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[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[S. 1228 Introduced in Senate (IS)]

113th CONGRESS
  1st Session
                                S. 1228

 To establish a program to provide incentive payments to participating 
 Medicare beneficiaries who voluntarily establish and maintain better 
                                health.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

                             June 26, 2013

Mr. Wyden (for himself and Mr. Portman) introduced the following bill; 
     which was read twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL

 
 To establish a program to provide incentive payments to participating 
 Medicare beneficiaries who voluntarily establish and maintain better 
                                health.

    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 ``Medicare Better Health Rewards 
Program Act of 2013''.

SEC. 2. MEDICARE BETTER HEALTH REWARDS PROGRAM.

    Part B of title XVIII of the Social Security Act (42 U.S.C. 1395j 
et seq.) is amended by adding at the end the following new section:

                ``medicare better health rewards program

    ``Sec. 1849.  (a) In General.--The Secretary shall establish a 
Better Health Rewards Program (in this section referred to as the 
`Program') under which incentives are provided to Medicare 
beneficiaries who voluntarily agree to participate in the Program.
    ``(b) Enrollment.--A health professional participating in the 
Program shall provide their patients who are Medicare beneficiaries 
with a description of and an opportunity to enroll in the Program on a 
voluntary basis. If a Medicare beneficiary elects to enroll in the 
Program, the health professional shall inform the Secretary of the 
individual's enrollment through a process established by the Secretary, 
which does not impose additional administrative requirements on the 
participating health professional.
    ``(c) Establishment of Better Health Target Standards.--
            ``(1) In general.--
                    ``(A) Establishment.--The Secretary shall establish 
                standards for measuring better health targets and 
                points for achieving such standards for participating 
                Medicare beneficiaries, including such standards and 
                points with respect to the following:
                            ``(i) Annual wellness visit.
                            ``(ii) Tobacco cessation.
                            ``(iii) Body Mass Index (BMI).
                            ``(iv) Diabetes screening test.
                            ``(v) Cardiovascular disease screening.
                            ``(vi) Cholesterol level screening.
                            ``(vii) Screening tests and specified 
                        vaccinations.
                    ``(B) Consultation.--In establishing standards and 
                points for achieving such standards under this 
                subsection, the Secretary--
                            ``(i) shall consult with 1 or more 
                        nationally recognized health care quality 
                        organizations, as determined appropriate by the 
                        Secretary; and
                            ``(ii) may consult with physicians and 
                        other professionals experienced with wellness 
                        programs.
                    ``(C) Points.--The number of points awarded for a 
                year for achieving standards with respect to each of 
                the targets described in clauses (i) through (vii) of 
                subparagraph (A) shall not exceed 5. Such points may be 
                awarded on a sliding scale, based on standards 
                established under this subsection, as determined 
                appropriate by the Secretary.
            ``(2) Modification of better health target standards and 
        assigned points.--
                    ``(A) In general.--The Secretary may modify 
                standards for measuring better health targets and, 
                subject to paragraph (1)(C), points for achieving such 
                standards for participating Medicare beneficiaries 
                under this subsection.
                    ``(B) Consultation.--In modifying standards and 
                points for achieving such standards under this 
                paragraph, the Secretary--
                            ``(i) shall consult with 1 or more 
                        nationally recognized health care quality 
                        organizations, as determined appropriate by the 
                        Secretary; and
                            ``(ii) may consult with physicians and 
                        other professionals experienced with wellness 
                        programs.
    ``(d) Conduct of Program.--
            ``(1) Duration.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                Program shall be conducted for not less than a 3-year 
                period.
                    ``(B) Expansion.--The Secretary shall expand the 
                duration and scope of the Program, to the extent 
                determined appropriate by the Secretary, if--
                            ``(i) the Secretary determines that such 
                        expansion is expected to--
                                    ``(I) reduce spending under this 
                                title without reducing the quality of 
                                care; or
                                    ``(II) improve the quality of care 
                                and reduce spending;
                            ``(ii) the Chief Actuary of the Centers for 
                        Medicare & Medicaid Services certifies that 
                        such expansion would reduce program spending 
                        under this title; and
                            ``(iii) the Secretary determines that such 
                        expansion would not deny or limit the coverage 
                        or provision of benefits under this title for 
                        individuals.
            ``(2) Collection and use of baseline data.--During the 
        first year of the Program, a health professional shall 
        establish and report to the Secretary baseline information for 
        each participating Medicare beneficiary who is a patient of the 
        health professional as part of that beneficiary's first year 
        assessment under paragraph (3)(A). The health professional 
        shall use such data to aid in the determination of whether and 
        to what extent the participating Medicare beneficiary is 
        meeting the target standards under subsection (c) in each of 
        years 2 and 3 of the Program.
            ``(3) Required assessments for participating medicare 
        beneficiaries.--
                    ``(A) First year.--During year 1 of the Program, a 
                health professional shall furnish to each participating 
                Medicare beneficiary that is a patient of the health 
                professional either an annual wellness visit or an 
                initial preventive physical examination.
                    ``(B) Second and third years.--During each of years 
                2 and 3 of the Program, a health professional shall 
                furnish to each participating Medicare beneficiary that 
                is a patient of the health professional an annual 
                wellness visit to determine whether and to what extent 
                the participating Medicare beneficiary has met the 
                target standards under subsection (c).
    ``(e) Determination of Points and Payment of Incentives.--
            ``(1) Determination of points.--During each of years 2 and 
        3 of the Program, a health professional shall--
                    ``(A) evaluate and report to the Secretary whether 
                each participating Medicare beneficiary that is a 
                patient of the health professional has achieved the 
                target standards under subsection (c); and
                    ``(B) determine the total amount of points that 
                each such participating Medicare beneficiary has 
                achieved for the year based on the points assigned for 
                achieving such standards under subsection (c).
            ``(2) Incentive payment.--
                    ``(A) In general.--The Secretary shall pay to each 
                participating Medicare beneficiary who achieves at 
                least 20 points under paragraph (1)(B) for the year an 
                incentive payment. Such payment shall be equal to an 
                amount determined appropriate by the Secretary, but no 
                case shall such amount exceed the following:

