II 

Calendar No. 280 

113TH CONGRESS 

1ST SESSION S. 1871 

To amend title XVIII of the Social Security Act to repeal the Medicare 

sustainable growth rate formula and to improve beneficiary access under 

the Medicare program, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

DECEMBER 19, 2013 

Mr. BAUCUS, from the Committee on Finance, reported the following original 

bill; which was read twice and placed on the calendar 

A BILL 

To amend title XVIII of the Social Security Act to repeal 

the Medicare sustainable growth rate formula and to 

improve beneficiary access 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; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘SGR Repeal and Medicare Beneficiary Access Act of 

6 2013’’. 


smartinez on DSK6TPTVN1PROD with BILLS
2 

•S 1871 PCS

1 (b) TABLE OF CONTENTS.—The table of contents of 

2 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—MEDICARE PAYMENT FOR PHYSICIANS’ SERVICES 

Sec. 101. Repealing the sustainable growth rate (SGR) and improving Medicare 

payment for physicians’ services. 

Sec. 102. Priorities and funding for quality measure development. 

Sec. 103. Encouraging care management for individuals with chronic care 

needs. 

Sec. 104. Ensuring accurate valuation of services under the physician fee 

schedule. 

Sec. 105. Promoting evidence-based care. 

Sec. 106. Empowering beneficiary choices through access to information on 

physicians’ services. 

Sec. 107. Expanding claims data availability to improve care. 

TITLE II—EXTENSIONS AND OTHER PROVISIONS 

Subtitle A—Medicare Extensions 

Sec. 201. Work geographic adjustment. 

Sec. 202. Medicare payment for therapy services. 

Sec. 203. Medicare ambulance services. 

Sec. 204. Revision of the Medicare-dependent hospital (MDH) program. 

Sec. 205. Revision of Medicare inpatient hospital payment adjustment for lowvolume hospitals. 

Sec. 206. Specialized Medicare Advantage plans for special needs individuals. 

Sec. 207. Reasonable cost reimbursement contracts. 

Sec. 208. Quality measure endorsement and selection. 

Sec. 209. Permanent extension of funding outreach and assistance for low-income programs. 

Subtitle B—Medicaid and Other Extensions 

Sec. 211. Qualifying individual program. 

Sec. 212. Transitional Medical Assistance. 

Sec. 213. Express lane eligibility. 

Sec. 214. Pediatric quality measures. 

Sec. 215. Special diabetes programs. 

Subtitle C—Human Services Extensions 

Sec. 221. Abstinence education grants. 

Sec. 222. Personal responsibility education program. 

Sec. 223. Family-to-family health information centers. 

Sec. 224. Health workforce demonstration project for low-income individuals. 

Subtitle D—Program Integrity 

Sec. 231. Reducing improper Medicare payments. 

Sec. 232. Authority for Medicaid fraud control units to investigate and prosecute complaints of abuse and neglect of Medicaid patients in 

home and community-based settings. 


smartinez on DSK6TPTVN1PROD with BILLS
3 

•S 1871 PCS

Sec. 233. Improved use of funds received by the HHS Inspector General from 

oversight and investigative activities. 

Sec. 234. Preventing and reducing improper Medicare and Medicaid expenditures. 

Subtitle E—Other Provisions 

Sec. 241. Commission on Improving Patient Directed Health Care. 

Sec. 242. Expansion of the definition of inpatient hospital services for certain 

cancer hospitals. 

Sec. 243. Quality measures for certain post-acute care providers relating to notice and transfer of patient health information and patient care 

preferences. 

Sec. 244. Criteria for medically necessary, short inpatient hospital stays. 

Sec. 245. Transparency of reasons for excluding additional procedures from the 

Medicare ambulatory surgical center (ASC) approved list. 

Sec. 246. Supervision in critical access hospitals. 

Sec. 247. Requiring State licensure of bidding entities under the competitive acquisition program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). 

Sec. 248. Recognition of attending physician assistants as attending physicians 

to serve hospice patients. 

Sec. 249. Remote patient monitoring pilot projects. 

Sec. 250. Community-Based Institutional Special Needs Plan Demonstration 

Program. 

Sec. 251. Applying CMMI waiver authority to PACE in order to foster innovations. 

Sec. 252. Improve and modernize Medicaid data systems and reporting. 

Sec. 253. Fairness in Medicaid supplemental needs trusts. 

Sec. 254. Helping Ensure Life- and Limb-Saving Access to Podiatric Physicians. 

Sec. 255. Demonstration program to improve community mental health services. 

Sec. 256. Annual Medicaid DSH report. 

Sec. 257. Implementation. 

