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[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 10136 Introduced in House (IH)]

<DOC>

118th CONGRESS
  2d Session
                               H. R. 10136

To amend title XVIII of the Social Security Act to align payment under 
  Medicare for specified surgical procedures with high-cost supplies 
     furnished in office-based facilities, and for other purposes.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                           November 15, 2024

  Mr. Bilirakis (for himself, Mr. Davis of Illinois, and Mr. Murphy) 
 introduced the following bill; which was referred to the Committee on 
   Energy and Commerce, and in addition to the Committee on Ways and 
 Means, for a period to be subsequently determined by the Speaker, in 
   each case for consideration of such provisions as fall within the 
                jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL

 
To amend title XVIII of the Social Security Act to align payment under 
  Medicare for specified surgical procedures with high-cost supplies 
     furnished in office-based facilities, and for other purposes.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Promoting Fairness for Medicare 
Providers Act of 2024''.

SEC. 2. ALIGNING PAYMENT UNDER MEDICARE FOR SPECIFIED HIGH SUPPLY COST 
              SURGICAL PROCEDURES FURNISHED IN OFFICE-BASED FACILITIES.

    (a) Coverage of Facility Services.--Section 1832(a)(2)(F) of the 
Social Security Act (42 U.S.C. 1395k(a)(2)(F)) is amended--
            (1) in the matter preceding clause (i), by striking 
        ``specified by the Secretary'';
            (2) in clause (i)--
                    (A) by inserting ``specified by the Secretary'' 
                before ``pursuant''; and
                    (B) at the end, by striking ``or'';
            (3) in clause (ii)--
                    (A) by inserting ``specified by the Secretary'' 
                before ``pursuant''; and
                    (B) at the end, by striking the semicolon and 
                inserting ``, or''; and
            (4) by adding at the end the following new clause:
                            ``(iii) that are specified high supply cost 
                        surgical procedures (as defined in section 
                        1834(aa)(4) with respect to a year (beginning 
                        with 2025) and furnished during such year in an 
                        office-based facility (as defined in section 
                        1834(aa)(5));''.
    (b) Payment Rules.--
            (1) Payment for facility services.--Section 1833(a)(1) of 
        the Social Security Act (42 U.S.C. 1395l(a)) is amended--
                    (A) by striking ``and (HH)'' and inserting 
                ``(HH)''; and
                    (B) by inserting before the semicolon at the end 
                the following ``, and (II) with respect to facility 
                services furnished in connection with a specified high 
                supply cost surgical procedure (as defined in section 
                1834(aa)(4)) with respect to a year (beginning with 
                2025) furnished to an individual in an office-based 
                facility (as defined in section 1834(aa)(5)) during 
                such year, the amounts paid shall be, subject to 
                section 1834(aa)(3), 80 percent of the payment amount 
                determined under section 1834(aa) for such facility 
                services furnished in connection with such procedure at 
                such office-based facility''.
            (2) Payment determination for specified high supply cost 
        surgical procedures furnished in office-based facilities.--
        Section 1834 of the Social Security Act (42 U.S.C. 1395l(a)) is 
        amended by adding at the end the following new subsection:
    ``(aa) Payment for Specified High Supply Cost Surgical Procedures 
Furnished in Office-Based Facilities.--
            ``(1) In general.--In the case of a specified high supply 
        cost surgical procedure furnished in an office-based facility 
        during 2025 or a subsequent year, subject to paragraphs (2) and 
        (3), payment for such procedure shall be determined under this 
        part in the same manner as payment would be determined under 
        this part if such procedure had been furnished in an ambulatory 
        surgical center and not considered office-based under section 
        1833(i)(1)(B), except that payment for facility services 
        furnished in connection with such procedure shall be equal to 
        90 percent of the amount that would be payable for facility 
        services furnished in connection with such procedure under 
        section 1833(i) for such year if such procedure had been 
        furnished in an ambulatory surgical center and treated as a 
        service commonly furnished in such a center.
            ``(2) Application in case of device-intensive procedures.--
        In applying paragraph (1) in the case of a specified high 
        supply cost surgical procedure that is a device-intensive 
        procedure (as described in section 416.171(b)(2) of title 42, 
        Code of Federal Regulations (or any successor regulation)), 
        instead of the payment amount applied under such paragraph, the 
        payment amount for the facility services with respect to such 
        procedure shall be the amount that would be calculated under 
        section 416.172(h)(2)(ii) of title 42, Code of Federal 
        Regulations (or any successor regulation) with respect to a 
        procedure that has been assigned device-intensive status, 
        except that in applying such calculation the non-device portion 
        described in paragraph (B) of such section shall be equal to 90 
        percent of the amount that would otherwise be calculated for 
        such portion.
            ``(3) Limitation on copayment amount to inpatient hospital 
        deductible amount.--
                    ``(A) In general.--In no case shall the amount of 
                coinsurance for facility services furnished in 
                connection with a specified high supply cost surgical 
                procedure in an office-based facility during a year 
                exceed the amount of the inpatient hospital deductible 
                established under section 1813(b) for that year.
                    ``(B) Maintaining payment to provider.--In the case 
                that an individual enrolled under this part would, 
                without application of subparagraph (A), be subject to 
                an amount of coinsurance for facility services 
                furnished in connection with a specified high supply 
                cost surgical procedure in an office-based facility 
                during a year that exceeds the amount of the inpatient 
                hospital deductible established under section 1813(b) 
                for that year, the Secretary shall increase the amount 
