewed reported being unsure about what a plan of safe care should look like for families where these gaps do not exist  Also, in a written response to our survey, one state expressed uncertainty about CPS’ role if required to work with infants who do not typically receive CPS services  For example, a Pennsylvania official said that it is unclear what types of interventions child welfare should conduct with families of infants exposed to legal substances, such as medications prescribed by doctors, when the caregivers are taking their medications correctly  Similarly, officials also questioned whether a plan would be necessary, and what the plan would entail, for caregivers who are already addressing their substance use disorder and taking steps to ensure their infant’s safety  Officials from a local Kentucky CPS office described a case in which a mother was participating in medication-assisted treatment, had attended counseling three times per week throughout her pregnancy, and was continuing treatment in the postpartum period  Through CPS’ investigation, the agency found that the case was not substantiated, in part, because there were no additional services that CPS could connect her with that she was not already receiving  Officials across the three states we visited also said that state and federal drug and alcohol confidentiality restrictions may challenge their ability to monitor plans of safe care  To monitor plans of safe care, CPS staff may need access to confidential information in order to know how caregivers are progressing in treatment, particularly now that these plans must address the substance use disorder needs of the caregiver  However, federal law restricts the disclosure and use of alcohol and drug patient records maintained in connection with the performance of any federal- assisted alcohol and drug abuse program  Generally, confidential information may be disclosed in accordance with the prior written consent of the patient  State and local CPS staff we interviewed said that strict confidentiality requirements make it challenging for drug and alcohol treatment providers to share information about mothers and infants  A CPS state director from Pennsylvania said that treatment providers are often reluctant to provide CPS case workers with information or updates on a mother’s treatment, which prevents child welfare workers from fully understanding how mothers are progressing with their treatment and the extent to which those in treatment are adhering to prescribed directions as outlined by treatment providers  In addition, one official from a state we visited said state statutes regarding sharing of drug and alcohol treatment information may be more restrictive than the federal statute  Some states have developed ways to obtain confidential information about mothers in substance use disorder treatment  For example, officials from one local CPS office told us that in instances when they have to develop a long-term plan of safe care for families, they have mothers sign a release of information form in order to obtain updates about her treatment adherence from the medication- assisted treatment provider  Similarly, a local Massachusetts CPS office told us that typically staff obtain releases from mothers so that they can verify whether mothers are actively participating in their treatment and that there are no records of relapse  In HHS’ role to assist states in the delivery of child welfare services, two agencies—ACF and the Substance Abuse and Mental Health Services Administration (SAMHSA)—provided technical assistance to states through the National Center on Substance Abuse and Child Welfare (NCSACW)  In addition, in ACF’s role to administer and monitor states’ implementation of CAPTA, the agency has provided some guidance to states on the provisions pertaining to substance-affected infants and has begun its monitoring responsibilities  ACF and SAMHSA, which leads public health efforts to reduce the impact of substance abuse and mental illness, established the NCSACW in 2002  The NCSACW provides technical assistance to states, and has issued publications and hosted forums to help states develop policies and procedures around issues affecting substance-affected infants  The technical assistance has focused on a broad range of issues, including collaboration among service providers, and plans of safe care  With respect to collaboration, NCSACW has issued several studies that identify opportunities for strengthening interagency efforts to prevent, intervene, identify, and treat prenatal substance exposure  The NCSACW collaboration guides encourage states to involve CPS agencies with medical providers in an interagency collaborative setting, thereby facilitating the process for CPS agencies to be notified of substance- affected infants  Regarding plans of safe care, NCSACW has provided technical assistance and best practices to states around development of these plans  For example, in one state it has facilitated discussion groups to help the state develop a model plan  From calendar year 2011 to 2016, NCSACW processed approximately 600 requests from state CPS agencies for short-term technical assistance related to improving care for substance-affected infants and their families  This short-term technical assistance included activities such as responding to telephone inquiries, mailing information, identifying needed resources, and making referrals  The NCSACW has also provided in- depth assistance to 16 states to strengthen collaboration and linkages across child welfare, addiction treatment, medical communities, early care and education systems, and family courts to improve outcomes for substance-affected infants and their families  Through this in-depth assistance, NCSACW identified areas for improvement in states, including a lack of clarity regarding compliance with CAPTA requirements (such as identification, notification, and developing plans of safe care) and the need for state models to comply with CAPTA requirements to develop plans of safe care  In one state, the project overview report indicated that a next step for the in-depth technical assistance is to continue development of the plan of safe care model and ensure practices and protocols are in place across systems to meet CAPTA requirements  The report indicated that this will include ongoing work with hospitals to ensure consistent identification of infants with prenatal exposure and notifications to CPS  Although18 states reported in our survey that technical assistance from the NCSACW was very or extremely helpful, 11 reported that it was moderately helpful, 7 reported that it was slightly helpful, and 1 reported that it was not at all helpful  Eleven states reported that they were not familiar with this assistance  Since July 2016, when the most recent amendments to CAPTA were enacted, ACF has issued one information memorandum and two program instructions to states about provisions relating to substance-affected infants  According to an ACF official, information memoranda share information with states, while program instructions provide interpretations of the law and inform states of actions they must take  ACF issued an August 2016 information memorandum informing states of the 2016 amendments to CAPTA  The August 2016 information memorandum also provided states with best practices, drawing on an NCSACW guide on collaboration for developing multi-systemic approaches to assist child welfare, medical, substance use disorder treatment, and other systems to support families affected by opioid use disorders  In January 2017, ACF issued a program instruction which provided guidance to states on implementing the 2016 amendments to CAPTA made by CARA and informed states of the flexibilities that they have under the law  Particularly, the guidance noted that: “CAPTA does not define ‘substance abuse’ or ‘withdrawal symptoms resulting from prenatal drug exposure ’ We recognize that by deleting the term ‘illegal’ as applied to substance abuse affecting infants, the amendment potentially expands the population of infants and families subject to the provision [that states have policies and procedures in place to address their needs]  States have flexibility to define the phrase, ‘infants born and identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure,’ so long as the state’s policies and procedures address the needs of infants born affected by both legal (e g , prescribed drugs) and illegal substance abuse ” “While CAPTA does not specifically define a ‘plan of safe care,’ CARA amended the CAPTA state plan requirement       to require that a plan of safe care address the health and substance use disorder treatment needs of the infant and affected family or caregiver ” “CAPTA does not specify which agency or entity must develop the plan of safe care; therefore the state may determine which agency will develop the plans  We understand that in most instances the state already has identified the responsible agency in its procedures  When the state reviews and modifies its policies and procedures to incorporate the new safe care plan requirements in CARA, the state may wish to revisit its procedures regarding which agency develops the plan of safe care, including any role for agencies collaborating with CPS in caring for the infant and family ” In addition, in April 2017, ACF issued a program instruction on reporting requirements, including changes in those requirements brought about by the 2016 amendments to CAPTA  ACF conducted limited monitoring of states prior to the amendments passed in 2016  According to ACF officials, if presented with evidence of potential deficiencies, the agency would attempt to learn more about the state’s activities  In one instance, ACF reviewed South Carolina’s policies and found them to not be in compliance with the notification and safe care plan requirements of CAPTA  It directed the state to develop a program improvement plan to bring it into full compliance, which South Carolina submitted in April 2016  In a recent progress report (February–April 2017), South Carolina reported that it was focused on updating statutes, developing policies and procedures, training child protective service workers, and building relations with health care providers  In response to the 2016 amendments to CAPTA that added the requirement for HHS to monitor state policies and procedures to address the needs of substance-affected infants, ACF officials told us that staff in regional offices will review states’ annual reports, submitted in June 2017  In its program instruction describing the reporting requirements, ACF asked each state to submit a new Governor’s Assurance, as well as a narrative explaining what they have done in response to the amendments  Specifically, ACF asked states to provide information on any changes that were made in state laws, policies, or procedures related to identifying and referring infants affected by substance abuse to CPS as a result of prenatal drug exposure  It also requested updates on states’ policies and procedures regarding the development of plans of safe care; a description of how states have developed systems to monitor plans of safe care; and a description of any outreach or coordination efforts the states have taken to implement the amendments, among other things  According to ACF officials, as of October 1, 2017, some states have provided information and a Governor’s Assurance demonstrating compliance with the amended provisions and some states have been placed on Program Improvement Plans, but the agency does not yet have information on the status of all states  An ACF official explained that, in their annual reports, some states either acknowledged that they are trying to get legislation enacted to bring them into compliance with the law and it has failed, or that they are not in compliance, for example, because they were limiting their policies to those infants affected only by illegal substances  In addition, in May 2017, ACF issued a technical bulletin informing states of the new data collection requirements that resulted from the 2016 amendments to CAPTA  ACF stated that it intends to collect data required by the amendments to CAPTA through the National Child Abuse and Neglect Data System, beginning with states’ submission of fiscal year 2018 data  This system is maintained by ACF and contains data from states about children who have been abused or neglected  ACF issued a Federal Register notice about the proposed data elements and requested comments on the accuracy and quality of the proposed data collection, among other things; the comment period closed in July 2017  In the Federal Register notice, ACF notes that the 2016 amendments to CAPTA require it to collect information from state CPS agencies on the number of notifications from health care providers that are accepted for investigation or screened out  Further, of those infants screened in, ACF is required to collect data on the number of safe care plans developed for substance- affected infants as well as the number of infants for whom a referral was made for appropriate services, including services for the affected family or caregiver  In the Federal Register notice, ACF proposed to collect this information using a combination of existing and new data from states  Thirty-two states reported in our survey that they already collect data on the incidence of substance-affected and/or substance-exposed infants; 15 of those 32 states also collect data on the incidence of NAS  Further, 18 states reported that they collect data on the number of notifications health care providers make to CPS  Of those states, 8 reported that they collect specific data on notifications related to infants diagnosed with NAS  Most states reported in our survey that additional guidance and assistance would be extremely or very helpful (see figure 3)  For example, 38 states reported that additional guidance on requirements for health care providers to notify CPS of substance-affected infants would be extremely or very helpful  Similarly, 37 states reported that additional guidance on developing, implementing, and