1 TITLE I—MEDICARE PAYMENT 

2 FOR PHYSICIANS’ SERVICES 

3 SEC. 101. REPEALING THE SUSTAINABLE GROWTH RATE 

4 (SGR) AND IMPROVING MEDICARE PAYMENT 

5 FOR PHYSICIANS’ SERVICES. 

6 (a) STABILIZING FEE UPDATES.— 

7 (1) REPEAL OF SGR PAYMENT METHOD8 OLOGY.—Section 1848 of the Social Security Act 

9 (42 U.S.C. 1395w–4) is amended— 


smartinez on DSK6TPTVN1PROD with BILLS
4 

•S 1871 PCS

1 (A) in subsection (d)— 

2 (i) in paragraph (1)(A), by inserting 

3 ‘‘or a subsequent paragraph’’ after ‘‘para4 graph (4)’’; and 

5 (ii) in paragraph (4)— 

6 (I) in the heading, by inserting 

7 ‘‘AND ENDING WITH 2013’’ after 

8 ‘‘YEARS BEGINNING WITH 2001’’; and 

9 (II) in subparagraph (A), by in10 serting ‘‘and ending with 2013’’ after 

11 ‘‘a year beginning with 2001’’; and 

12 (B) in subsection (f)— 

13 (i) in paragraph (1)(B), by inserting 

14 ‘‘through 2013’’ after ‘‘of each succeeding 

15 year’’; and 

16 (ii) in paragraph (2), by inserting 

17 ‘‘and ending with 2013’’ after ‘‘beginning 

18 with 2000’’. 

19 (2) UPDATE OF RATES FOR 2014 AND SUBSE20 QUENT YEARS.—Subsection (d) of section 1848 of 

21 the Social Security Act (42 U.S.C. 1395w–4) is 

22 amended by adding at the end the following new 

23 paragraphs: 

24 ‘‘(15) UPDATE FOR 2014 THROUGH 2023.—The 

25 update to the single conversion factor established in 


smartinez on DSK6TPTVN1PROD with BILLS
5 

•S 1871 PCS

1 paragraph (1)(C) for each of 2014 through 2023 

2 shall be zero percent. 

3 ‘‘(16) UPDATE FOR 2024 AND SUBSEQUENT

4 YEARS.—The update to the single conversion factor 

5 established in paragraph (1)(C) for 2024 and each 

6 subsequent year shall be— 

7 ‘‘(A) for items and services furnished by a 

8 qualifying APM participant (as defined in sec9 tion 1833(z)(2)) for such year, 2 percent; and 

10 ‘‘(B) for other items and services, 1 per11 cent.’’. 

12 (3) MEDPAC REPORTS.— 

13 (A) INITIAL REPORT.—Not later than July 

14 1, 2016, the Medicare Payment Advisory Com15 mission shall submit to Congress a report on 

16 the relationship between— 

17 (i) physician and other health profes18 sional utilization and expenditures (and the 

19 rate of increase of such utilization and ex20 penditures) of items and services for which 

21 payment is made under section 1848 of the 

22 Social Security Act (42 U.S.C. 1395w–4); 

23 and 

24 (ii) total utilization and expenditures 

25 (and the rate of increase of such utilization 


smartinez on DSK6TPTVN1PROD with BILLS
6 

•S 1871 PCS

1 and expenditures) under parts A, B, and D 

2 of title XVIII of such Act. 

3 Such report shall include a methodology to de4 scribe such relationship and the impact of 

5 changes in such physician and other health pro6 fessional practice and service ordering patterns 

7 on total utilization and expenditures under 

8 parts A, B, and D of such title. 

9 (B) FINAL REPORT.—Not later than July 

10 1, 2020, the Medicare Payment Advisory Com11 mission shall submit to Congress a report on 

12 the relationship described in subparagraph (A), 

13 including the results determined from applying 

14 the methodology included in the report sub15 mitted under such subparagraph. 

16 (b) CONSOLIDATION OF CERTAIN CURRENT LAW

17 PERFORMANCE PROGRAMS WITH NEW VALUE-BASED

18 PERFORMANCE INCENTIVE PROGRAM.— 

19 (1) EHR MEANINGFUL USE INCENTIVE PRO20 GRAM.— 

21 (A) SUNSETTING SEPARATE MEANINGFUL

22 USE PAYMENT ADJUSTMENTS.—Section 

23 1848(a)(7)(A) of the Social Security Act (42 

24 U.S.C. 1395w–4(a)(7)(A)) is amended— 


smartinez on DSK6TPTVN1PROD with BILLS
7 

•S 1871 PCS

1 (i) in clause (i), by striking ‘‘or any 

2 subsequent payment year’’ and inserting 

3 ‘‘or 2016’’; 

4 (ii) in clause (ii)— 

5 (I) in the matter preceding sub6 clause (I), by striking ‘‘Subject to 

7 clause (iii), for’’ and inserting ‘‘For’’; 

8 (II) in subclause (I), by adding 

9 at the end ‘‘and’’; 

10 (III) in subclause (II), by strik11 ing ‘‘; and’’ and inserting a period; 

12 and 

13 (IV) by striking subclause (III); 

14 and 

15 (iii) by striking clause (iii). 