------------------------------------------------------------------------
                                                        Year 3 or a
          ``Points               Year 2 Payment       Subsequent  Year
                                     Amount            Payment Amount
------------------------------------------------------------------------
20-24 points................  $100...............                   $200
------------------------------------------------------------------------
25 or more points...........  $200...............                  $400.
------------------------------------------------------------------------

                    ``(B) Inflation adjustment.--The dollar amounts 
                specified in this paragraph shall be increased, 
                beginning with 2017, from year to year based on the 
                percentage increase in the consumer price index for all 
                urban consumers (all items; United States city 
                average), rounded to the nearest $1.
            ``(3) Final determination of standards achievement made by 
        participating health professional.--Under the Program, a 
        participating health professional shall make the final 
        determination as to whether or not a participating Medicare 
        beneficiary has met the target standards under subsection (c) 
        and what screening tests and specified vaccinations, or other 
        services, are necessary for purposes of making such 
        determination.
    ``(f) Spending Benchmarks.--
            ``(1) In general.--The Secretary shall collect relevant 
        data, including data on claims paid under this title for 
        services furnished to participating Medicare beneficiaries 
        during the Program, for purposes of determining the aggregate 
        estimated savings achieved under this title for participating 
        Medicare beneficiaries during each of years 2 and 3 of the 
        Program in accordance with paragraph (2) (and for a subsequent 
        year if the Program is expanded under subsection (d)(1)(B)).
            ``(2) Determination of aggregate estimated savings.--
                    ``(A) In general.--The amount of the aggregate 
                estimated savings under this title for participating 
                Medicare beneficiaries under paragraph (1), with 
                respect to a year, shall be equal to--
                            ``(i) the estimated savings determined 
                        under subparagraph (B) for the year; minus
                            ``(ii) the aggregate incentive payments 
                        made under the Program during the year.
                    ``(B) Determination of estimated savings.--For 
                purposes of subparagraph (A)(i), the estimated savings 
                determined under this subparagraph for a year shall be 
                equal to--
                            ``(i) the estimated aggregate expenditures 
                        under this title (as projected under 
                        subparagraph (C)) for the year; minus
                            ``(ii) the actual aggregate expenditures 
                        under this title (as determined by the 
                        Secretary and taking into account any reduction 
                        in specific health risks of the participating 
                        Medicare beneficiaries) for the year.
                    ``(C) Projection of estimated aggregate claims 
                cost.--
                            ``(i) Benchmark base year.--The Secretary 
                        shall establish a benchmark base year amount of 
                        expenditures under this title for participating 
                        Medicare beneficiaries during year 1 of the 
                        Program.
                            ``(ii) Projection.--The Secretary shall use 
                        the benchmark base year amount established 
                        under clause (i) to project the estimated 
                        aggregate expenditures for all participating 
                        Medicare beneficiaries during each of years 2 
                        and 3 of the Program as if the beneficiaries 
                        were not participating in the Program. In 
                        making such projection, the Secretary may 
                        include adjustments for health status or other 
                        specific risk factors and geographic variation 
                        for the participating Medicare beneficiaries.
                    ``(D) Public report of determination and other 