monitoring plans to ensure the safety and well-being of substance-affected infants would be extremely or very helpful  In written responses to our survey, states suggested ideas for additional guidance, training, and technical assistance to help them address the needs of substance-affected infants  States’ suggestions ranged from assisting in the development of substance abuse training curriculum for staff to video conferences with other states to share information about implementing CAPTA  A few states suggested that the guidance ACF has provided to date is not clear and reported grappling with the meaning of terms such as “affected” and “legal vs  illegal” substances, and two states requested “concrete guidance” and “specificity ” A few other states suggested that it would be helpful to obtain additional information about meeting the requirements of plans of safe care within the constraints of state and federal confidentiality laws, technical assistance on what plans of safe care look like, and a format for a plan of safe care  ACF officials told us that states have flexibility with implementing the law and the agency does not anticipate issuing additional written guidance on the amendments to CAPTA made by CARA  ACF officials explained, in October 2017, that they were finalizing their review of the plans that states were required to submit  These plans are expected to include details on how the states are addressing the CAPTA requirements  While ACF could not provide the number, officials reported that some of the state plans submitted to date did not meet the requirements and those states have been asked to develop program improvement plans  They expect states to work with the ACF regional offices, which will provide or facilitate technical assistance to states on their implementation of the provisions, as needed  In addition to the review of state plans, ACF officials explained that regional officials may learn about states’ needs for technical assistance through meetings or informational exchanges  Finally, the NCSACW is expected to review and prepare a summary of CAPTA state plans, current state statutes and policies and procedures relating to amended CAPTA requirements  In addition, according to ACF, NCSACW will continue to offer technical assistance on the development and implementation of plans of safe care to states  Technical assistance may include responding to requests for information, disseminating written materials and resources, and conducting webinars/conference calls  Further, ACF reported that some states will receive more in-depth technical assistance, albeit in some instances on a time-limited basis  Undertaking these actions can enhance states’ understanding of CAPTA requirements and better address known challenges such as the ones described in this report  However, more specific guidance from HHS on the issues which states have expressed confusion can assist them in better understanding CAPTA requirements and providing more effective protections and services for the children and families most in need  The opioid epidemic has generated a significant increase in the number of substance-affected infants born and diagnosed with NAS  These vulnerable infants may be at risk for child abuse and neglect if adequate supports and services are not available to ensure their safety  CAPTA requires states to have policies and procedures to address the needs of these infants and their families, including mothers with a substance use disorder  However, states have experienced challenges implementing new CAPTA requirements  Many states reported in our survey that they are not completely adhering to the law  This is reflected in ACF’s review of state plans, some of which are resulting in program improvement plans  States cite challenges that stem, in part, from ACF’s lack of specificity in providing guidance on implementing CAPTA requirements  Specifically, states report that ACF has not provided clear guidance about which substance-affected infants health care providers are required to notify CPS about, as well what a plan of safe care is and for whom it should be developed  Given the challenges that states reported facing in implementing the provisions, a majority reported wanting more help from ACF, such as trainings and teleconferences with other states, to help overcome their challenges  Additional guidance and assistance from HHS would help states better understand what they need to do to develop policies and procedures that meet the needs of children and families affected by substance use  The Secretary of HHS should direct ACF to provide additional guidance and technical assistance to states to address known challenges and enhance their understanding of CAPTA requirements, including the requirements for health care providers to notify CPS of substance- affected infants and the development of a plan of safe care for these infants  We provided a draft of this report to HHS for review and comment  HHS’s comments are reproduced in appendix I  HHS also provided technical comments, which we incorporated into our report where appropriate  HHS did not concur with our recommendation  HHS stated that: in January 2017, ACF clarified in guidance several of the issues raised in the report, including the population of infants and families covered by the provision and the state flexibility inherent in determining which infants are “affected by” substance abuse, and the terminology used in the federal law of what a “plan of safe care” is; ACF believes it is necessary to allow states the flexibility to meet the requirements in the context of their state CPS program; several of the challenges that the GAO notes are not specific to CAPTA compliance with the safe care plan and notification requirements; and it does see the value in continuing to provide technical assistance to states to address known challenges and to enhance their understanding of CAPTA requirements  With respect to HHS’ January 2017 guidance, state officials reported in our survey and during site visits that they found some terms unclear and were uncertain about what is required of them  In written responses to our survey, states reported challenges understanding how to define substance-affected under CAPTA  In addition, as we note in our report, the guidance about plans of safe care described the following: “While CAPTA does not specifically define a ‘plan of safe care,’ CARA amended the CAPTA state plan requirement       to require that a plan of safe care address the health and substance use disorder treatment needs of the infant and affected family or caregiver ” States reported in our survey and in follow-up discussions that this lack of specificity remained an ongoing challenge for them  For example, as we discuss in our report, one state that we followed up with in August 2017 was still unsure about whether its safety plans would meet CAPTA requirements for plans of safe care  In addition, as of October 2017, HHS confirmed that some state plans did not meet CAPTA requirements and that the states were asked to develop program improvement plans  Accordingly, a key ongoing challenge was not addressed by the January guidance  Regarding allowing states flexibility to meet CAPTA requirements, we acknowledge in our report that HHS said that states have flexibility  However, in our survey and site visits, states indicated that they would find it helpful for HHS to provide them with greater specificity around terms, including the degree of flexibility they are allowed  States added that this would include parameters within which they can develop policies and procedures that meet CAPTA requirements  We continue to believe that additional guidance addressing these concerns would benefit states and could be provided without imposing additional mandates  Concerning HHS’ third point that some of the issues raised in the report are not specific to CAPTA, the states we visited interpret CAPTA to require that plans of safe care be developed for all substance-affected infants who are referred to CPS  During our discussions with states and in responses to our survey, state officials did not delineate which federal requirement impacted their approach to serving children and families  As stated in our conclusion, vulnerable infants may be at risk for child abuse and neglect if adequate supports and services are not available to ensure their safety  Lastly, HHS indicated that it will continue to provide technical assistance to states and fund demonstration sites to establish or enhance collaboration across community agencies and courts  Although continuing to provide technical assistance to states should be beneficial, our findings demonstrate that additional guidance is also needed  For example, 38 states reported that additional guidance on requirements for health care providers to notify CPS of substance-affected infants would be extremely or very helpful  Similarly, 37 states reported that additional guidance on developing, implementing, and monitoring plans to ensure the safety and well-being of substance-affected infants would be extremely or very helpful  Overall, given the results of our review, we continue to believe our recommendation is warranted  Effective implementation of our recommendation should help states better implement protections for children  As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date  At that time, we will send copies of this report to the appropriate congressional committees and the Secretary of Health and Human Services  In addition, the report is available at no charge on the GAO website at http://www gao gov  If you or your staff have any questions about this report, please contact me at (202) 512-7215 or larink@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report  GAO staff who made key contributions to this report are listed in appendix II  Kathryn A  Larin, (202) 512-7215 or larink@gao gov  In addition to the contact above, Sara Schibanoff Kelly (Assistant Director), Ramona L  Burton (Analyst-in-Charge), Kay E  Brown, Hannah Dodd, Ada Nwadugbo, and Srinidhi Vijaykumar made key contributions to this report  Also contributing to this report were Sandra L  Baxter, James Bennett, Gina Hoover, Jessica Orr, Rhiannon Patterson, Jean McSween, and James Rebbe 


Report 2: Medicare is a federal program that pays for covered health care services of qualified beneficiaries  It was established in 1965 under Title XVIII of the Social Security Act to provide health insurance to individuals 65 and older, and has been expanded over the years to include permanently disabled individuals under 65  The program is administered by the Centers for Medicare & Medicaid Services (CMS), within the U S  Department of Health and Human Services (HHS)  Medicare consists of four distinct parts: Part A (Hospital Insurance, or HI) covers inpatient hospital services, skilled nursing care, hospice care, and some home health services  The HI trust fund is mainly funded by a dedicated payroll tax of 2 9% of earnings, shared equally between employers and workers  Since 2013, workers with income of more than $200,000 per year for single tax filers (or more than $250,000 for joint tax filers) pay an additional 0 9% on income over those amounts  Part B (Supplementary Medical Insurance, or SMI) covers physician services, outpatient services, and some home health and preventive services  The SMI trust fund is funded through beneficiary premiums (set at 25% of estimated program costs for the aged) and general revenues (the remaining amount, approximately 75%)  Part C (Medicare Advantage, or MA) is a private plan option for beneficiaries that covers all Parts A and B services, except hospice  Individuals choosing to enroll in Part C must also enroll in Part B  Part C is funded through the HI and SMI trust funds  Part D covers outpatient prescription drug benefits  Funding is included in the SMI trust fund and is financed through beneficiary premiums, general revenues, and state transfer payments  Medicare serves approximately one in six Americans and virtually all of the population aged 65 and older  In 2019, the program will cover an estimated 61 million persons (52 million aged and 9 million disabled)  The Congressional Budget Office (CBO) estimates that total Medicare spending in 2019 will be about $772 billion; of this amount, approximately $749 billion will be spent on benefits  About 28% of Medicare benefit spending is for hospital inpatient and hospital outpatient services (see Figure 1 )  CBO also estimates that federal Medicare spending (after deduction of beneficiary premiums and other offsetting receipts) will be about $637 billion in 2019, accounting for about 14% of total federal spending and 3% of GDP  Medicare is required to pay for all covered services provided to eligible persons, so long as specific criteria are met  Spending under the program (except for a portion of administrative costs) is considered mandatory spending and is not subject to the appropriations process  Medicare is expected to be a high-priority issue in the current Congress  The program has a significant impact on beneficiaries and other stakeholders as well as on the economy in general through its coverage of important health care benefits for the aged and disabled, the payment of premiums and other cost sharing by those beneficiaries, its payments to providers who supply those health care services, and its interaction with other insurance coverage  Projections of future Medicare expenditures and funding indicate that the program will place increasing financial demands on the federal budget and on beneficiaries  In response to these concerns, Congress may consider a range of Medicare reform options, from making changes within the current structure, including modifying provider payments and revising existing oversight and regulatory mechanisms, to restructuring the entire program  The committees of jurisdiction for the mandatory spending (benefits) portion of Medicare are the Senate Committee on Finance, the House Committee on Ways and Means, and the House Committee on Energy and Commerce  The House and Senate Committees