16 (B) CONTINUATION OF MEANINGFUL USE

17 DETERMINATIONS FOR VBP PROGRAM.—Section 

18 1848(o)(2) of the Social Security Act (42 

19 U.S.C. 1395w–4(o)(2)) is amended— 

20 (i) in subparagraph (A), in the matter 

21 preceding clause (i)— 

22 (I) by striking ‘‘For purposes of 

23 paragraph (1), an’’ and inserting 

24 ‘‘An’’; and 


smartinez on DSK6TPTVN1PROD with BILLS
8 

•S 1871 PCS

1 (II) by inserting ‘‘, or pursuant 

2 to subparagraph (D) for purposes of 

3 subsection (q), for a performance pe4 riod under such subsection for a year’’ 

5 after ‘‘under such subsection for a 

6 year’’; and 

7 (ii) by adding at the end the following 

8 new subparagraph: 

9 ‘‘(D) CONTINUED APPLICATION FOR PUR10 POSES OF VBP PROGRAM.—With respect to 

11 2017 and each subsequent payment year, the 

12 Secretary shall, for purposes of subsection (q) 

13 and in accordance with paragraph (1)(F) of 

14 such subsection, determine whether an eligible 

15 professional who is a VBP eligible professional 

16 (as defined in subsection (q)(1)(C)) for such 

17 year is a meaningful EHR user under this 

18 paragraph for the performance period under 

19 subsection (q) for such year.’’. 

20 (2) QUALITY REPORTING.— 

21 (A) SUNSETTING SEPARATE QUALITY RE22 PORTING INCENTIVES.—Section 1848(a)(8)(A) 

23 of the Social Security Act (42 U.S.C. 1395w– 

24 4(a)(8)(A)) is amended— 


smartinez on DSK6TPTVN1PROD with BILLS
9 

•S 1871 PCS

1 (i) in clause (i), by striking ‘‘or any 

2 subsequent year’’ and inserting ‘‘or 2016’’; 

3 and 

4 (ii) in clause (ii)(II), by striking ‘‘and 

5 each subsequent year’’. 

6 (B) CONTINUATION OF QUALITY MEAS7 URES AND PROCESSES FOR VBP PROGRAM.— 

8 Section 1848 of the Social Security Act (42 

9 U.S.C. 1395w–4) is amended— 

10 (i) in subsection (k), by adding at the 

11 end the following new paragraph: 

12 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

13 OF VBP PROGRAM.—The Secretary shall, in accord14 ance with subsection (q)(1)(F), carry out the provi15 sions of this subsection for purposes of subsection 

16 (q).’’; and 

17 (ii) in subsection (m)— 

18 (I) by redesignating the para19 graph (7) added by section 10327(a) 

20 of Public Law 111–148 as paragraph 

21 (8); and 

22 (II) by adding at the end the fol23 lowing new paragraph: 

24 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

25 OF VBP PROGRAM.—The Secretary shall, in accordVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
10 

•S 1871 PCS

1 ance with subsection (q)(1)(F), carry out the proc2 esses under this subsection for purposes of sub3 section (q).’’. 

4 (3) VALUE-BASED PAYMENTS.— 

5 (A) SUNSETTING SEPARATE VALUE-BASED

6 PAYMENTS.—Clause (iii) of section 

7 1848(p)(4)(B) of the Social Security Act (42 

8 U.S.C. 1395w–4(p)(4)(B)) is amended to read 

9 as follows: 

10 ‘‘(iii) APPLICATION.—The Secretary 

11 shall apply the payment modifier estab12 lished under this subsection for items and 

13 services furnished on or after January 1, 

14 2015, but before January 1, 2017, with re15 spect to specific physicians and groups of 

16 physicians the Secretary determines appro17 priate. Such payment modifier shall not be 

18 applied for items and services furnished on 

19 or after January 1, 2017.’’. 

20 (B) CONTINUATION OF VALUE-BASED PAY21 MENT MODIFIER MEASURES FOR VBP PRO22 GRAM.—Section 1848(p) of the Social Security 

23 Act (42 U.S.C. 1395w–4(p)) is amended— 

24 (i) in paragraph (2), by adding at the 

25 end the following new subparagraph: 


smartinez on DSK6TPTVN1PROD with BILLS
11 

•S 1871 PCS

1 ‘‘(C) CONTINUED APPLICATION FOR PUR2 POSES OF VBP PROGRAM.—The Secretary shall, 

3 in accordance with subsection (q)(1)(F), carry 

4 out subparagraph (B) for purposes of sub5 section (q).’’; and 

6 (ii) in paragraph (3), by adding at the 

7 end the following: ‘‘With respect to 2017 

8 and each subsequent year, the Secretary 

9 shall, in accordance with subsection 

10 (q)(1)(F), carry out this paragraph for 

11 purposes of subsection (q).’’. 

12 (c) VALUE-BASED PERFORMANCE INCENTIVE PRO13 GRAM.— 

14 (1) IN GENERAL.—Section 1848 of the Social 

15 Security Act (42 U.S.C. 1395w–4) is amended by 

16 adding at the end the following new subsection: 

17 ‘‘(q) VALUE-BASED PERFORMANCE INCENTIVE PRO18 GRAM.— 

19 ‘‘(1) ESTABLISHMENT.— 

20 ‘‘(A) IN GENERAL.—Subject to the suc21 ceeding provisions of this subsection, the Sec22 retary shall establish an eligible professional 

23 value-based performance incentive program (in 

24 this subsection referred to as the ‘VBP pro25 gram’) under which the Secretary shall— 


smartinez on DSK6TPTVN1PROD with BILLS
12 

•S 1871 PCS

1 ‘‘(i) develop a methodology for assess2 ing the total performance of each VBP eli3 gible professional according to performance 

4 standards under paragraph (3) for a per5 formance period (as established under 

6 paragraph (4)) for a year; 

7 ‘‘(ii) using such methodology, provide 

8 for a composite performance score in ac9 cordance with paragraph (5) for each such 

10 professional for each performance period; 

11 and 

12 ‘‘(iii) use such composite performance 

13 score of the VBP eligible professional for a 

14 performance period for a year to make 

15 VBP program incentive payments under 

16 paragraph (7) to the professional for the 

17 year. 