                program information.--Not later than 90 days after 
                determining the aggregate estimated savings (if any) 
                under subparagraph (A) with respect to a year, the 
                Secretary shall make available to the public a report 
                containing a description of the amount of the savings 
                determined, including the methodology and any other 
                calculations or determinations involved in the 
                determination of such amount. Such report shall 
                include--
                            ``(i) a description of any reduction in 
                        specific health risks of participating Medicare 
                        beneficiaries identified by the Secretary;
                            ``(ii) a description of--
                                    ``(I) standards for measuring 
                                better health targets under subsection 
                                (c); and
                                    ``(II) the points available for 
                                achieving each such standard under that 
                                subsection; and
                            ``(iii) recommendations for such 
                        legislation and administrative action as the 
                        Secretary determines appropriate.
            ``(3) Monitoring of program costs.--During the operation of 
        the Program, the Chief Actuary of the Centers for Medicare & 
        Medicaid Services shall--
                    ``(A) monitor the Program to determine whether or 
                not the Program is reducing aggregate expenditures 
                under this title; and
                    ``(B) submit to the Secretary an annual report on 
                the results of such monitoring.
            ``(4) Required action if aggregate incentive payments 
        exceed savings.--If the Secretary, taking into account the 
        reports under paragraph (3)(B), determines that the aggregate 
        expenditures under this title exceed the aggregate expenditures 
        under this title that would have been made if the Program had 
        not been implemented, the Secretary shall provide for changes 
        to the provisions of the program in order to eliminate such 
        excess.
    ``(g) Waiver Authority.--The Secretary may waive such requirements 
of titles XI and XVIII as may be necessary to carry out the purposes of 
the Program established under this section.
    ``(h) Definitions.--In this section:
            ``(1) Annual wellness visit.--The term `annual wellness 
        visit' includes personalized prevention plan services (as 
        defined in section 1861(hhh)(1)).
            ``(2) Health professional.--The term `health professional' 
        includes a physician (as defined in section 1861(r)(1)) and a 
        practitioner described in clause (i) of section 1842(b)(18)(C).
            ``(3) Initial preventive physical examination.--The term 
        `initial preventive physical examination' has the meaning given 
        that term in section 1861(ww)(1).
            ``(4) Medicare beneficiary.--The term `Medicare 
        beneficiary' means an individual enrolled in part B.
            ``(5) Participating medicare beneficiary.--The term 
        `participating Medicare beneficiary' means a Medicare 
        beneficiary who enrolls in the Program under subsection (b).
            ``(6) Screening tests.--The term `screening tests' means 
        any of the following that are determined by a health 
        professional to be appropriate for a participating Medicare 
        beneficiary:
                    ``(A) Colorectal cancer screening tests (as defined 
                in section 1861(pp)).
                    ``(B) Screening mammography (as described in 
                section 1861(jj)).
                    ``(C) Screening pap smear and screening pelvic exam 
                (as defined in section 1861(nn)).
                    ``(D) Screening for glaucoma (as defined in section 
                1861(uu)).
                    ``(E) Bone mass measurement (as defined in section 
                1861(rr)) for qualified individuals described in 
                paragraph (2)(A) of such section.
                    ``(F) HIV screening for high-risk groups (as 
                identified by the Secretary).
            ``(7) Specified vaccinations.--The term `specified 
        vaccinations' means the vaccinations described in section 
        1861(ww)(1) that are determined by a health professional to be 
        appropriate for a participating Medicare beneficiary.''.

SEC. 3. PARTICIPATION BY MEDICARE ADVANTAGE PLANS.