on Appropriations have jurisdiction over the discretionary spending used to administer and oversee the program  Medicare was enacted in 1965 (P L  89-97) in response to the concern that only about half of the nation's seniors had health insurance, and most of those had coverage only for inpatient hospital costs  The new program, which became effective July 1, 1966, included Part A coverage for hospital and posthospital services and Part B coverage for doctors and other medical services  As is the case for the Social Security program, Part A is financed by payroll taxes levied on current workers and their employers; persons must pay into the system for 40 quarters to become entitled to premium-free benefits  Medicare Part B is voluntary, with a monthly premium required of beneficiaries who choose to enroll  Payments to health care providers under both Part A and Part B were originally based on the most common form of payment at the time, namely "reasonable costs" for hospital and other institutional services or "usual, customary and reasonable charges" for physicians and other medical services  Medicare is considered a social insurance program and is the second-largest such federal program, after Social Security  The 1965 law also established Medicaid, the federal/state health insurance program for the poor; this was an expansion of previous welfare-based assistance programs  Some low-income individuals qualify for both Medicare and Medicaid  In the ensuing years, Medicare has undergone considerable change  P L  92-603, enacted in 1972, expanded program coverage to certain individuals under 65 (the disabled and persons with end-stage renal disease (ESRD)), and introduced managed care into Medicare by allowing private insurance entities to provide Medicare benefits in exchange for a monthly capitated payment  This law also began to place limitations on the definitions of reasonable costs and charges in order to gain some control over program spending which, even initially, exceeded original projections  During the 1980s and 1990s, a number of laws were enacted that included provisions designed to further stem the rapid increase in program spending through modifications to the way payments to providers were determined, and to postpone the insolvency of the Medicare Part A trust fund  This was typically achieved through tightening rules governing payments to providers of services and limiting the annual updates in such payments  The program moved from payments based on reasonable costs and reasonable charges to payment systems under which a predetermined payment amount was established for a specified unit of service  At the same time, beneficiaries were given expanded options to obtain covered services through private managed care arrangements, typically health maintenance organizations (HMOs)  Most Medicare payment provisions were incorporated into larger budget reconciliation bills designed to control overall federal spending  This effort culminated in the enactment of the Balanced Budget Act of 1997 (BBA 97; P L  105-33 )  This law slowed the rate of growth in payments to providers and established new payment systems for certain categories of providers, including establishing the sustainable growth rate (SGR) methodology for determining the annual update to Medicare physician payments  It also established the Medicare+Choice program, which expanded private plan options for beneficiaries and changed the way most of these plans were paid  BBA 97 further expanded preventive services covered by the program  Subsequently, Congress became concerned that the BBA 97 cuts in payments to providers were somewhat larger than originally anticipated  Therefore, legislation was enacted in both 1999 (Balanced Budget Refinement Act of 1999, or BBRA; P L  106-113 ) and 2000 (Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, or BIPA; P L  106-554 ) to mitigate the impact of BBA 97 on providers  In 2003, Congress enacted the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA; P L  108-173 ), which included a major benefit expansion and placed increasing emphasis on the private sector to deliver and manage benefits  The MMA included provisions that (1) created a new voluntary outpatient prescription drug benefit to be administered by private entities; (2) replaced the Medicare+Choice program with the Medicare Advantage (MA) program and raised payments to plans in order to increase their availability for beneficiaries; (3) introduced the concept of income testing into Medicare, with higher-income persons paying larger Part B premiums beginning in 2007; (4) modified some provider payment rules; (5) expanded covered preventive services; and (6) created a specific process for overall program review if general revenue spending exceeded a specified threshold  During the 109 th Congress, two laws were enacted that incorporated minor modifications to Medicare's payment rules  These were the Deficit Reduction Act of 2005 (DRA; P L  109-171 ) and the Tax Relief and Health Care Act of 2006 (TRHCA; P L  109-432 )  In the 110 th Congress, additional changes were incorporated in the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA; P L  110-173 ) and the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA; P L  110-275 )  In the 111 th Congress, comprehensive health reform legislation was enacted that, among other things, made statutory changes to the Medicare program  The Patient Protection and Affordable Care Act (ACA; P L  111-148 ), enacted on March 23, 2010, included numerous provisions affecting Medicare payments, payment rules, covered benefits, and the delivery of care  The Health Care and Education Affordability Reconciliation Act of 2010 (the Reconciliation Act, or HCERA; P L  111-152 ), enacted on March 30, 2010, made changes to a number of Medicare-related provisions in the ACA and added several new provisions  Included in the ACA, as amended, are provisions that (1) constrain Medicare's annual payment increases for certain providers; (2) change payment rates in the MA program so that they more closely resemble those in fee-for-service; (3) reduce payments to hospitals that serve a large number of low-income patients; (4) create an Independent Payment Advisory Board (IPAB) to make recommendations to adjust Medicare payment rates; (5) phase out the Part D prescription drug benefit "doughnut hole"; (6) increase resources and enhance activities to prevent fraud and abuse; and (7) provide incentives to increase the quality and efficiency of care, such as creating value-based purchasing programs for certain types of providers, allowing accountable care organizations (ACOs) that meet certain quality and efficiency standards to share in the savings, creating a voluntary pilot program that bundles payments for physician, hospital, and post-acute care services, and adjusting payments to hospitals for readmissions related to certain potentially preventable conditions  In the 112 th and 113 th Congresses, the American Taxpayer Relief Act of 2012 (ATRA; P L  112-240 ), the Continuing Appropriations Resolution of 2014 ( P L  113-67 ), and the Protecting Access to Medicare Act of 2014 (PAMA; P L  113-93 ) primarily made short-term modifications to physician payment updates and payment adjustments for certain types of providers  PAMA also established a new skilled nursing facility (SNF) value-based purchasing program and a new system for determining payments for clinical diagnostic laboratory tests  The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT; P L  113-185 ) required that post-acute care providers—defined in the law as long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), SNFs, and home health agencies (HHAs)—report standardized patient assessment data and data on quality measures and resource use  IMPACT also modified the annual update to the hospice aggregate payment cap and required that hospices be reviewed every three years to ensure that they are compliant with existing regulations related to patient health and safety and quality of care  In the 114 th Congress, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P L  114-10 ) repealed the SGR formula for calculating updates to Medicare payment rates to physicians and other practitioners and established an alternative set of methods for determining the annual updates   MACRA also introduced alternatives to the current fee-for-service (FFS) based physician payments by creating a new merit-based incentive payment system (MIPS) and put in place processes for developing, evaluating, and adopting alternative payment models (APMs)  Additionally, MACRA reduced updates to hospital and post-acute care provider payments, extended several expiring provider payment adjustments, made adjustments to income-related premiums in Parts B and D, and prohibited using Social Security numbers on beneficiaries' Medicare cards  Among other changes, the Increasing Choice, Access, and Quality in Health Care for Americans Act (Division C of the 21 st Century Cures Act; P L  114-255 ) made adjustments to LTCH reimbursement and modified the average length of stay criteria, which determines whether a hospital qualifies as an LTCH  It also delayed payment reductions and required the Secretary of Health and Human Services (the Secretary) to make changes to how payments are determined for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)  Lastly, it allowed beneficiaries with ESRD to enroll in MA beginning January 1, 2021  In the 115 th Congress, the Bipartisan Budget Act of 2018 (BBA 18; P L  115-123 ) made a number of changes to federal health care programs, including Medicare  For example, BBA 18 included provisions designed to expand care for beneficiaries with chronic health conditions, such as promoting team-based care by providers, increasing the use of telehealth services, and expanding certain MA supplemental benefits  In addition, BBA 18 extended for five years a number of existing Medicare provisions that were set to expire (or that had temporarily expired), including the Medicare dependent hospital program and add-on payments for low-volume hospitals, rural home health services, and certain ambulance services  BBA 18 also specified payment updates for the Medicare physician fee schedule, SNFs, and home health services; reduced payments for non-emergency ambulance transports; and required modification of the home health prospective payment system starting in 2020  In addition, the act provided for indefinite authority for MA special needs plans, repealed limits on outpatient therapy services, and eliminated the IPAB  Starting in 2019, the act will require that pharmaceutical manufacturers participating in Medicare Part D provide a larger discount on brand-name drugs purchased by enrollees in the coverage gap and will create a new high-income premium category under Parts B and D  Most persons aged 65 or older are automatically entitled to premium-free Part A because they or their spouse paid Medicare payroll taxes for at least 40 quarters (about 10 years) on earnings covered by either the Social Security or the Railroad Retirement systems  Persons under the age of 65 who receive cash disability benefits from Social Security or the Railroad Retirement systems for at least 24 months are also entitled to Part A  (Since there is a five-month waiting period for cash payments, the Medicare waiting period is effectively 29 months ) The 24-month waiting period is waived for persons with amyotrophic lateral sclerosis (ALS, "Lou Gehrig's disease")  Individuals of any age with ESRD who receive dialysis on a regular basis or a kidney transplant are generally eligible for Medicare  Medicare coverage for individuals with ESRD usually starts the first day of the fourth month of dialysis treatments  In addition, individuals with one or more specified lung diseases or types of cancer who lived for six months during a certain period prior to diagnosis in an area subject to a public health emergency declaration by the Environmental Protection Agency (EPA) as of June 17, 2009, are also deemed entitled to benefits under Part A and eligible to enroll in Part B  Persons over the age of 65 who are not entitled to premium-free Part A may obtain coverage by paying a monthly premium ($437 in 2019) or, for persons with at least 30 quarters of covered employment, a reduced monthly premium ($240 in 2019)  In addition, disabled persons who lose their cash benefits solely because of higher earnings, and subsequently lose their extended Medicare coverage, may continue their Medicare enrollment by paying a premium, subject to limitations  Generally, enrollment in Medicare Part B is voluntary  All persons entitled to Part A (and persons over the age of 65 who are not entitled to premium-free Part A) may enroll in Part B by paying a monthly premium  In 2019, the monthly premium is $135 50; however, about 3 5% of Part B enrollees pay less, due to a "hold-harmless" provision in the Social Security Act  Since 2007, higher-income Part B enrollees pay higher premiums  (See " Part B Financing  ") Although enrollment in Part B is voluntary for most individuals, in most cases, those who enroll in Part A by paying a premium also must enroll in Part B  Additionally, ESRD beneficiaries and Medicare Advantage enrollees (discussed below) also must enroll in Part B  Together, Parts A and B of Medicare comprise "original Medicare," which covers benefits on a fee-for-service basis  Beneficiaries have another option for coverage through private plans, called the Medicare Advantage (MA or Part C) program  When beneficiaries first become eligible for Medicare, they may choose either original Medicare or they may enroll in a private MA plan  Each fall, there is an annual open enrollment period during which time Medicare beneficiaries may choose a different MA plan, or leave or join the MA program  Beneficiaries are to receive information about their options to help them make informed decisions  In 2019, the annual open enrollment period runs from October 15 to December 7 for plan choices starting the following January  Since 2012, MA plans with a 5-star quality rating have been allowed