18 ‘‘(B) PROGRAM IMPLEMENTATION.—The 

19 VBP program shall apply to payments for items 

20 and services furnished on or after January 1, 

21 2017. 

22 ‘‘(C) VBP ELIGIBLE PROFESSIONAL DE23 FINED.— 

24 ‘‘(i) IN GENERAL.—For purposes of 

25 this subsection, subject to clauses (ii) and 


smartinez on DSK6TPTVN1PROD with BILLS
13 

•S 1871 PCS

1 (iv), the term ‘VBP eligible professional’ 

2 means— 

3 ‘‘(I) for the first and second 

4 years for which the VBP program ap5 plies to payments (and for the per6 formance period for such first and 

7 second year), a physician (as defined 

8 in section 1861(r)), a physician assist9 ant, nurse practitioner, and clinical 

10 nurse specialist (as such terms are de11 fined in section 1861(aa)(5)), and a 

12 certified registered nurse anesthetist 

13 (as defined in section 1861(bb)(2)); 

14 and 

15 ‘‘(II) for the third year for which 

16 the VBP program applies to payments 

17 (and for the performance period for 

18 such third year) and for each suc19 ceeding year (and for the performance 

20 period for each such year), the profes21 sionals described in subclause (I) and 

22 such other eligible professionals (as 

23 defined in subsection (k)(3)(B)) as 

24 specified by the Secretary. 


smartinez on DSK6TPTVN1PROD with BILLS
14 

•S 1871 PCS

1 ‘‘(ii) EXCLUSIONS.—For purposes of 

2 clause (i), the term ‘VBP eligible profes3 sional’ does not include, with respect to a 

4 year, an eligible professional (as defined in 

5 subsection (k)(3)(B))— 

6 ‘‘(I) who is a qualifying APM 

7 participant (as defined in section 

8 1833(z)(2)); 

9 ‘‘(II) who, subject to clause (vii), 

10 is a partial qualifying APM partici11 pant (as defined in clause (iii)) for the 

12 most recent period for which data are 

13 available and who, for the perform14 ance period with respect to such year, 

15 does not report on applicable meas16 ures and activities described in para17 graph (2)(B) that are required to be 

18 reported by such a professional under 

19 the VBP program; or 

20 ‘‘(III) who, for the performance 

21 period with respect to such year, does 

22 not exceed the low-volume threshold 

23 measurement selected under clause 

24 (iv). 


smartinez on DSK6TPTVN1PROD with BILLS
15 

•S 1871 PCS

1 ‘‘(iii) PARTIAL QUALIFYING APM PAR2 TICIPANT.—For purposes of this subpara3 graph, the term ‘partial qualifying APM 

4 participant’ means, with respect to a year, 

5 an eligible professional for whom the Sec6 retary determines the minimum payment 

7 percentage (or percentages), as applicable, 

8 described in paragraph (2) of section 

9 1833(z) for such year have not been satis10 fied, but who would be considered a quali11 fying APM participant (as defined in such 

12 paragraph) for such year if— 

13 ‘‘(I) with respect to 2017 and 

14 2018, the reference in subparagraph 

15 (A) of such paragraph to 25 percent 

16 was instead a reference to 20 percent; 

17 ‘‘(II) with respect to 2019 and 

18 2020— 

19 ‘‘(aa) the reference in sub20 paragraph (B)(i) of such para21 graph to 50 percent was instead 

22 a reference to 40 percent; and 

23 ‘‘(bb) the references in sub24 paragraph (B)(ii) of such para25 graph to 50 percent and 25 perVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
16 

•S 1871 PCS

1 cent of such paragraph were in2 stead references to 40 percent 

3 and 20 percent, respectively; and 

4 ‘‘(III) with respect to 2021 and 

5 subsequent years— 

6 ‘‘(aa) the reference in sub7 paragraph (C)(i) of such para8 graph to 75 percent was instead 

9 a reference to 50 percent; and 

10 ‘‘(bb) the references in sub11 paragraph (C)(ii) of such para12 graph to 75 percent and 25 per13 cent of such paragraph were in14 stead references to 50 percent 

15 and 20 percent, respectively. 

16 ‘‘(iv) SELECTION OF LOW-VOLUME

17 THRESHOLD MEASUREMENT.—The Sec18 retary shall select one of the following low19 volume threshold measurements to apply 

20 for purposes of clause (ii)(III): 

21 ‘‘(I) The minimum number (as 

22 determined by the Secretary) of indi23 viduals enrolled under this part who 

24 are treated by the VBP eligible proVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
17 

•S 1871 PCS

1 fessional for the performance period 

2 involved. 

