I 

117TH CONGRESS 

1ST SESSION H. R. 2166 

To amend title XVIII of the Social Security Act to require the inclusion 

of certain audio-only diagnoses in the determination of risk adjustment 

for Medicare Advantage plans and PACE programs, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 23, 2021 

Ms. SEWELL (for herself, Mr. BILIRAKIS, Mr. CA ́RDENAS, Mrs. WALORSKI, 

Mr. KIND, Mr. SMITH of Missouri, Ms. HOULAHAN, and Mr. 

FITZPATRICK) introduced the following bill; which was referred to the 

Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, 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 require 

the inclusion of certain audio-only diagnoses in the determination of risk adjustment for Medicare Advantage 

plans and PACE programs, 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 ‘‘Ensuring Parity in 

5 MA and PACE for Audio-Only Telehealth Act of 2021’’. 


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1 SEC. 2. REQUIRING THE INCLUSION OF CERTAIN AUDIO2 ONLY DIAGNOSES IN THE DETERMINATION 

3 OF RISK ADJUSTMENT FOR MEDICARE AD4 VANTAGE PLANS AND PACE PROGRAMS. 

5 (a) IN GENERAL.—Section 1853(a)(1) of the Social 

6 Security Act (42 U.S.C. 1395w–23(a)(1)) is amended by 

7 adding at the end the following new subparagraph: 

8 ‘‘(J) INCLUSION OF CERTAIN AUDIO-ONLY

9 DIAGNOSES FOR PURPOSES OF RISK ADJUST10 MENT.— 

11 ‘‘(i) IN GENERAL.—For purposes of 

12 determining the appropriate adjustment 

13 for health status under subparagraph 

14 (C)(i) for plan years 2020 and 2021 (and 

15 for such other plan years determined ap16 propriate by the Secretary), the Secretary, 

17 in determining the diseases or conditions 

18 of an individual, shall take into account di19 agnoses obtained through a telehealth en20 counter, and in the case of a qualified di21 agnosis (as defined in clause (ii)) made 

22 with respect to such individual by a quali23 fied provider (as so defined), shall not re24 quire the use of video communications with 

25 respect to such telehealth encounter. 


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1 ‘‘(ii) DEFINITIONS.—For purposes of 

2 this subparagraph: 

3 ‘‘(I) QUALIFIED DIAGNOSIS.— 

4 The term ‘qualified diagnosis’ means 

5 a diagnosis made with respect to a 

6 chronic disease or condition of an in7 dividual during a plan year if such di8 agnosis was also made with respect to 

9 such individual in one of the last of 

10 the 3 plan years preceding such plan 

11 year. 

12 ‘‘(II) QUALIFIED PROVIDER.— 

13 The term ‘qualified provider’ means, 

14 with respect to a qualified diagnosis 

15 made with respect to an individual 

16 during a plan year, a provider of serv17 ices, clinician or supplier that— 

18 ‘‘(aa) furnished an item or 

19 service to such individual during 

20 the 3-year period ending on the 

21 date such diagnosis was so made; 

22 or 

23 ‘‘(bb) is in the same practice 

24 (as determined by tax identifica25 tion number) of a provider of 


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1 services or supplier who fur2 nished such an item or service to 

3 such individual during such pe4 riod.’’. 

5 (b) PACE PROGRAM CONFORMING AMENDMENT.— 

6 Section 1894(d)(2) of the Social Security Act (42 U.S.C. 

7 1395eee(d)(2)) is amended by adding at the end the fol8 lowing new sentence: ‘‘For purposes of applying the ad9 justment under subparagraph (C)(i) of section 1853(a)(1) 

10 to such amounts, subparagraph (J) of such section shall 

11 be applied as if each reference to ‘plan year’ and ‘plan 

12 years 2020 and 2021’ were instead a reference to ‘year’ 

13 and ‘2020 and 2021’, respectively.’’. 

14 SEC. 3. REQUIRING PARITY IN TELEHEALTH PAYMENTS 

15 DURING THE COVID–19 EMERGENCY. 

16 Section 1834(m) of the Social Security Act (42 

17 U.S.C. 1395m(m)) is amended by adding at the end the 

18 following new paragraph: 

19 ‘‘(9) SPECIAL RULE FOR TELEHEALTH PAY20 MENT PARITY DURING THE COVID–19 EMER21 GENCY.—In the case of a telehealth service fur22 nished during the emergency period described in sec23 tion 1135(g)(1)(B) for which payment may be made 

24 under this subsection (including any service for 

25 which payment may be so made due to application 


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1 of a waiver made under section 1135(b)), the 

2 amount of such payment shall be equal to the 

3 amount that would have been paid for such service 

4 had such service been furnished in-person.’’. 

Æ 


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