to enroll Medicare beneficiaries who are either in traditional Medicare or in an MA plan with a lower quality rating at any time  Finally, each individual enrolled in either Part A or Part B is also entitled to obtain qualified prescription drug coverage through enrollment in a Part D prescription drug plan  Similar to Part B, enrollment in Part D is voluntary and the beneficiary pays a monthly premium  Since 2011, some higher-income enrollees pay higher premiums, similar to enrollees in Part B  Generally, beneficiaries enrolled in an MA plan providing qualified prescription drug coverage (MA-PD plan) must obtain their prescription drug coverage through that plan  In general, individuals who do not enroll in Part B or Part D during an initial enrollment period (when they first become eligible for Medicare) must pay a permanent penalty of increased monthly premiums if they choose to enroll at a later date  Individuals who do not enroll in Part B during their initial enrollment period may enroll only during the annual general enrollment period, which occurs from January 1 to March 31 each year  Coverage begins the following July 1  However, the law waives the Part B late enrollment penalty for current workers who have primary coverage through their own or a spouse's employer-sponsored plan  These individuals have a special enrollment period once their employment ends; as long as they enroll in Part B during this time, they will not be subject to penalty  Individuals who do not enroll in Part D during their initial enrollment period may enroll during the annual open enrollment period, which corresponds with the Part C annual enrollment period—from October 15 to December 7, with coverage effective the following January  Individuals are not subject to the Part D penalty if they have maintained "creditable" drug coverage through another source, such as retiree health coverage offered by a former employer or union  However, once employees retire or have no access to "creditable" Part D coverage, a penalty will apply unless they sign up for coverage during a special enrollment period  Finally, for persons who qualify for the low-income subsidy for Part D, the delayed-enrollment penalty does not apply  Medicare Parts A, B, and D each cover different services, with Part C providing a private plan alternative for all Medicare services covered under Parts A and B, except hospice  The Parts A-D covered services are described below, along with a description of Medicare's payments  Part A provides coverage for inpatient hospital services, posthospital skilled nursing facility (SNF) services, hospice care, and some home health services, subject to certain conditions and limitations  Approximately 20% of fee-for-service enrollees use Part A services during a year  Medicare inpatient hospital services include (1) bed and board; (2) nursing services; (3) use of hospital facilities; (4) drugs, biologics, supplies, appliances, and equipment; and (5) diagnostic and therapeutic items and services  (Physicians' services provided during an inpatient stay are paid under the physician fee schedule and discussed below in the " Physicians and Nonphysician Practitioner Services " section ) Coverage for inpatient services is linked to an individual's benefit period or "spell of illness" (defined as beginning on the day a patient enters a hospital and ending when he or she has not been in a hospital or skilled nursing facility for 60 days)  An individual admitted to a hospital more than 60 days after the last discharge from a hospital or SNF begins a new benefit period  Coverage in each benefit period is subject to the following conditions: Days 1-60  Beneficiary pays a deductible ($1,364 in 2019)  Days 61-90  Beneficiary pays a daily co-payment charge ($341 in 2019)  Days 91-150  After 90 days, the beneficiary may draw on one or more of 60 lifetime reserve days, provided they have not been previously used  (Each of the 60 lifetime reserve days can be used only once during an individual's lifetime ) For lifetime reserve days, the beneficiary pays a daily co-payment charge ($682 in 2019); otherwise the beneficiary pays all costs  Days 151 and over  Beneficiary pays for all costs for these days  Inpatient mental health care in a psychiatric facility is limited to 190 days during a patient's lifetime  Cost sharing is structured similarly to that for stays in a general hospital (above)  Medicare makes payments to most acute care hospitals under the inpatient prospective payment system (IPPS), using a prospectively determined amount for each discharge  Medicare's payments to hospitals is the product of two components: (1) a discharge payment amount adjusted by a wage index for the area where the hospital is located or where it has been reclassified, and (2) the weight associated with the Medicare severity-diagnosis related group (MS-DRG) to which the patient is assigned  This weight reflects the relative costliness of the average patient in that MS-DRG, which is revised annually, generally effective October 1 st of each year  Additional payments are made to hospitals for cases with extraordinary costs (outliers), for indirect costs incurred by teaching hospitals for graduate medical education, and to disproportionate share hospitals (DSH) which provide a certain volume of care to low-income patients  Additional payments may also be made for qualified new technologies that have been approved for special add-on payments  Medicare also makes payments outside the IPPS system for direct costs associated with graduate medical education (GME) for hospital residents, subject to certain limits  In addition, Medicare pays hospitals for 65% of the allowable costs associated with beneficiaries' unpaid deductible and co-payment amounts as well as for the costs for certain other services  IPPS payments may be reduced by certain quality-related programs based on a hospital's quality performance  These quality-related programs include the Hospital Readmissions Reduction Program, the Hospital-Acquired Condition Reduction Program, and the Hospital Value-Based Purchasing Program  Further, hospitals may receive Medicare payment reductions for failing to demonstrate meaningful use of certified electronic health record (EHR) technology  Additional payment adjustments or special treatment under the IPPS may apply for hospitals meeting one of the following designations: (1) sole community hospitals (SCHs), (2) Medicare dependent hospitals, (3) rural referral centers, and (4) low-volume hospitals  Certain hospitals or distinct hospital units are exempt from IPPS and paid on an alternative basis, including (1) inpatient rehabilitation facilities, (2) long-term care hospitals, (3) psychiatric facilities including hospitals and distinct part units, (4) children's hospitals, (5) cancer hospitals, and (6) critical access hospitals  Medicare covers up to 100 days of posthospital care for persons needing skilled nursing or rehabilitation services on a daily basis  The SNF stay must be preceded by an inpatient hospital stay of at least 3 consecutive calendar days, and the transfer to the SNF typically must occur within 30 days of the hospital discharge  Medicare requires SNFs to provide services for a condition the beneficiary was receiving treatment for during his or her qualifying hospital stay (or for an additional condition that arose while in the SNF)  There is no beneficiary cost sharing for the first 20 days of a Medicare-covered SNF stay  For days 21 to 100, beneficiaries are subject to daily co-payment charges ($170 50 in 2019)  The 100-day limit begins again with a new spell of illness  SNF services are paid under a prospective payment system (PPS), which is based on a per diem urban or rural base payment rate, adjusted for case mix (average severity of illness) and area wages  The per diem rate generally covers all services, including room and board, provided to the patient that day  The case-mix adjustment is made using the resource utilization groups (RUGs) classification system, which uses patient assessments to assign a beneficiary to one of 66 groups that reflect the beneficiary's expected use of services  Patient assessments are done at various times during a patient's stay and a beneficiary's designated RUG category can change with changes in the beneficiary's condition  Extra payments are not made for extraordinarily costly cases ("outliers")  The Medicare hospice benefit covers services designed to provide palliative care and management of a terminal illness; the benefit includes drugs and medical and support services  These services are provided to Medicare beneficiaries with a life expectancy of six months or less for two 90-day periods, followed by an unlimited number of 60-day periods  The individual's attending physician and the hospice physician must certify the need for the first benefit period, but only the hospice physician needs to recertify for subsequent periods  Since January 1, 2011, a hospice physician or nurse practitioner must have a face-to-face encounter with the individual to determine continued eligibility prior to the 180 th day recertification, and for each subsequent recertification  Hospice care is provided in lieu of most other Medicare services related to the curative treatment of the terminal illness  Beneficiaries electing hospice care from a hospice program may receive curative services for illnesses or injuries unrelated to their terminal illness, and they may disenroll from the hospice at any time  Nominal cost sharing is required for drugs and respite care  Payment for hospice care is based on one of four prospectively determined rates (which correspond to four different levels of care) for each day a beneficiary is under the care of the hospice  The four rate categories are routine home care, continuous home care, inpatient respite care, and general inpatient care  Payment rates are adjusted to reflect differences in area wage levels, using the hospital wage index  Payments to a hospice are limited by two caps; the first limits the number of days of inpatient care to 20% or less of total patient care days, and the second limits the average annual payment per beneficiary  Home health services and services for individuals with end-stage renal disease are covered under both Parts A and B of Medicare  Medicare covers visits by participating home health agencies for beneficiaries who (1) are confined to home and (2) need either skilled nursing care on an intermittent basis or physical or speech language therapy  After establishing such eligibility, the continuing need for occupational therapy services may extend the eligibility period  Covered services include part-time or intermittent nursing care, physical or occupational therapy or speech language pathology services, medical social services, home health aide services, and medical supplies and durable medical equipment  The services must be provided under a plan of care established by a physician, and the plan must be reviewed by the physician at least every 60 days  There is no beneficiary cost sharing for home health services (though some other Part B services provided in connection with the visit, such as durable medical equipment, may be subject to cost-sharing charges)  Home health services are covered under both Medicare Parts A and B  There are special eligibility requirements and benefit limits for home health services furnished under Part A to beneficiaries who are enrolled in both Parts A and B  For such a beneficiary, Part A pays for only postinstitutional home health services furnished for up to 100 visits during a spell of illness, while Part B covers any medically necessary home health services that exceed the 100-visit limit, as well as medically necessary home health services that do not qualify as "postinstitutional " For beneficiaries enrolled in only Part A or only Part B, the requirements described above do not apply  Part A or Part B, as applicable, covers all medically necessary episodes of home health care, without a visit limit, regardless of whether the episode follows a hospitalization  Regardless of whether the beneficiary is enrolled in Part A only, in Part B only, or in both parts, the scope of the Medicare home health benefit is the same, Medicare's payments to HHAs are calculated using the same methods, and beneficiaries have no cost-sharing  Home health services are paid under a home health PPS, based on 60-day episodes of care; a patient may have an unlimited number of episodes  The physician's certification of an initial 60-day episode of home health must be supported by a face-to-face encounter with the patient related to the primary reason that the patient needs home health services  Under the PPS, for episodes with five or greater visits, a nationwide base payment amount is adjusted by differences in wages (using the hospital wage index)  This amount is then adjusted for case mix using the applicable Home Health Resource Group (HHRG) to which the beneficiary has been assigned  The HHRG applicable to a beneficiary is determined following an assessment of the patient's condition and care needs using the Outcome and Assessment Information Set (OASIS); there are 153 HHRGs  For episodes with four or fewer visits, the PPS reimburses the provider for each visit performed  Further payment adjustments may be made for services provided in rural areas, outlier visits (for extremely costly patients), a partial episode for beneficiaries that have an intervening event during their episode, or an agency's failure to submit quality data to CMS  Since January 1, 2016, home health agencies in nine states are being reimbursed under a home health value-based purchasing (HHVBP) model  These home health agencies can receive increased or decreased home health reimbursements depending on their performance across certain quality measures  Individuals with end-stage renal disease (ESRD) are eligible for all services covered under Parts A and B  Kidney transplantation services, to the extent they are inpatient hospital services, are subject to the inpatient hospital PPS and are reimbursed by both Parts A and B  However, kidney