                paid to the office-based facility as specified under 
                section 1833(a)(1)(II) for such facility services by 
                the amount by which--
                            ``(i) the coinsurance payable by the 
                        individual for such facility services without 
                        application of this paragraph; exceeds
                            ``(ii) the coinsurance payable by the 
                        individual for such facility services with 
                        application of this paragraph.
            ``(4) Specified high supply cost surgical procedure 
        defined.--
                    ``(A) In general.--For purposes of this part, 
                subject to subparagraphs (B) and (C), the term 
                `specified high supply cost surgical procedure' means a 
                surgical procedure that as of 2023--
                            ``(i) when performed in an ambulatory 
                        surgical center, was payable under section 
                        1833(i); and
                            ``(ii) when performed in a physician's 
                        office--
                                    ``(I) was payable under section 
                                1848 at the practice expense relative 
                                value unit-based amount for non-
                                facility sites of service; and
                                    ``(II) included a HCPCS code with a 
                                supply item for which the price input 
                                for such supply item, used for 
                                determining the practice expense 
                                relative value units for such code, was 
                                greater than $500.
                    ``(B) Review and revisions to specified services.--
                            ``(i) In general.--For each year (beginning 
                        with 2026), the Secretary shall review the 
                        procedures included in the definition of 
                        specified high supply cost surgical procedures 
                        under this paragraph and, based on such review 
                        and through rulemaking--
                                    ``(I) shall add a surgical 
                                procedure (not described in 
                                subparagraph (A)) for inclusion in such 
                                definition if the procedure, with 
                                respect to such year, satisfies the 
                                criteria specified in clause (ii); and
                                    ``(II) may remove a surgical 
                                procedure from inclusion in such 
                                definition if the procedure, with 
                                respect to such year, satisfies the 
                                criteria specified in clause (iii).
                            ``(ii) Criteria for required inclusion.--
                        For purposes of clause (i)(I), a surgical 
                        procedure satisfies the criteria specified in 
                        this clause, with respect to a year, if--
                                    ``(I) when performed in an 
                                ambulatory surgical center, the 
                                procedure is payable under section 
                                1833(i); and
                                    ``(II) when performed in a 
                                physician's office, the procedure--
                                            ``(aa) would be, without 
                                        application of this subsection 
                                        or section 1833(a)(i)(II), 
                                        payable under section 1848 at 
                                        the practice expense relative 
                                        value unit-based amount for 
                                        non-facility sites of services; 
                                        and
                                            ``(bb) includes a HCPCS 
                                        code with a supply item for 
                                        which the price input for such 
                                        supply item, used for 
                                        determining the practice 
                                        expense relative value units 
                                        for such code, is greater than 
                                        the threshold specified in 
                                        clause (iv) for such year.
                            ``(iii) Criteria for permissive removal.--
                        For purposes of clause (i)(II), a surgical 
                        procedure satisfies the criteria described in 
                        this clause, with respect to a year, if, when 
                        performed in a physician's office, the 
                        procedure includes a HCPCS code with a supply 
                        item for which the price input for such supply 
                        item, used for determining the practice expense 
                        relative value units for such code, does not 
                        exceed the amount equal to 80 percent of the 
                        threshold specified in clause (iv) for such 
                        year.
                            ``(iv) Dollar amount threshold specified.--
                        For purposes of clauses (ii) and (iii), the 
                        threshold specified in this clause is--
                                    ``(I) with respect to 2026, the 
                                dollar amount specified in subparagraph 
                                (A)(ii), increased by the percentage 
                                increase in the MEI (as defined in 
                                section 1842(i)(3)) over the 3-year 
                                period ending with 2026; or
                                    ``(II) with respect to a subsequent 
                                year, the amount specified in this 
                                clause for the preceding year increased 
                                by the percentage increase in the MEI 
                                (as defined in section 1842(i)(3)) for 
                                such subsequent year.
                    ``(C) Special rule for use of more than one of the 
                same supply item in a procedure.--In the case of a 
                surgical procedure that requires the use of more than 
                one of the same supply item in such procedure--
                            ``(i) in applying subparagraph (A)(ii)(II), 
                        if as of 2023 the sum of the price inputs 