3 ‘‘(II) The minimum number (as 

4 determined by the Secretary) of items 

5 and services furnished to individuals 

6 enrolled under this part by such pro7 fessional for such performance period. 

8 ‘‘(III) The minimum amount (as 

9 determined by the Secretary) of al10 lowed charges billed by such profes11 sional under this part for such per12 formance period. 

13 ‘‘(v) TREATMENT OF NEW MEDICARE

14 ENROLLED ELIGIBLE PROFESSIONALS.—In 

15 the case of a professional who first be16 comes a Medicare enrolled eligible profes17 sional during the performance period for a 

18 year (and had not previously submitted 

19 claims under this title such as a person, an 

20 entity, or a part of a physician group or 

21 under a different billing number or tax 

22 identifier), such professional shall not be 

23 treated under this subsection as a VBP eli24 gible professional until the subsequent year 


smartinez on DSK6TPTVN1PROD with BILLS
18 

•S 1871 PCS

1 and performance period for such subse2 quent year. 

3 ‘‘(vi) CLARIFICATION.—In the case of 

4 items and services furnished during a year 

5 by an individual who is not a VBP eligible 

6 professional (including pursuant to clauses 

7 (ii) and (v)) with respect to a year, in no 

8 case shall a reduction under paragraph (6) 

9 or a VBP program incentive payment 

10 under paragraph (7) apply to such indi11 vidual for such year. 

12 ‘‘(vii) PARTIAL QUALIFYING APM PAR13 TICIPANT CLARIFICATION.—In the case of 

14 an eligible professional who is a partial 

15 qualifying APM participant, with respect 

16 to a year, and who for the performance pe17 riod for such year reports on applicable 

18 measures and activities described in para19 graph (2)(B) that are required to be re20 ported by such a professional under the 

21 VBP program, such eligible professional is 

22 considered to be a VBP eligible profes23 sional with respect to such year. 

24 ‘‘(D) APPLICATION TO GROUP PRAC25 TICES.— 


smartinez on DSK6TPTVN1PROD with BILLS
19 

•S 1871 PCS

1 ‘‘(i) IN GENERAL.—Under the VBP 

2 program: 

3 ‘‘(I) QUALITY PERFORMANCE

4 CATEGORY.—The Secretary shall es5 tablish and apply a process that in6 cludes features of the provisions of 

7 subsection (m)(3)(C) for VBP eligible 

8 professionals in a group practice with 

9 respect to assessing performance of 

10 such group with respect to the per11 formance category described in clause 

12 (i) of paragraph (2)(A). 

13 ‘‘(II) OTHER PERFORMANCE CAT14 EGORIES.—The Secretary may estab15 lish and apply a process that includes 

16 features of the provisions of sub17 section (m)(3)(C) for VBP eligible 

18 professionals in a group practice with 

19 respect to assessing the performance 

20 of such group with respect to the per21 formance categories described in 

22 clauses (ii) through (iv) of such para23 graph. 

24 ‘‘(ii) ENSURING COMPREHENSIVENESS

25 OF GROUP PRACTICE ASSESSMENT.—The 


smartinez on DSK6TPTVN1PROD with BILLS
20 

•S 1871 PCS

1 process established under clause (i) shall to 

2 the extent practicable reflect the full range 

3 of items and services furnished by the 

4 VBP eligible professionals in the group 

5 practice involved. 

6 ‘‘(iii) CLARIFICATION.—VBP eligible 

7 professionals electing to be a virtual group 

8 under paragraph (5)(J) shall not be con9 sidered VBP eligible professionals in a 

10 group practice for purposes of applying 

11 this subparagraph. 

12 ‘‘(E) USE OF REGISTRIES.—Under the 

13 VBP program, the Secretary shall encourage 

14 the use of qualified clinical data registries pur15 suant to subsection (m)(3)(E) in carrying out 

16 this subsection. 

17 ‘‘(F) APPLICATION OF CERTAIN PROVI18 SIONS.—In applying a provision of subsection 

19 (k), (m), (o), or (p) for purposes of this sub20 section, the Secretary shall— 

21 ‘‘(i) adjust the application of such 

22 provision to ensure the provision is con23 sistent with the provisions of this sub24 section; and 


smartinez on DSK6TPTVN1PROD with BILLS
21 

•S 1871 PCS

1 ‘‘(ii) not apply such provision to the 

2 extent that the provision is duplicative with 

3 a provision of this subsection. 

4 ‘‘(2) MEASURES AND ACTIVITIES UNDER PER5 FORMANCE CATEGORIES.— 

6 ‘‘(A) PERFORMANCE CATEGORIES.—Under 

7 the VBP program, the Secretary shall use the 

8 following performance categories (each of which 

9 is referred to in this subsection as a perform10 ance category) in determining the composite 

11 performance score under paragraph (5): 

12 ‘‘(i) Quality. 

13 ‘‘(ii) Resource use. 

14 ‘‘(iii) Clinical practice improvement 

15 activities. 

16 ‘‘(iv) Meaningful use of certified EHR 

17 technology. 