acquisition costs are paid on a reasonable cost basis under Part A  Dialysis treatments, when an individual is admitted to a hospital, are covered under Part A  Part B covers their dialysis services, drugs, biologicals (including erythropoiesis stimulating agents used in treating anemia as a result of ESRD), diagnostic laboratory tests, and other items and services furnished to individuals for the treatment of ESRD  In effect since January 1, 2011, the ESRD prospective payment system (PPS) makes no payment distinction as to the site where renal dialysis services are provided  With the implementation of the ESRD PPS, Medicare dialysis payments provide a single "bundled" payment for Medicare renal dialysis services that includes (1) items and services included in the former payment system's base rate as of December 31, 2010; (2) erythropoiesis stimulating agents (ESAs) for the treatment of ESRD; (3) other drugs and biologicals for which payment was made separately (before bundling); and (4) diagnostic laboratory tests and other items and services furnished to individuals for the treatment of ESRD  The system is case-mix adjusted based on factors such as patient weight, body mass index, comorbidities, length of time on dialysis, age, race, ethnicity, and other appropriate factors as determined by the Secretary  Under the ESRD Quality Incentive Program, dialysis facilities that fail to meet certain performance standards receive reduced payments  Medicare Part B covers physicians' services, outpatient hospital services, durable medical equipment, and other medical services  Initially, over 98% of the eligible population voluntarily enrolled in Part B, but in recent years the percentage has fallen to about 91%  About 89% of enrollees in original (FFS) Medicare use Part B services during a year  The program generally pays 80% of the approved amount (most commonly, a fee schedule or other predetermined amount) for covered services in excess of the annual deductible ($185 in 2019)  The beneficiary is liable for the remaining 20%  Most providers and practitioners are subject to limits on amounts they can bill beneficiaries for covered services  For example, physicians and some other practitioners may choose whether or not to accept "assignment" on a claim  When a physician signs a binding agreement to accept assignment for all Medicare patients, the physician accepts the Medicare payment amount as payment in full and can bill the beneficiary only the 20% coinsurance plus any unmet deductible  The physician agrees to accept assignment on all Medicare claims in a given year and is referred to as a "participating physician " There are several advantages to being a participating provider, including higher payment under the Medicare fee schedule, a lower beneficiary co-payment, and automatic forwarding of Medigap claims  Physicians who do not agree to accept assignment on all Medicare claims in a given year are referred to as nonparticipating physicians  Nonparticipating physicians may or may not accept assignment for a given service  If they do not, they may charge beneficiaries more than the fee schedule amount on nonassigned claims; however, these "balance billing" charges are subject to certain limits  Alternatively, physicians may choose not to accept any Medicare payment and enter into private contracts with their patients where no Medicare restrictions on payment or balance billing apply; however, this requires that physicians "opt out" of Medicare for two years  For some providers, such as nurse practitioners and physician assistants, assignment is mandatory; these providers can only bill the beneficiary the 20% coinsurance and any unmet deductible  For other Part B services, such as durable medical equipment, assignment is optional; for these services, applicable providers may bill beneficiaries for amounts above Medicare's recognized payment level and may do so without limit  Medicare Part B covers medically necessary physician services and medical services provided by some nonphysician practitioners  Covered nonphysician practitioner services include, but are not limited to, those provided by physician assistants, nurse practitioners, certified registered nurse anesthetists, and clinical social workers  Certain limitations apply for services provided by chiropractors and podiatrists  Beneficiary cost sharing is typically 20% of the approved amount, although most preventive services require no coinsurance from the beneficiary  A number of Part B services are paid under the Medicare physician fee schedule (MPFS), including services of physicians, nonphysician practitioners, and therapists  There are over 7,000 service codes under the MPFS  The fee schedule assigns relative values to each service code  These relative values reflect physician work (based on time, skill, and intensity involved), practice expenses (e g , overhead and nonphysician labor), and malpractice expenses  The relative values are adjusted for geographic variations in the costs of practicing medicine  These geographically adjusted relative values are converted into a dollar payment amount by a national conversion factor  Annual updates to payments are determined through changes in the conversion factor  MACRA made several fundamental changes to how Medicare pays for physician and practitioner services by (1) changing the methodology for determining the annual updates to the conversion factor, (2) establishing a merit-based incentive payment system (MIPS) to consolidate and replace several existing incentive programs and to apply value and quality adjustments to the MPFS, and (3) establishing the development of, and participation in, alternative payment models (APMs)  Prior to MACRA, the SGR system, which had been in place since BBA 97, tied annual updates to the Medicare fee schedule to cumulative Part B expenditure targets  MACRA repealed the SGR methodology, established annual fee schedule updates in the short term, and put in place a new method for determining updates thereafter  As a result of the MACRA changes, the update to physician payments under the MPFS was 0% from January 2015 through June 2015; for the remainder of that year—July 2015 through December 2015—the payments were increased by 0 5%  In each of the next four years, 2016 through 2019, the payments were to increase by 0 5% each year; however, the BBA 18 reduced the 2019 update to 0 25%  For the next six years, from 2020 through 2025, the payment update will be 0%  In addition to changes to the annual update, MACRA established two pathways for payment reform, collectively referred to as the Quality Payment Program (QPP)  Medicare payment to all physicians and other practitioners will be determined by which conditions of the QPP, either MIPS or APM, the participant satisfies  The MIPS is a new program that remains based on FFS rates but combines four categories of performance measures (quality of care, cost/resource use, clinical practice improvement activities, and promoting interoperability) into a single adjustment to the base MPFS payment  Following several years of data collection and feedback on measures, the MIPS adjustments will affect actual payments for the first time in 2019  In contrast, qualified advanced APMs are intended to be alternatives to FFS, incorporating new approaches to paying for medical care that reward quality and efficiency while de-emphasizing the number of services billed (volume of care)  Proposed advanced APMs are evaluated by an ad hoc committee (the Physician-Focused Payment Models Technical Advisory Committee), which provides comments and recommendations to the Secretary as to whether new payment models meet the criteria of APMs  For 2019, there are 13 advanced APMs under the QPP, though not all are available to all physicians and practitioners, as some are restricted to certain special services (e g , oncology care, joint replacement) or geographic locations (e g , Vermont's Medicare ACO Initiative, Maryland's Total Cost of Care Model)  MACRA established incentives to make APMs more attractive than MIPS  First, qualifying participants in advanced APMs are eligible for an annual prepaid bonus (paid 2019-2024)  Second, beginning in 2026, there will be two update factors, one for items and services furnished by a participant in an advanced APM and another for those electing to remain in the modified FFS payment system (MIPS) that do not participate in an advanced APM  The update factor for the advanced APM participants will be 0 75%, and the update factor for MIPS will be 0 25%, causing a difference between the payment levels that will grow over time  Medicare covers medically necessary outpatient physical and occupational therapy and speech-language pathology services  Beginning in 1997 and for many years subsequently but intermittently, beneficiaries faced limits ( therapy caps ) on how much Medicare would pay for outpatient therapy services in a calendar year  BBA 18 permanently repealed the outpatient therapy caps beginning January 1, 2018, and established a requirement that therapy services exceeding $3,000 would trigger a manual medical review (MMR) of the medical necessity of these services, in years 2018-2028  Beginning with 2029, the annual MMR threshold limit is to be increased by the percentage increase in the MEI, and it is to be applied separately for (1) physical therapy services and speech-language pathology services combined and (2) occupational therapy services  Medicare statute prohibits payments for covered items and services that are "not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member," which would effectively exclude the coverage of preventive and screening services  However, Congress has explicitly added and expanded Medicare coverage for a number of such services through legislation, including through MMA, MIPPA, and ACA  Under current law, if a preventive service is recommended for use by the U S  Preventive Services Task Force (USPSTF, an independent evidence-review panel) and Medicare covers the service, all cost sharing must be waived  Also, the Secretary may add coverage of a USPSTF-recommended service that is not already covered  Coverage for preventive and screening services currently includes, among other services, (1) a "welcome to Medicare" physical exam during the first year of enrollment in Part B and an annual visit and prevention plan thereafter; (2) flu vaccine (annual), pneumococcal vaccine, and hepatitis B vaccine (for persons at high risk); (3) screening tests for breast, cervical, prostate, and colorectal cancers; (4) screening for other conditions such as depression, alcohol misuse, heart disease, glaucoma, and osteoporosis; and (5) intensive behavioral therapy for heart disease and for obesity  Payments for these services are provided under the physician fee schedule and/or the clinical laboratory fee schedule  Part B covers outpatient clinical laboratory tests, such as certain blood tests, urinalysis, and some screening tests, provided by Medicare-participating laboratories  These services may be furnished by labs located in hospitals and physician offices, as well as by independent labs  Beneficiaries have no co-payments or deductibles for covered clinical lab services  From 1984 until recently, payments for outpatient clinical laboratory services were made on the basis of the Medicare clinical laboratory fee schedule (CLFS), which set payment amounts as the lesser of the amount billed, the local fee for a geographic area, or a national limit amount  Most clinical lab services were paid at the national limit amount  The national limits were set at a percentage (74%) of the median of all local fee schedule amounts for each laboratory test code; therefore, fee schedule amounts may differ by region  In general, annual increases in clinical lab fees have been based on the percentage change in the CPI-U  However, since 1987, Congress has specified lower updates  Beginning in 2014, with certain exceptions, laboratory tests provided in hospital outpatient departments are no longer paid separately under the CLFS and are instead included in the OPPS payments  PAMA introduced a new method for determining clinical laboratory payments and required CMS to base Medicare CLFS reimbursement on reported private insurance payment amounts  Medicare has been using weighted median private insurer rates to calculate Medicare payment rates for laboratory tests paid under the CLFS since January 1, 2018  These payment rates are national and do not vary by geographic area  Part B also covers diagnostic nonlaboratory x-ray tests and other diagnostic tests, as well as x-ray, radium, and radioisotope therapy  Generally, these services are paid for under the physician fee schedule, with beneficiaries responsible for a 20% coinsurance payment  Medicare covers a wide variety of equipment and devices under the heading of durable medical equipment (DME), prosthetics, and orthotics (PO) if they are medically necessary and are prescribed by a physician  DME is defined as equipment that (1) can withstand repeated use, (2) has an expected life of at least three years (effective for items classified as DME after January 1, 2012), (3) is used primarily to serve a medical purpose, (4) is not generally useful in the absence of an illness or injury, and (5) is appropriate for use in the home  DME includes such items as hospital beds, wheelchairs, blood glucose monitors, and oxygen and oxygen equipment  It also includes related supplies (S), such as drugs and biologics that are necessary for the effective use of the product  Prosthetics (P) are items that replace all or part of a body organ or its function, such as colostomy bags, pacemakers, and artificial eyes, arms, or legs  Orthotics (O) are braces that support a weak or deformed body member, such as leg or back braces  Except in competitive bidding areas (CBAs, described below), Medicare pays for most durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) based on fee schedules  Medicare pays 80% of the lower of the supplier's charge for the item or the fee schedule amount  The beneficiary is responsible for the remaining 20%  