                        described in such subparagraph of all of such 
                        same supply items exceeds the dollar amount 
                        specified in such subparagraph, then the 
                        procedure shall be treated as satisfying the 
                        requirement of such subparagraph; and
                            ``(ii) in applying subparagraph (B), with 
                        respect to 2026 or a subsequent year--
                                    ``(I) if the sum of the price 
                                inputs described in clause (ii)(II)(bb) 
                                of such subparagraph of all of such 
                                same supply items exceeds the threshold 
                                specified in clause (iv) of such 
                                subparagraph for such year, then the 
                                procedure shall be treated as 
                                satisfying the criterion described in 
                                such clause (ii)(II)(bb) with respect 
                                to such year; and
                                    ``(II) if the sum of the price 
                                inputs described in clause (iii) of 
                                such subparagraph of all of such same 
                                supply items does not exceed the amount 
                                described in such clause for such year, 
                                then the procedure shall be treated as 
                                satisfying the criteria described in 
                                such clause with respect to such year.
            ``(5) Office-based facility defined.--For purposes of this 
        part, the term `office-based facility' means a physician's 
        office that, with respect to facility services furnished in 
        connection with specified high supply cost surgical 
        procedures--
                    ``(A) meets health, safety, and other standards 
                specified by the Secretary in regulations; and
                    ``(B) has entered into an agreement with the 
                Secretary under which the physician's office--
                            ``(i) accepts the payment amount determined 
                        under this subsection as full payment for such 
                        facility services;
                            ``(ii) accepts an assignment described in 
                        section 1842(b)(3)(B)(ii) with respect to 
                        payment for all such facility services 
                        furnished by the office to individuals enrolled 
                        under this part; and
                            ``(iii) participates under this part and is 
                        paid as an office-based facility with respect 
                        to all such procedures.''.
            (3) Conforming amendments.--
                    (A) For services furnished in an ambulatory 
                surgical center.--Section 1833(i)(2) of the Social 
                Security Act (42 U.S.C. 1395l(i)(2)) is amended by 
                adding at the end the following new subparagraph:
                    ``(F) For purposes of determining payment under 
                this subsection for a specified high supply cost 
                surgical procedure (as defined in section 1834(aa)(4) 
                with respect to a year (beginning with 2025)) furnished 
                in an ambulatory surgical center during such year, such 
                procedure shall be treated as a service commonly 
                furnished in an ambulatory surgical center.''.
                    (B) For services furnished in an off-campus 
                outpatient department of a provider.--Section 
                1833(t)(21)(C) of the Social Security Act (42 U.S.C. 
                1395l(t)(21)(C)) is amended by adding at the end the 
                following new sentence: ``In applying the previous 
                sentence in the case of a specified high supply cost 
                surgical procedure (as defined in section 1834(aa)(4) 
                with respect to a year) furnished by an off-campus 
                outpatient department of a provider, payment shall be 
                determined under section 1834(aa).''.
                    (C) For clarification on applicable payment for obf 
                facility services.--Section 1833(a)(4) of the Social 
                Security Act (42 U.S.C. 1395l(a)(4)) is amended by 
                inserting ``(other than in clause (iii) of such 
                section)'' after ``section 1832(a)(2)(F)''.
    (c) Provider Agreement and Medicare Enrollment.--
            (1) In general.--Section 1866(e) of the Social Security Act 
        (42 U.S.C. 1395cc(e)) is amended--
                    (A) in paragraph (2), by striking at the end 
                ``and'';
                    (B) in paragraph (3), at the end, by striking the 
                period and adding ``; and''; and
                    (C) by adding at the end the following new 
                paragraph:
            ``(4) an office-based facility (as defined in paragraph (5) 
        of section 1834(aa)), but only with respect to the furnishing 
        during a year of specified high supply cost surgical procedures 
        (as defined in paragraph (4) of such section with respect to 
        such year).''.
            (2) Consultation with state agencies regarding conditions 
        of participation.--Section 1863 of the Social Security Act (42 
        U.S.C. 1395z) is amended by striking ``or by ambulatory 
        surgical centers under section 1832(a)(2)(F)(i)'' and inserting 
        ``by ambulatory surgical centers under section 
        1832(a)(2)(F)(i), or by office-based facilities (as defined in 
        section 1834(aa)(5)) with respect to furnishing specified high 
        supply cost surgical procedures (as defined in section 
        1834(aa)(4))''.
            (3) Use of state agencies to determine compliance with 
        conditions of participation.--Section 1864(a) of the Social 
        Security Act (42 U.S.C. 1395aa(a)) is amended--
                    (A) in the first sentence, by inserting ``or 
                whether a physician's office is an office-based 
                facility (as defined in section 1834(aa)(5),'' after 
                ``standards specified under section 
                1832(a)(2)(F)(i),''; and
                    (B) in the fifth sentence, by inserting ``office-
                based facility (as defined in section 1834(aa)(5)) with 
                respect to furnishing ambulatory high supply cost 
                surgical procedures (as defined in section 
                1834(aa)(4)),'' after each occurrence of ``ambulatory 
                surgical center,''.
                                 <all>
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