II 

116TH CONGRESS 

1ST SESSION S. 966 

To amend title XVIII of the Social Security Act to modernize the physician 

self-referral prohibitions to promote care coordination in the merit-based 

incentive payment system and to facilitate physician practice participation 

in alternative payment models under the Medicare program, and for 

other purposes. 

IN THE SENATE OF THE UNITED STATES 

APRIL 1, 2019 

Mr. PORTMAN (for himself and Mr. BENNET) introduced the following bill; 

which was read twice and referred to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to modernize 

the physician self-referral prohibitions to promote care 

coordination in the merit-based incentive payment system 

and to facilitate physician practice participation in alternative payment models under the Medicare program, and 

for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Medicare Care Coordi5 nation Improvement Act of 2019’’. 


kjohnson on DSK79L0C42 with BILLS
2 

•S 966 IS

1 SEC. 2. MODERNIZATION OF LIMITATIONS ON PHYSICIAN 

2 SELF-REFERRAL. 

3 (a) FACILITATION OF PARTICIPATION IN ALTER4 NATIVE PAYMENT MODELS.— 

5 (1) IN GENERAL.—Section 1833 of the Social 

6 Security Act (42 U.S.C. 1395l) is amended— 

7 (A) in subsection (z), as added by section 

8 101(e)(2) of the Medicare Access and CHIP 

9 Reauthorization Act of 2015 (Public Law 114– 

10 10), by adding at the end the following para11 graph: 

12 ‘‘(5) WAIVER AUTHORITY.— 

13 ‘‘(A) IN GENERAL.—The provisions of sub14 section (f) of section 1899 shall apply with re15 spect to covered APM entities to the same ex16 tent and in the same manner as such provisions 

17 apply with respect to accountable care organiza18 tions under such section. 

19 ‘‘(B) COVERED APM ENTITIES.— 

20 ‘‘(i) IN GENERAL.—For purposes of 

21 subparagraph (A), the term ‘covered APM 

22 entity’ means, subject to clause (ii) of this 

23 subparagraph and subparagraph (C), each 

24 of the following: 


kjohnson on DSK79L0C42 with BILLS
3 

•S 966 IS

1 ‘‘(I) An eligible alternative pay2 ment entity as defined in paragraph 

3 (3)(D). 

4 ‘‘(II) An entity participating in 

5 an alternative payment model as de6 fined in paragraph (3)(C), including 

7 such participation that qualifies as a 

8 clinical practice improvement activity 

9 under section 1848(q)(2)(B)(iii)(VI). 

10 ‘‘(III) An entity participating in 

11 a physician-focused payment model 

12 for which comments and recommenda13 tions have, under subparagraph (C) of 

14 section 1868(c)(2), been submitted in15 dicating that such model meets the 

16 criteria described in subparagraph (A) 

17 of such section. 

18 ‘‘(IV) An entity participating in 

19 any other model that the Secretary 

20 determines is a covered APM entity 

21 for purposes of subparagraph (A), in22 cluding such a determination made 

23 pursuant to one or more physicians 

24 submitting a proposal to the Secretary 

25 for an alternative payment model. 


kjohnson on DSK79L0C42 with BILLS
4 

•S 966 IS

1 ‘‘(ii) INCLUSION OF CERTAIN ENTI2 TIES.—Such term may include an entity 

3 engaging in activities that the Secretary 

4 has determined constitute significant 

5 progress toward establishing a model re6 ferred to in any of subclauses (I) through 

7 (IV). Any waiver under this paragraph 

8 with respect to an entity described in the 

9 preceding sentence may only be approved 

10 for three years. 

11 ‘‘(C) CERTAIN REQUIREMENTS.—A model 

12 referred to in any of subclauses (I) through 

13 (IV) of subparagraph (B)(i) may not be consid14 ered a covered APM entity for purposes of sub15 paragraph (A) unless the model meets the re16 quirements described in section 

17 1877(b)(6)(B).’’; and 

18 (B) by redesignating subsection (z), as 

19 added by section 514(a) of the Medicare Access 

20 and CHIP Reauthorization Act of 2015 (Public 

21 Law 114–10), as subsection (aa). 

22 (2) CONFORMING AMENDMENT.—Section 

23 514(c)(1) of the Medicare Access and CHIP Reau24 thorization Act of 2015 (Public Law 114–10) is 


kjohnson on DSK79L0C42 with BILLS
5 

•S 966 IS

1 amended by striking ‘‘subsection (z)’’ and inserting 

2 ‘‘subsection (aa)’’. 

3 (b) EXCEPTION FACILITATING THE DEVELOPMENT

4 AND OPERATION OF ALTERNATIVE PAYMENT MODELS.— 

5 Section 1877(b) of the Social Security Act (42 U.S.C. 

6 1395nn(b)) is amended by adding at the end the following 

7 new paragraph: 

8 ‘‘(6) DEVELOPMENT AND OPERATION OF AL9 TERNATIVE PAYMENT MODELS.— 

10 ‘‘(A) IN GENERAL.—In the case of items 

11 and services furnished pursuant to an arrange12 ment that meets the requirements described in 

13 subparagraph (B) entered into for the purpose 

14 of developing or operating a covered APM enti15 ty (as defined in section 1833(z)(5)(B)), includ16 ing— 

17 ‘‘(i) an advanced alternative payment 

18 model described in section 1833(z) (includ19 ing a physician-focused payment model re20 ferred to in section 1868(c)); 

21 ‘‘(ii) a MIPS APM (as defined by the 

22 Secretary); and 

23 ‘‘(iii) any other alternative payment 

24 model that the Secretary may, by regula25 tion, specify. 


kjohnson on DSK79L0C42 with BILLS
6 

•S 966 IS

1 ‘‘(B) REQUIREMENTS.— 

2 ‘‘(i) IN GENERAL.—Subject to clause 

3 (ii), the requirements described in this sub4 paragraph with respect to an arrangement 

5 relating to an alternative payment model 

6 are as follows: 

7 ‘‘(I) The arrangement is in writ8 ing, identifies the services, items, or 

9 actions subject to the arrangement 

10 and is signed by the parties to the ar11 rangement. 

12 ‘‘(II) The arrangement includes a 

13 description of the alternative payment 

14 model. 

15 ‘‘(III) Under the arrangement 

16 written reports are submitted to the 

17 Secretary on a semi-annual basis on 

18 the progress achieved in the develop19 ment and operation of the alternative 

20 payment model. 

21 ‘‘(IV) The arrangement meets 

22 such other requirements as the Sec23 retary may impose by regulation as 

24 needed to protect against a significant 

25 risk of program or patient abuse. 


kjohnson on DSK79L0C42 with BILLS
7 

•S 966 IS

1 ‘‘(ii) CLARIFICATION.—The Secretary 

2 shall not prohibit or restrict an arrange3 ment from meeting the requirements de4 scribed in this subparagraph on the basis 

5 that the arrangement takes into account 

6 the volume or value of referrals if such ar7 rangement otherwise meets the require8 ments described in clause (i).’’. 

Æ 


kjohnson on DSK79L0C42 with BILLS