In general, fee schedule amounts are updated each year by a (1) measure of price inflation, and (2) a measure of economy-wide productivity, which may result in lower fee schedule amounts from one year to the next  Since 2016, the fee schedule rates that applied outside of competitive bidding areas for certain DMEPOS have been reduced based on price information from the competitive bidding program  The reductions were phased in during 2016, and fully phased in starting in January 2017  In response to concerns that the adjusted rates were too low, the Secretary again applied the phase-in rate for rural and noncontiguous areas not subject to competitive bidding starting in June 2018  Currently, two different fee schedules apply outside of CBAs  First, in rural or noncontiguous areas, the fee schedule is a 50/50 blend of the fee schedule with and without the reductions based on information from competitive bidding (i e , the phase-in methodology)  Second, in nonrural and contiguous areas, the fee schedule amounts are fully adjusted by information from the competitive bidding program  Numerous studies and investigations indicated that Medicare paid more for certain items of DME and PO than some other health insurers and some retail outlets  Such overpayments were attributed, in part, to the fee schedule mechanism of payment  MMA required the Secretary to establish a Competitive Acquisition Program for certain DMEPOS in specified areas  Instead of paying for medical equipment based on a fee schedule established by law, payment for items in competitive bidding areas was based on the supplier bids  The program started in 9 metropolitan areas in January 2011 and had expanded to 130 competitive bidding areas in 2018  However, the program has been suspended while a new bidding methodology is established  During the gap, the payments for previously competitively bid items in competitive bidding areas will be the amounts that applied on December 31, 2018, increased, yearly, by a measure of inflation  Certain specified outpatient prescription drugs and biologics are covered under Medicare Part B  (However, most outpatient prescription drugs are covered under Part D, discussed below ) Covered Part B drugs and biologics include drugs furnished incident to physician services, immunosuppressive drugs following a Medicare-covered organ transplant, erythropoietin for treatment of anemia for individuals with ESRD when not part of the ESRD composite rate, oral anticancer drugs (provided they have the same active ingredients and are used for the same indications as chemotherapy drugs that would be covered if furnished incident to physician services), certain vaccines under selected conditions, and drugs administered through DME  Generally, Medicare reimburses physicians and other providers, such as hospital outpatient clinics, for covered Part B drugs and biologics at 106% of the volume weighted average sales price of all drugs billed under the same billing code, although some Part B drugs, such as those administered through DME, are reimbursed at 95% of the drug's average wholesale price  Health care providers also are paid separately for administering Medicare Part B drugs  Medicare pays 80% of the amount paid to providers, and beneficiaries are responsible for the remaining 20%  A hospital outpatient is a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient  Generally, payments under the hospital outpatient prospective payment system (OPPS) cover the operating and capital-related costs that are directly related and integral to performing a procedure or furnishing a service on an outpatient basis  These payments cover services such as the use of an operating suite, treatment, procedure, or recovery room; use of an observation bed as well as anesthesia; certain drugs or pharmaceuticals; incidental services; and other necessary or implantable supplies or services  Payments for services such as those provided by physicians and other professionals as well as therapy and clinical diagnostic laboratory services, among others, are separate  Under the OPPS, the unit of payment for acute care hospitals is the individual service or procedure as assigned to an ambulatory payment classification (APC)  To the extent possible, integral services and items (excluding physician services paid under the physician fee schedule) are bundled within each APC  Specified new technologies are assigned to "new technology APCs" until clinical and cost data are available to permit assignment into a "clinical APC " Medicare's hospital outpatient payment is calculated by multiplying the relative weight associated with an APC by a conversion factor  For most APCs, 60% of the conversion factor is geographically adjusted by the wage index used for the inpatient prospective payment system  Except for new technology APCs, each APC has a relative weight that is based on the median cost of services in that APC  The OPPS also includes pass-through payments for new technologies (specific drugs, biologicals, and devices) and payments for outliers  The Medicare Payment Advisory Commission (MedPAC) has recommended site-neutral payment policies that base payments on the resources needed to provide high-quality care in the most efficient setting  The Bipartisan Budget Act of 2015 (BBA 15; P L  114-74 ) gave CMS the authority to add new restrictions on Medicare payments for services furnished in provider-based off-campus hospital outpatient departments (HOPDs) to address discrepancies between payments under the MPFS and the OPPS for similar services  In its 2019 OPPS Final Rule, CMS explicitly applies the site-neutral policy to clinic visits, the most commonly billed service in hospital outpatient departments  An ambulatory surgical center (ASC) is a distinct entity that furnishes outpatient surgical procedures to patients who do not require an overnight stay after the procedure  According to MedPAC, most ASCs are freestanding facilities rather than part of a larger facility, such as a hospital  Medicare covers surgical and medical services performed in an ambulatory surgical center that are (1) commonly performed on an inpatient basis but may be safely performed in an ASC; (2) not of a type that are commonly performed or that may be safely performed in physicians' offices; (3) limited to procedures requiring a dedicated operating room or suite and generally requiring a postoperative recovery room or short-term (not overnight) convalescent room; and (4) not otherwise excluded from Medicare coverage  Medicare pays for surgery-related facility services provided in ASCs using a prospective payment system based on the OPPS  (Associated physician fees are paid for separately under the physician fee schedule ) Each of the approximately 3,500 procedures approved for payment in an ASC is classified into an APC group on the basis of clinical and cost similarity  The ASC system primarily uses the same payment groups as the OPPS; however, ASC payment rates are generally lower  The ASC weights are scaled (reduced) to account for the different mix of services in an ASC, and the ASC conversion factor (the base payment amount) is lower  A different payment method is used to set ASC payment for office-based procedures, separately payable radiology services, separately payable drugs, and device-intensive procedures  In addition, separate payments are made for certain ancillary items and services when they are integral to surgical procedures, including corneal tissue acquisition, brachytherapy sources, certain radiology services, many drugs, and certain implantable devices  The application of the site-neutral payment policy to clinic visits also affects such payments to ASCs (see discussion above)  Medicare Part B covers emergency and nonemergency ambulance services to or from a hospital, a critical access hospital, a skilled nursing facility, or a dialysis facility for End-Stage Renal Disease (ESRD) beneficiaries who require dialysis when other modes of transportation could endanger the Medicare beneficiary's health  In most cases, the program covers 80% of the allowed amount for the service, and the beneficiary is responsible for the remaining 20%  Generally, ambulance services are covered if (1) transportation of the beneficiary occurs; (2) the beneficiary is taken to an appropriate location (generally, the closest appropriate facility); (3) the ambulance service is medically necessary (other forms of transportation are contraindicated); (4) the ambulance provider or supplier meets state licensing requirements; and (5) the transportation is not part of a Medicare Part A covered stay  Medicare covers both scheduled and nonscheduled nonemergency transports if the beneficiary is bed-confined or meets other medical necessity criteria  Medicare may also cover emergency ambulance transportation by airplane or helicopter if the beneficiary's location is not easily reached by ground transportation or if long distance or obstacles, such as heavy traffic, would prevent the individual from obtaining needed care  Medicare pays for ambulance services according to a national fee schedule  The fee schedule establishes seven categories of ground ambulance services and two categories of air ambulance services  Medicare pays for different levels of ambulance services, which reflect the staff training and equipment required to meet the patient's medical condition or health needs  Generally, basic life support is provided by emergency medical technicians (EMTs)  Advanced life support is provided by EMTs with advanced training or by paramedics  Some rural ground and air ambulance services may qualify for increased payments  Also, ambulance providers that are CAHs, or that are entities that are owned and operated by a CAH, are paid on a reasonable-cost basis rather than the fee schedule if they are the only ambulance provider within a 35-mile radius  Medicare covers Part B services in rural health clinics (RHCs) and federally qualified health centers (FQHCs) provided by (1) physicians and specified nonphysician practitioners; (2) visiting nurses for homebound patients in home health shortage areas; (3) registered dieticians or nutritional professionals for diabetes training and medical nutrition therapy; and (4) others, as well as certain drugs administered by a physician or nonphysician practitioner  RHCs are paid based on an "all-inclusive" cost-based rate per beneficiary visit subject to a per visit upper limit, adjusted annually for inflation  For cost-reporting periods that began on or after October 1, 2014, FQHCs are paid a base payment rate per visit (with a limit, in most cases, of one billable visit per day) under a PPS methodology  Each FQHC's PPS rate is adjusted based on the location where the service is furnished using geographic adjustment factors, which are the geographic practice cost indices (GPCI) used in Medicare's physician fee schedule (MPFS)  This rate is increased by 34% for new patients (those not seen in the FQHC organization within the past three years)  The 34% increase also applies when a beneficiary receives a comprehensive initial Medicare visit (an initial preventive physician examination or an initial annual wellness visit) or a subsequent annual wellness visit  Effective January 1, 2017, the FQHC PPS base rate is updated annually using an FQHC-specific market basket  Medicare's payment to the FQHC is equal to 80% of the lesser of the adjusted PPS rate or the FQHC's actual charges associated with the visit, and the beneficiary is responsible for a 20% coinsurance  Medicare Advantage (MA) is an alternative way for Medicare beneficiaries to receive covered benefits  Under MA, private health plans are paid a per-person amount to provide all Medicare covered benefits (except hospice) to beneficiaries who enroll in their plan  Medicare beneficiaries who are eligible for Part A, enrolled in Part B, and do not have ESRD are eligible to enroll in an MA plan if one is available in their area  Some MA plans may choose their service area (local MA plans), while others agree to serve one or more regions defined by the Secretary (regional MA plans)  In 2019, nearly all Medicare beneficiaries have access to an MA plan and approximately a third of beneficiaries are enrolled in one  Private plans may use different techniques to influence the medical care used by enrollees  Some plans, such as health maintenance organizations (HMOs), may require enrollees to receive care from a restricted network of medical providers; enrollees may be required to see a primary care physician who will coordinate their care and refer them to specialists as necessary  Other types of private plans, such as private fee-for-service (PFFS) plans, may look more like original Medicare, with fewer restrictions on the providers an enrollee can see and minimal coordination of care  In general, MA plans offer additional benefits or require smaller co-payments or deductibles than original Medicare  Sometimes beneficiaries pay for these additional benefits through a higher monthly premium, but sometimes they are financed through plan savings  The extent of extra benefits and reduced cost sharing varies by plan type and geography  However, MA plans are seen by some beneficiaries as an attractive alternative to more expensive supplemental insurance policies found in the private market  By contract with CMS, a plan agrees to provide all required services covered in return for a capitated monthly payment adjusted for the demographics and health history of their enrollees  The same monthly payment is made regardless of how many or few services a beneficiary actually uses  In general, the plan is at-risk if costs, in the aggregate, exceed program payments; conversely, the plan can retain savings if aggregate costs are less than payments  Payments to MA plans are based on a comparison of each plan's estimated cost of providing Medicare covered services (a bid) relative to the maximum amount the federal government will pay for providing those services in the plan's service area (a benchmark)  If a plan's bid is less than the benchmark, its payment equals its bid plus a rebate  The size