    Section 1859 of the Social Security Act (42 U.S.C. 1395w-28) is 
amended by adding at the end the following new subsection:
    ``(h) Providing Incentives for Voluntary Participation in a Better 
Health Rewards Program.--
            ``(1) In general.--Effective for plan years beginning on or 
        after the date of enactment of the Medicare Better Health 
        Rewards Program Act of 2013, a Medicare Advantage organization 
        may provide to individuals enrolled in an MA plan offered by 
        the organization incentive payments, including cash, cash-
        equivalent, or other types of incentives, for voluntary 
        participation in a Better Health Rewards Program (in this 
        subsection referred to as the `Program') that rewards 
        individuals for meeting certain health targets established by 
        the Secretary.
            ``(2) Limitation.--In no case shall the monthly bid amount 
        submitted by a Medicare Advantage organization under section 
        1834(a)(6) (or the monthly premium charged by the organization 
        under section 1854(b)) with respect to an MA plan offered by 
        the organization take into account any incentive payments made 
        to enrollees under the Program.
            ``(3) Implementation.--The Program under this subsection 
        shall be conducted in a similar manner to the manner in which 
        the program under section 1849 is conducted, in accordance with 
        standards established by the Secretary.
            ``(4) Notification and provision of information.--A 
        Medicare Advantage organization seeking to participate in the 
        Program shall--
                    ``(A) notify the Secretary of the organization's 
                intent to participate in the Program; and
                    ``(B) agree to provide to the Secretary--
                            ``(i) information regarding--
                                    ``(I) which enrollees participate 
                                in the Program;
                                    ``(II) the scores of those 
                                enrollees with respect to applicable 
                                health targets under the Program; and
                                    ``(III) the incentives enrollees 
                                receive for meeting such health 
                                targets; and
                            ``(ii) any other information specified by 
                        the Secretary for purposes of this subsection.
            ``(5) Waiver authority.--The Secretary may waive such 
        requirements of titles XI and XVIII as may be necessary to 
        carry out the purposes of the Program established under this 
        subsection.''.

SEC. 4. PARTICIPATION OF SECTION 1876 COST PLANS.

    Section 1876 of the Social Security Act (42 U.S.C. 1395mm) is 
amended by inserting at the end the following:
    ``(l) Providing Incentives for Voluntary Participation in a Better 
Health Rewards Program.--
            ``(1) In general.--Effective for contract periods beginning 
        on or after the date of enactment of the Medicare Better Health 
        Rewards Program Act of 2013, an eligible organization may 
        provide to members enrolled under this section with the 
        organization incentive payments, including cash, cash-
        equivalent, or other types of incentives, for voluntary 
        participation in a Better Health Rewards Program (in this 
        subsection referred to as the `Program') that rewards members 
        for meeting certain health targets established by the 
        Secretary.
            ``(2) Limitation.--In no case shall the payment to an 
        eligible organization under this section (or the premium rate 
        charged by the organization under this section) with respect to 
        members enrolled with the organization take into account any 
        incentive payments made to members under the Program.
            ``(3) Implementation.--The Program under this subsection 
        shall be conducted in a similar manner to the manner in which 
        the program under section 1849 is conducted, in accordance with 
        standards established by the Secretary.
            ``(4) Notification and provision of information.--An 
        eligible organization seeking to participate in the Program 
        shall--
                    ``(A) notify the Secretary of the organization's 
                intent to participate in the Program; and
                    ``(B) agree to provide to the Secretary--
                            ``(i) information regarding--
                                    ``(I) which members participate in 
                                the Program;
                                    ``(II) the scores of those members 
                                with respect to applicable health 
                                targets under the Program; and
                                    ``(III) the incentives members 
                                receive for meeting such health 
                                targets; and
                            ``(ii) any other information specified by 
                        the Secretary for purposes of this subsection.
            ``(5) Waiver authority.--The Secretary may waive such 
        requirements of titles XI and XVIII as may be necessary to 
        carry out the purposes of the Program established under this 
        subsection.''.

SEC. 5. PARTICIPATION OF PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY 
              (PACE).