18 ‘‘(B) MEASURES AND ACTIVITIES SPECI19 FIED FOR EACH CATEGORY.—For purposes of 

20 paragraph (3)(A) and subject to subparagraph 

21 (C), measures and activities specified for a per22 formance period (as established under para23 graph (4)) for a year are as follows: 

24 ‘‘(i) QUALITY.—For the performance 

25 category described in subparagraph (A)(i), 


smartinez on DSK6TPTVN1PROD with BILLS
22 

•S 1871 PCS

1 the quality measures established for such 

2 period under subsections (k) and (m), in3 cluding under subsection (m)(3)(E), and 

4 the measures of quality of care established 

5 for such period under subsection (p)(2). 

6 ‘‘(ii) RESOURCE USE.—For the per7 formance category described in subpara8 graph (A)(ii), the measurement of resource 

9 use for such period under subsection 

10 (p)(3), using the methodology under sub11 section (r), as appropriate, and, as feasible 

12 and applicable, accounting for the cost of 

13 covered part D drugs. 

14 ‘‘(iii) CLINICAL PRACTICE IMPROVE15 MENT ACTIVITIES.—For the performance 

16 category described in subparagraph 

17 (A)(iii), clinical practice improvement ac18 tivities under subcategories specified by the 

19 Secretary for such period, which shall in20 clude at least the following: 

21 ‘‘(I) The subcategory of expanded 

22 practice access, which shall include ac23 tivities such as same day appoint24 ments for urgent needs and after 

25 hours access to clinician advice. 


smartinez on DSK6TPTVN1PROD with BILLS
23 

•S 1871 PCS

1 ‘‘(II) The subcategory of popu2 lation management, which shall in3 clude activities such as monitoring 

4 health conditions of individuals to pro5 vide timely health care interventions 

6 or participation in a qualified clinical 

7 data registry. 

8 ‘‘(III) The subcategory of care 

9 coordination, which shall include ac10 tivities such as timely communication 

11 of test results, timely exchange of 

12 clinical information to patients and 

13 other providers, and use of remote 

14 monitoring or telehealth. 

15 ‘‘(IV) The subcategory of bene16 ficiary engagement, which shall in17 clude activities such as the establish18 ment of care plans for individuals 

19 with complex care needs, beneficiary 

20 self-management training, and using 

21 shared decision-making mechanisms. 

22 ‘‘(V) The subcategory of patient 

23 safety and practice assessment, such 

24 as through use of clinical or surgical 


smartinez on DSK6TPTVN1PROD with BILLS
24 

•S 1871 PCS

1 checklists and practice assessments 

2 related to maintaining certification. 

3 ‘‘(VI) The subcategory of partici4 pation in an alternative payment 

5 model (as defined in section 

6 1833(z)(3)(C)). 

7 In establishing activities under this clause, 

8 the Secretary shall give consideration to 

9 the circumstances of small practices (con10 sisting of 10 or fewer professionals) and 

11 practices located in rural areas and in 

12 health professional shortage areas (as des13 ignated under section 332(a)(1)(A) of the 

14 Public Health Service Act). 

15 ‘‘(iv) MEANINGFUL EHR USE.—For 

16 the performance category described in sub17 paragraph (A)(iv), the requirements estab18 lished for such period under subsection 

19 (o)(2) for determining whether an eligible 

20 professional is a meaningful EHR user. 

21 ‘‘(C) ADDITIONAL PROVISIONS.— 

22 ‘‘(i) EMPHASIZING OUTCOME MEAS23 URES UNDER QUALITY PERFORMANCE CAT24 EGORY.—In applying subparagraph (B)(i), 


smartinez on DSK6TPTVN1PROD with BILLS
25 

•S 1871 PCS

1 the Secretary shall, as feasible, emphasize 

2 the application of outcome measures. 

3 ‘‘(ii) APPLICATION OF ADDITIONAL

4 SYSTEM MEASURES.—The Secretary may 

5 use measures used for a payment system 

6 other than for physicians for purposes of 

7 the performance category described in sub8 paragraph (A)(i). 

9 ‘‘(iii) GLOBAL AND POPULATION10 BASED MEASURES.—The Secretary may 

11 use global measures, such as global out12 come measures, and population-based 

13 measures for purposes of the performance 

14 category described in subparagraph (A)(i). 

15 ‘‘(iv) REQUEST FOR INFORMATION

16 FOR CLINICAL PRACTICE IMPROVEMENT

17 ACTIVITIES.—In initially applying subpara18 graph (B)(iii), the Secretary shall use a re19 quest for information to solicit rec20 ommendations from stakeholders for iden21 tifying activities described in such subpara22 graph and specifying criteria for such ac23 tivities. 

24 ‘‘(v) CONTRACT AUTHORITY FOR

25 CLINICAL PRACTICE IMPROVEMENT ACTIVIVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00025 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
26 

•S 1871 PCS

1 TIES PERFORMANCE CATEGORY.—In apply2 ing subparagraph (B)(iii), the Secretary 

3 may contract with entities to assist the 

4 Secretary in— 

5 ‘‘(I) identifying activities de6 scribed in subparagraph (B)(iii); 

7 ‘‘(II) specifying criteria for such 

8 activities; and 

9 ‘‘(III) determining whether a 

10 VBP eligible professional meets such 

11 criteria. 