of the rebate is dependent on plan quality and ranges from 50% to 70% of the difference between the bid and the benchmark  The rebate must be returned to enrollees in the form of additional benefits, reduced cost sharing, reduced Part B or Part D premiums, or some combination of these options  If a plan's bid is equal to or above the benchmark, its payment will be the benchmark amount and each enrollee in that plan will pay an additional premium, equal to the amount by which the bid exceeds the benchmark  The MA benchmarks are determined through statutorily specified formulas that have changed over time  Since BBA 97, formulas have increased the benchmark amounts, in part, to encourage plan participation in all areas of the country  As a result, however, the benchmark amounts (and plan payments) in some areas have been higher than the average cost of original FFS Medicare  The ACA changed the way benchmarks are calculated by tying them closer to (or below) spending in FFS Medicare, and adjusting them based on plan quality  In a recent analysis, MedPAC found that "over the past few years, plan bids and payments have come down in relation to FFS spending while MA enrollment continues to grow  The pressure of lower benchmarks has led to improved efficiencies and more competitive bids that enable MA plans to continue to increase enrollment by offering benefits that beneficiaries find attractive " In 2006, the MA program began to offer MA regional plans  Regional MA plans must agree to serve one or more regions designated by the Secretary  There are 26 MA regions consisting of states or groups of states  Regional plan benchmarks include two components: (1) a statutorily determined amount (comparable to benchmarks described above) and (2) a weighted average of plan bids  Thus, a portion of the benchmark is competitively determined  Similar to local plans, plans with bids below the benchmark are given a rebate, while plans with bids above the benchmark require an additional enrollee premium  In general, MA eligible individuals may enroll in any MA plan that serves their area  However, some MA plans may restrict their enrollment to beneficiaries who meet additional criteria  For example, employer-sponsored MA plans are generally only available to the retirees of the company sponsoring the plan  In addition, Medicare Special Needs Plans (SNPs) are a type of coordinated care MA plan that exclusively enrolls, or enrolls a disproportionate percentage of, special needs individuals  Special needs individuals are any MA eligible individuals who are either institutionalized as defined by the Secretary, eligible for both Medicare and Medicaid, or have a severe or disabling chronic condition and would benefit from enrollment in a specialized MA plan  Medicare Part D provides coverage of outpatient prescription drugs to Medicare beneficiaries who choose to enroll in this optional benefit  (As previously discussed, Part B provides limited coverage of some outpatient prescription drugs ) In 2019, about 47 million (about 77%) of eligible Medicare beneficiaries are estimated to be enrolled in a Part D plan  Prescription drug coverage is provided through private prescription drug plans (PDPs), which offer only prescription drug coverage, or through Medicare Advantage prescription drug plans (MA-PDs), which offer prescription drug coverage that is integrated with the health care coverage they provide to Medicare beneficiaries under Part C  Plans must meet certain minimum requirements; however, there are significant variations among them in benefit design, including differences in premiums, drugs included on plan formularies, and cost sharing for particular drugs  Part D prescription drug plans are required to offer either "standard coverage" or alternative coverage that has actuarially equivalent benefits  In 2019, "standard coverage" has a $415 deductible and a 25% coinsurance for costs between $415 and $3,820  From this point, there is reduced coverage until the beneficiary has out-of-pocket costs of $5,100 (an estimated $8,139 54 in total spending); this coverage gap has been labeled the "doughnut hole " Once the beneficiary reaches the catastrophic limit, the program pays all costs except for the greater of 5% coinsurance or $3 40 for a generic drug and $8 50 for a brand-name drug  As required by the ACA, in 2010, Medicare sent a tax-free, one-time $250 rebate check to each Part D enrollee who reached the doughnut hole  Additionally, starting in 2011, the coverage gap is being gradually reduced each year  Under the ACA, the coverage gap for both brand-name and generic drugs was to be eliminated in 2020, but Congress moved up the date to 2019 for brand-name drugs as part of BBA 18  In 2019, a 70% discount is provided by drug manufacturers and Medicare pays an additional 5% of the cost of brand-name drugs dispensed during the coverage gap  In 2019, Medicare also pays 63% of the cost of generic drugs dispensed during the coverage gap and enrollees pay 37%  (See Figure 2  ) By 2020, through a combination of manufacturer discounts and increased Medicare coverage, Part D enrollees will be responsible for 25% of the costs for brand-name and generic drugs in the coverage gap (the same as during the initial coverage period)  Most plans offer actuarially equivalent benefits rather than the standard package, including alternatives such as reducing or eliminating the deductible, or using tiered cost sharing with lower cost sharing for generic drugs  Medicare's payments to plans are determined through a competitive bidding process, and enrollee premiums are tied to plan bids  Plans are paid a risk-adjusted monthly per capita amount based on their bids during a given plan year  Part D plan sponsors determine payments for drugs and are expected to negotiate prices  The federal government is prohibited from interfering in the price negotiations between drug manufacturers, pharmacies, and plans (the so-called "non-interference clause")  Part D also provides enhanced coverage for low-income enrolled individuals, such as persons who previously received drug benefits under Medicaid (known as "dual eligibles"—enrollees in both Medicare and Medicaid)  Additionally, certain persons who do not qualify for Medicaid, but whose incomes are below 150% of poverty, may also receive assistance for some portion of their premium and cost-sharing charges  The MMA included significant incentives for employers to continue to offer coverage to their retirees by providing a 28% federal subsidy  In 2019, the maximum potential subsidy per covered retiree is $2,264 for employers or unions offering drug coverage that is at least actuarially equivalent (called "creditable" coverage) to standard coverage  Employers or unions may select an alternative option (instead of taking the subsidy) with respect to Part D, such as electing to pay a portion of the Part D premiums  They may also elect to provide enhanced coverage, though this has some financial consequences for the employer or union  Alternatively, employers or unions may contract with a PDP or MA-PD to offer the coverage or become a Part D plan sponsor themselves for their retirees  A variety of public and private entities are involved in carrying out Medicare administrative and oversight functions  CMS, an agency within HHS, has primary operational responsibilities  Such responsibilities include managing program finances, developing policies and regulations, setting payment rates, and developing the program's information-technology infrastructure  CMS conducts its activities through its headquarters and 10 regional offices  The Social Security Administration, however, enrolls beneficiaries into the program and issues Medicare beneficiary cards  CMS also contracts with various private entities, including private health insurance companies, to help administer the program  For example, Medicare Administrative Contractors (MACs) process and pay Parts A and B reimbursement claims, enroll providers and suppliers, educate providers and suppliers on billing requirements, support appeal processes, and answer provider and supplier inquiries through call centers, as well as other activities  Qualified Independent Contractors (QICs) perform second-level reviews on appeals initially reviewed by MACs  Medicare's quality assurance activities are primarily handled by State Survey Agencies and Quality Improvement Organizations (QIOs), which operate in all states and the District of Columbia, Puerto Rico, and the U S  Virgin Islands  The State Survey Agencies are responsible for inspecting Medicare provider facilities (e g , nursing homes, home health agencies, and hospitals) to ensure that they are in compliance with federal safety and quality standards referred to as Conditions (or Requirements) of Participation  Alternatively, some types of providers, including hospitals, may receive certification through private accrediting agencies, such as the Joint Commission  QIOs are mostly private, not-for-profit organizations that monitor the quality of care delivered to Medicare beneficiaries and educate providers on the latest quality-improvement techniques  Medicare program integrity activities, such as audits, provider education, medical review, and predictive data analysis, also are carried out by a variety of government and private entities  For example, the Center for Program Integrity within CMS works together with the U S  Department of Justice (DOJ) and the HHS Office of Inspector General (OIG) to identify and prevent fraud, waste, and abuse in Medicare  CMS also works with private contractors to carry out certain program-integrity functions  Unified Program Integrity Contractors (UPICs) perform integrity-related activities including data analysis to identify potentially fraudulent claims (bills) for Medicare Parts A and B, home health and hospice services, and DME  Similarly, the National Benefit Integrity Medicare Drug Integrity Contractor (MEDIC) is responsible for identifying and investigating fraud, waste, and abuse in Medicare Advantage and Part D  When appropriate, the UPICs and MEDIC work with and refer cases to law enforcement, including OIG and DOJ  In addition, Recovery Audit Contractors (RACs) are responsible for identifying improper Medicare payments, including both underpayments and overpayments, and for recouping any overpayments made to providers  Each year, the Comprehensive Error Rate Testing (CERT) program quantifies a national improper Medicare payment rate by examining a random sample of claims  In turn, the Supplemental Medical Review Contractor targets medical reviews in areas where OIG, RACs, and CERT have identified vulnerabilities and/or questionable billing patterns to identify ways to lower improper payment rates  As required by the ACA, the Center for Medicare and Medicaid Innovation (CMMI) was established in January 2011 to test and evaluate innovative payment and service delivery models to reduce program expenditures under Medicare  Examples of these models include providing payment incentives for groups of doctors, hospitals, and other health care providers (Accountable Care Organizations, or ACOs) to coordinate the services they provide to Medicare beneficiaries; bundling payments for services provided in different settings during a beneficiary's episode of care; and reimbursing health providers based on the quality of care rather than on the volume of services  CMMI also plays an important role in developing and implementing the new physician payment models required by MACRA  Medicare beneficiary education and outreach duties are shared between CMS and the Social Security Administration  Each year, CMS mails out a "Medicare and You" handbook to beneficiaries, which provides information on their benefits for the upcoming year  Additional educational materials and responses to frequently asked questions may be found on the CMS-maintained "Medicare gov" website, and beneficiaries may call a CMS-operated 1-800 number for assistance with specific questions and help with selecting and enrolling in a Medicare Advantage and/or Part D plan  A Medicare beneficiary ombudsman is also available to provide assistance to Medicare consumers with their complaints, grievances, and requests  The Social Security Administration is responsible for notifying low-income Medicare beneficiaries about programs that may be able to assist them with their medical and prescription drug expenses  The Social Security Administration also provides general Medicare eligibility and enrollment information on its webpage and on Social Security benefit statements  Finally, CMS partners with community-based organizations, such as State Health Insurance Assistance Programs, in every state to provide educational resources and personalized assistance to Medicare beneficiaries  Medicare's financial operations are accounted for through two trust funds maintained by the Department of the Treasury—the Hospital Insurance (HI) trust fund for Part A and the Supplementary Medical Insurance (SMI) trust fund for Parts B and D  For beneficiaries enrolled in Medicare Advantage (Part C), payments are made on their behalf in appropriate portions from the HI and SMI trust funds  HI is primarily funded by payroll taxes, while SMI is primarily funded through general revenue transfers and premiums  (See Figure 3  ) The HI and SMI trust funds are overseen by a Board of Trustees that provides annual reports to Congress  The trust funds are accounting mechanisms  Income to the trust funds is credited to the fund in the form of interest-bearing government securities  Expenditures for services and administrative costs are recorded against the fund  These securities represent obligations that the government has issued to itself  As long as a trust fund has a balance, the Department of the Treasury is authorized to make payments for it from the U S  Treasury  Medicare expenditures are primarily paid for through mandatory spending—generally Medicare pays for all covered health care services provided to beneficiaries  Aside from certain constraints in HI described below, the program is not subject to spending limits  