    (a) Medicare.--Section 1894 of the Social Security Act (42 U.S.C. 
1395eee) is amended by inserting at the end the following:
    ``(j) Providing Incentives for Voluntary Participation in a Better 
Health Rewards Program.--
            ``(1) In general.--Effective for PACE program agreements 
        entered into on or after the date of enactment of the Medicare 
        Better Health Rewards Program Act of 2013, a PACE provider may 
        provide to PACE program eligible individuals enrolled under 
        this section with the PACE provider incentive payments, 
        including cash, cash-equivalent, or other types of incentives, 
        for voluntary participation in a Better Health Rewards Program 
        (in this subsection referred to as the `Program') that rewards 
        enrollees for meeting certain health targets established by the 
        Secretary.
            ``(2) Limitation.--In no case shall the payment to a PACE 
        provider under this section (or any premium charged by the 
        provider under this section) with respect to PACE program 
        eligible individuals enrolled with the PACE provider take into 
        account any incentive payments made to individuals under the 
        Program.
            ``(3) Implementation.--The Program under this subsection 
        shall be conducted in a similar manner to the manner in which 
        the program under section 1849 is conducted, in accordance with 
        standards established by the Secretary.
            ``(4) Notification and provision of information.--A PACE 
        provider seeking to participate in the Program shall--
                    ``(A) notify the Secretary of the PACE provider's 
                intent to participate in the Program; and
                    ``(B) agree to provide to the Secretary--
                            ``(i) information regarding--
                                    ``(I) which PACE program eligible 
                                individuals enrolled with the PACE 
                                provider participate in the Program;
                                    ``(II) the scores of those 
                                individuals with respect to applicable 
                                health targets under the Program; and
                                    ``(III) the incentives individuals 
                                receive for meeting such health 
                                targets; and
                            ``(ii) any other information specified by 
                        the Secretary for purposes of this subsection.
            ``(5) Waiver authority.--The Secretary may waive such 
        requirements of titles XI, XVIII, and XIX as may be necessary 
        to carry out the purposes of the Program established under this 
        subsection.''.
    (b) Medicaid.--Section 1934 of the Social Security Act (42 U.S.C. 
1396u-4) is amended by adding at the end the following new subsection:
    ``(k) Providing Incentives for Voluntary Participation in a Better 
Health Rewards Program.--
            ``(1) In general.--Effective for PACE program agreements 
        entered into on or after the date of enactment of the Medicare 
        Better Health Rewards Program Act of 2013, a PACE provider may 
        provide to PACE program eligible individuals enrolled under 
        this section with the PACE provider incentive payments, 
        including cash, cash-equivalent, or other types of incentives, 
        for voluntary participation in a Better Health Rewards Program 
        (in this subsection referred to as the `Program') that rewards 
        enrollees for meeting certain health targets established by the 
        Secretary.
            ``(2) Limitation.--In no case shall the payment to a PACE 
        provider under this section (or any premium charged by the 
        provider under this section) with respect to PACE program 
        eligible individuals enrolled with the PACE provider take into 
        account any incentive payments made to individuals under the 
        Program.
            ``(3) Implementation.--The Program under this subsection 
        shall be conducted in a similar manner to the manner in which 
        the program under section 1849 is conducted, in accordance with 
        standards established by the Secretary.
            ``(4) Notification and provision of information.--A PACE 
        provider seeking to participate in the Program shall--
                    ``(A) notify the Secretary of the PACE provider's 
                intent to participate in the Program; and
                    ``(B) agree to provide to the Secretary--
                            ``(i) information regarding--
                                    ``(I) which PACE program eligible 
                                individuals enrolled with the PACE 
                                provider participate in the Program;
                                    ``(II) the scores of those 
                                individuals with respect to applicable 
                                health targets under the Program; and
                                    ``(III) the incentives individuals 
                                receive for meeting such health 
                                targets; and
                            ``(ii) any other information specified by 
                        the Secretary for purposes of this subsection.
            ``(5) Waiver authority.--The Secretary may waive such 
        requirements of titles XI, XVIII, and XIX as may be necessary 
        to carry out the purposes of the Program established under this 
        subsection.''.

SEC. 6. EXCLUSION OF INCENTIVE PAYMENTS.

    (a) In General.--Part III of subchapter B of chapter 1 of the 
Internal Revenue Code of 1986 is amended by inserting after section 
139D the following new section:

``SEC. 139E. MEDICARE BETTER HEALTH REWARDS PAYMENTS.

    ``Gross income shall not include any payment made under the 
following programs:
            ``(1) The Medicare Better Health Rewards Program 
        established under section 1849 of the Social Security Act.
            ``(2) A Better Health Rewards Program established pursuant 
        to section 1859(h), 1876(l), 1894(j), or 1934(k) of the Social 
        Security Act.''.
    (b) Clerical Amendment.--The table of sections for part III of 
subchapter B of chapter 1 of such Code is amended by inserting after 
the item relating to section 139D the following new item:

``Sec. 139E. Medicare Better Health Rewards payments.''.
                                 <all>
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