12 ‘‘(3) PERFORMANCE STANDARDS.— 

13 ‘‘(A) ESTABLISHMENT.—Under the VBP 

14 program, the Secretary shall establish perform15 ance standards with respect to measures and 

16 activities specified under paragraph (2)(B) for 

17 a performance period (as established under 

18 paragraph (4)) for a year. 

19 ‘‘(B) CONSIDERATIONS IN ESTABLISHING

20 STANDARDS.—In establishing such performance 

21 standards with respect to measures and activi22 ties specified under paragraph (2)(B), the Sec23 retary shall take into account the following: 

24 ‘‘(i) Historical performance standards. 

25 ‘‘(ii) Improvement rates. 


smartinez on DSK6TPTVN1PROD with BILLS
27 

•S 1871 PCS

1 ‘‘(iii) The opportunity for continued 

2 improvement. 

3 ‘‘(4) PERFORMANCE PERIOD.—The Secretary 

4 shall establish a performance period (or periods) for 

5 a year (beginning with the year described in para6 graph (1)(B)). Such performance period (or periods) 

7 shall begin and end prior to the beginning of such 

8 year and be as close as possible to such year. In this 

9 subsection, such performance period (or periods) for 

10 a year shall be referred to as the performance period 

11 for the year. 

12 ‘‘(5) COMPOSITE PERFORMANCE SCORE.— 

13 ‘‘(A) IN GENERAL.—Subject to the suc14 ceeding provisions of this paragraph, the Sec15 retary shall develop a methodology for assessing 

16 the total performance of each VBP eligible pro17 fessional according to performance standards 

18 under paragraph (3) with respect to applicable 

19 measures and activities specified in paragraph 

20 (2)(B) with respect to each performance cat21 egory applicable to such professional for a per22 formance period (as established under para23 graph (4)) for a year. Using such methodology, 

24 the Secretary shall provide for a composite as25 sessment (in this subsection referred to as the 


smartinez on DSK6TPTVN1PROD with BILLS
28 

•S 1871 PCS

1 ‘composite performance score’) for each such 

2 professional for each performance period. 

3 ‘‘(B) WEIGHTING PERFORMANCE CAT4 EGORIES, MEASURES, AND ACTIVITIES.—Under 

5 the methodology under subparagraph (A), the 

6 Secretary— 

7 ‘‘(i) may assign different scoring 

8 weights (including a weight of 0) for— 

9 ‘‘(I) each performance category 

10 based on the extent to which the cat11 egory is applicable to the type of eligi12 ble professional involved; and 

13 ‘‘(II) each measure and activity 

14 specified under paragraph (2)(B) with 

15 respect to each such category based 

16 on the extent to which the measure or 

17 activity is applicable to the type of eli18 gible professional involved; and 

19 ‘‘(ii) with respect to the performance 

20 category described in paragraph 

21 (2)(A)(i)— 

22 ‘‘(I) shall assign a higher scoring 

23 weight to outcomes measures than to 

24 other measures and increase the scorVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00028 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
29 

•S 1871 PCS

1 ing weight for outcome measures over 

2 time; and 

3 ‘‘(II) may assign a higher scoring 

4 weight to patient experience measures. 

5 ‘‘(C) INCENTIVE TO REPORT; ENCOUR6 AGING USE OF CERTIFIED EHR TECHNOLOGY

7 FOR REPORTING QUALITY MEASURES.— 

8 ‘‘(i) INCENTIVE TO REPORT.—Under 

9 the methodology established under sub10 paragraph (A), the Secretary shall provide 

11 that in the case of a VBP eligible profes12 sional who fails to report on an applicable 

13 measure or activity that is required to be 

14 reported by the professional, the profes15 sional shall be treated as achieving the 

16 lowest potential score applicable to such 

17 measure or activity. 

18 ‘‘(ii) ENCOURAGING USE OF CER19 TIFIED EHR TECHNOLOGY FOR REPORTING

20 QUALITY MEASURES.—Under the method21 ology established under subparagraph (A), 

22 the Secretary shall— 

23 ‘‘(I) encourage VBP eligible pro24 fessionals to report on applicable 

25 measures with respect to the performVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00029 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
30 

•S 1871 PCS

1 ance category described in paragraph 

2 (2)(A)(i) through the use of certified 

3 EHR technology; and 

4 ‘‘(II) with respect to a perform5 ance period, with respect to a year, 

6 for which a VBP eligible professional 

7 reports such measures through the 

8 use of such EHR technology, treat 

9 such professional as satisfying the 

10 clinical quality measures reporting re11 quirement described in subsection 

12 (o)(2)(A)(iii) for such year. 