Additionally, most Medicare expenditures (aside from premiums paid by beneficiaries) are paid for by current workers through income taxes and dedicated Medicare payroll taxes, that is, current income is used to pay current expenditures  Medicare taxes paid by current workers are not set aside to cover their future Medicare expenses  The primary source of funding for Part A is payroll taxes paid by employees and employers  Each pays a tax of 1 45% on the employee's earnings; the self-employed pay 2 9%  Beginning in 2013, some higher-income employees pay higher payroll taxes  Unlike Social Security, there is no upper limit on earnings subject to the tax  Other sources of income include (1) interest on federal securities held by the trust fund, (2) a portion of federal income taxes that individuals pay on their Social Security benefits, and (3) premiums paid by voluntary enrollees who are not automatically entitled to Medicare Part A  Income for Part A is credited to the HI trust fund  Part A expenditures for CY2019 are estimated to reach approximately $330 billion  Revenue to the trust fund is expected to consist of about $285 billion in payroll tax income and another $38 billion in interest and other income  The Medicare Trustees project that in CY2019, the HI trust fund will incur a deficit of approximately $7 billion  As long as the HI trust fund has a balance, the Treasury Department is authorized to make payments for Medicare Part A services  To date, the HI trust fund has never run out of money (i e , become insolvent), and there are no provisions in the Social Security Act that govern what would happen if that were to occur  Part A expenditures exceeded HI income each year from 2008 through 2015, and the assets credited to the trust fund were drawn down to make up the deficit in those years  Although the HI trust fund accumulated small surpluses in 2016 and 2017, the Medicare Trustees estimate that, beginning in 2018, expenditures will outpace income in all future years, and project that the HI trust fund will become insolvent in 2026 (i e , the balance of the trust fund will reach $0)  At that time there would no longer be sufficient funds to fully cover Part A expenditures  Medicare Part B is financed primarily from federal general revenues and from beneficiary premiums, which are set at 25% of estimated per capita program costs for the aged  (The disabled pay the same premium as the aged ) Income for Part B is credited to the SMI trust fund  Total spending for Part B is estimated to reach about $368 billion in CY2019, with premiums financing about $98 billion of that amount and general revenues financing most of the rest  Most beneficiaries who enroll in Medicare Part B pay a monthly premium  Individuals receiving Social Security benefits have their Part B premium payments automatically deducted from their Social Security benefit checks  Due to a "hold-harmless" provision in the Social Security Act, an individual's Social Security check cannot decrease from one year to the next as a result of the annual Part B premium increase (except in the case of higher-income individuals subject to income-related premiums)  The 2019 monthly Part B premium is $135 50  However, about 3 5% of Medicare enrollees are protected by the hold-harmless provision and pay lower premium amounts because the dollar amount of the 2019 cost-of-living increase in their Social Security benefits was not sufficient to cover the full premium increase  Since 2007, higher-income Part B enrollees have paid higher premiums  In 2019, individuals whose modified adjusted gross income (AGI) exceeds $85,000 and each member of a couple filing jointly whose modified AGI exceeds $170,000 are subject to higher premium amounts  These higher-income premiums range from 35% to 85% of the value of Part B and affect about 5% of Medicare enrollees  (See Appendix B for 2019 Part B premiums and high-income thresholds ) Payments for spending under the Medicare Advantage program are made in appropriate portions from the HI and SMI trust funds  There is no separate trust fund for Part C  Medicare Part D is financed through a combination of beneficiary premiums and federal general revenues  In addition, certain transfers are made from the states  These transfers, referred to as "clawback payments," represent a portion of the amounts states could otherwise have been expected to pay for drugs under Medicaid if drug coverage for the dual eligible population had not been transferred to Part D  Part D revenues are credited to a separate Part D account within the SMI trust fund  In CY2019, total spending for Part D is estimated to reach approximately $98 billion, with about $71 billion of that amount paid for by general revenues, $16 billion from beneficiary premiums, and $12 billion from state transfers  In 2019, the base beneficiary premium is $33 19; however, beneficiaries pay different premiums depending on the plan they have selected and whether they are entitled to low-income premium subsidies  Additionally, beginning in 2011, higher income Part D enrollees pay higher premiums  (The income thresholds are the same as for Part B, as described above ) On average, beneficiary premiums are set at 25 5% of expected total Part D costs for basic coverage  The Budget Control Act of 2011 (BCA; P L  112-25 ) provided for increases in the debt limit and established procedures designed to reduce the federal budget deficit, including the creation of a Joint Select Committee on Deficit Reduction  The failure of the Joint Committee to propose deficit reduction legislation by its mandated deadline triggered automatic spending reductions ("sequestration" of mandatory spending and reductions in discretionary spending) in fiscal years 2013 through 2021  The American Taxpayer Relief Act of 2012 (ATRA; P L  112-240 ) delayed the automatic reductions by two months, while the Bipartisan Budget Act of 2013 (BBA; P L  113-67 ) extended sequestration for mandatory spending for an additional two years—through FY2023  In 2014, the President signed into law an amended version of S  25 ( P L  113-82 ), which included a provision to extend BCA's sequester of mandatory spending through FY2024  BBA 15 extended the sequestration of mandatory spending another year, through FY2025  Most recently, BBA 18 extended the BCA mandatory spending sequester through FY2027  Section 256(d) of the Balanced Budget and Emergency Deficit Control Act of 1985 (BBEDCA; P L  99-177 ) contains special rules for the Medicare program in the event of a sequestration  Among other things, it specifies that for Medicare, sequestration is to begin the month after the sequestration order has been issued  Therefore, as the sequestration order was issued March 2013, Medicare sequestration began April 1, 2013, and will continue through March 31, 2028  Under sequestration, Medicare's benefit structure generally remains unchanged; however, benefit related payments are subject to 2% reductions  In other words, most Medicare payments to health care providers, as well as to MA and Part D plans, are being reduced by 2%  Certain Medicare payments are exempt from sequestration and therefore not reduced  These exemptions include (1) Part D low-income subsidies, (2) the Part D catastrophic subsidy, and (3) Qualified Individual (QI) premiums  Some non-benefit related Medicare expenses, such as administrative and operational spending, are subject to higher reductions, 6 2% in 2019  While Medicare provides broad protection against the costs of many, primarily acute care, services, the program does not cover all services that may be used by its aged and disabled beneficiaries  In general, Medicare does not cover eyeglasses, hearing aids, dentures, or most long-term care services  Further, unlike most private insurance policies, it does not include an annual "catastrophic" cap on out-of-pocket spending on cost-sharing charges for services covered under Parts A and B (except for persons enrolled in Medicare Advantage plans)  Most Medicare beneficiaries have some coverage in addition to Medicare  The following are the main sources of additional coverage for Medicare enrollees: Medicare Advantage  Many MA plans offer services in addition to those covered under original Medicare, reduced cost sharing, or reduced Part B or D premiums  All MA plans have a catastrophic cap  Employer Coverage  Coverage may be provided through a current or former employer  In recent years, a number of employers have cut back on the scope of retiree coverage  Some have dropped such coverage entirely, particularly for future retirees  As noted earlier, the MMA attempted to stem this trend, at least for prescription drug coverage, by offering subsidies to employers who offer drug coverage, at least as good as that available under Part D  Medigap  Individual insurance policies that supplement fee-for-service Medicare are referred to as Medigap policies  Beneficiaries with Medigap insurance typically have coverage for a portion of Medicare's deductibles and coinsurance; they may also have coverage for some items and services not covered by Medicare  Individuals select from a set of standardized plans, though not all plans are offered in all states  Medicaid  Certain low-income Medicare beneficiaries also may be eligible for full or partial benefits under their state's Medicaid program  Individuals eligible for both Medicare and Medicaid are referred to as dual eligibles  The lowest-income dual eligibles qualify for full Medicaid benefits, so that the majority of their health care expenses are paid by either Medicare or Medicaid; Medicare pays first, with Medicaid picking up most of the remaining costs  In addition to full-benefit dual eligibles, state Medicaid programs pay Medicare premiums and some cost sharing for other partial dual eligibles, who have higher income than full-benefit dual eligibles but are still considered to have low income  Other Public Sources  Individuals may have additional coverage through the Department of Veterans Affairs, or TRICARE for military retirees eligible for Medicare (and enrolled in Part B)  In 2015, about 87% of Medicare beneficiaries had some form of additional coverage  Some persons may have had more than one type of additional coverage  Appendix A  Abbreviations Appendix B  2019 Medicare Beneficiary Costs

ground_truth: Medicare is a federal program that pays for covered health care services of qualified beneficiaries. It was established in 1965 under Title XVIII of the Social Security Act to provide health insurance to individuals 65 and older, and has been expanded over the years to include permanently disabled individuals under the age of 65. Medicare, which consists of four parts (A-D), covers hospitalizations, physician services, prescription drugs, skilled nursing facility care, home health visits, and hospice care, among other services. Generally, individuals are eligible for Medicare if they or their spouse worked for at least 40 quarters in Medicare-covered employment, are 65 years old, and are a citizen or permanent resident of the United States. Individuals may also qualify for coverage if they are a younger person who cannot work because they have a medical condition that is expected to last at least one year or result in death, or have end-stage renal disease (permanent kidney failure requiring dialysis or transplant). The program is administered by the Centers for Medicare & Medicaid Services (CMS) within the Department of Health and Human Services (HHS) and by private entities that contract with CMS to provide claims processing, auditing, and quality oversight services. In FY2019, the program is expected to cover approximately 61 million persons (52 million aged and 9 million disabled) at a total cost of about $772 billion. Spending under the program (except for a portion of administrative costs) is considered mandatory spending and is not subject to the annual appropriations process. Services provided under Parts A and B (also referred to as "original" or "traditional" Medicare) are generally paid directly by the government on a "fee-for-service" basis, using different prospective payment systems or fee schedules. Under Parts C and D, private insurers are paid a monthly "capitated" amount to provide enrollees with required benefits. Medicare is required to pay for all covered services provided to eligible persons, so long as specific criteria are met. Since 1965, the Medicare program has undergone considerable change. For example, during the 111th Congress, the Patient Protection and Affordable Care Act (ACA; P.L. 111-148 and P.L. 111-152) made numerous changes to the Medicare program that modified provider reimbursements, provided incentives to increase the quality and efficiency of care, and enhanced certain Medicare benefits. In the 114th Congress, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10) changed the method for calculating updates to Medicare payment rates to physicians and altered how physicians and other practitioners will be paid in the future. Projections of future Medicare expenditures and funding indicate that the program will place increasing financial demands on the federal budget and on beneficiaries. For example, the Hospital Insurance (Part A) trust fund is projected to become insolvent in 2026. Additionally, although the Supplementary Medical Insurance (Parts B and D) trust fund is financed in large part through federal general revenues and cannot become insolvent, associated spending growth is expected to put increasing strains on the country's competing spending priorities. As such, Medicare is expected to be a high-priority issue in the current Congress, and Congress may consider a variety of Medicare reform options ranging from further modifications of provider payment mechanisms to redesigning the entire program. This report provides a general overview of the Medicare program including descriptions of the program's history, eligibility criteria, covered services, provider payment systems, and program administration and financing. A list of commonly used acronyms, as well as information on beneficiary cost sharing, may be found in the appendixes.