13 ‘‘(D) CLINICAL PRACTICE IMPROVEMENT

14 ACTIVITIES PERFORMANCE SCORE.— 

15 ‘‘(i) RULE FOR ACCREDITATION.—A 

16 VBP eligible professional who is in a prac17 tice that is certified as a patient-centered 

18 medical home or comparable specialty 

19 practice pursuant to subsection 

20 (b)(8)(B)(i) with respect to a performance 

21 period shall be given the highest potential 

22 score for the performance category de23 scribed in paragraph (2)(A)(iii) for such 

24 period. 


smartinez on DSK6TPTVN1PROD with BILLS
31 

•S 1871 PCS

1 ‘‘(ii) APM PARTICIPATION.—Partici2 pation by a VBP eligible professional in an 

3 alternative payment model (as defined in 

4 section 1833(z)(3)(C)) with respect to a 

5 performance period shall earn such eligible 

6 professional one-half of the highest poten7 tial score for the performance category de8 scribed in paragraph (2)(A)(iii) for such 

9 performance period. Nothing in the pre10 vious sentence shall prevent such profes11 sional from earning more than one-half of 

12 such highest potential score for such per13 formance period by performing additional 

14 activities with respect to such performance 

15 category. 

16 ‘‘(iii) SUBCATEGORIES.—A VBP eligi17 ble professional shall not be required to 

18 perform activities in each subcategory 

19 under paragraph (2)(B)(iii) to achieve the 

20 highest potential score for the performance 

21 category described in paragraph (2)(A)(iii). 

22 ‘‘(E) DISTRIBUTION.—The Secretary shall 

23 ensure that the application of the methodology 

24 developed under subparagraph (A) results in a 

25 continuous distribution of performance scores, 


smartinez on DSK6TPTVN1PROD with BILLS
32 

•S 1871 PCS

1 which shall result in differential payments 

2 under paragraph (7). 

3 ‘‘(F) ACHIEVEMENT AND IMPROVEMENT.— 

4 ‘‘(i) TAKING INTO ACCOUNT IMPROVE5 MENT.—Beginning with the second year to 

6 which the VBP program applies, in addi7 tion to the achievement score of a VBP eli8 gible professional, the methodology devel9 oped under subparagraph (A)— 

10 ‘‘(I) in the case of the perform11 ance score for the performance cat12 egory described in clauses (i) and (ii) 

13 of paragraph (2)(A), shall take into 

14 account the improvement of the pro15 fessional; and 

16 ‘‘(II) in the case of performance 

17 scores for other performance cat18 egories, may take into account the im19 provement of the professional. 

20 ‘‘(ii) ASSIGNING HIGHER WEIGHT FOR

21 ACHIEVEMENT.—Beginning with the 

22 fourth year to which the VBP program ap23 plies, under the methodology developed 

24 under subparagraph (A), the Secretary 

25 shall assign a higher scoring weight under 


smartinez on DSK6TPTVN1PROD with BILLS
33 

•S 1871 PCS

1 subparagraph (B) with respect to the 

2 achievement score of a VBP eligible profes3 sional with respect to a measure or activity 

4 specified under paragraph (2)(B) (or with 

5 respect to such a measure or activity and 

6 with respect to categories described in 

7 paragraph (2)(A)) than to any improve8 ment score applied under clause (i) with 

9 respect to such measure or activity (or 

10 such measure or activity and categories). 

11 ‘‘(G) WEIGHTS FOR THE PERFORMANCE

12 CATEGORIES.— 

13 ‘‘(i) IN GENERAL.—Under the meth14 odology developed under subparagraph (A), 

15 subject to clauses (ii) and (iii), the com16 posite performance score shall be deter17 mined as follows: 

18 ‘‘(I) QUALITY.—Thirty percent of 

19 such score shall be based on perform20 ance with respect to the category de21 scribed in clause (i) of paragraph 

22 (2)(A). 

23 ‘‘(II) RESOURCE USE.—Thirty 

24 percent of such score shall be based 

25 on performance with respect to the 


smartinez on DSK6TPTVN1PROD with BILLS
34 

•S 1871 PCS

1 category described in clause (ii) of 

2 paragraph (2)(A). 

3 ‘‘(III) CLINICAL PRACTICE IM4 PROVEMENT ACTIVITIES.—Fifteen 

5 percent of such score shall be based 

6 on performance with respect to the 

7 category described in clause (iii) of 

8 paragraph (2)(A). 

9 ‘‘(IV) MEANINGFUL USE OF CER10 TIFIED EHR TECHNOLOGY.—Twenty11 five percent of such score shall be 

12 based on performance with respect to 

13 the category described in clause (iv) of 

14 paragraph (2)(A). 

15 ‘‘(ii) AUTHORITY TO ADJUST PER16 CENTAGES IN CASE OF HIGH EHR MEAN17 INGFUL USE ADOPTION.—In any year in 

18 which the Secretary estimates that the pro19 portion of eligible professionals (as defined 

20 in subsection (o)(5)) who are meaningful 

21 EHR users (as determined under sub22 section (o)(2)) is 75 percent or greater, the 

23 Secretary may reduce the percent applica24 ble under clause (i)(IV), but not below 15 

25 percent. If the Secretary makes such reVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00034 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
35 

•S 1871 PCS

1 duction for a year, the percentages applica2 ble under one or more of subclauses (I), 

3 (II), and (III) of clause (i) for such year 

4 shall be increased in a manner such that 

5 the total percentage points of the increase 

6 under this clause for such year equals the 

7 total number of percentage points reduced 

8 under the preceding sentence for such 

9 year. 

10 ‘‘(iii) AUTHORITY TO ADJUST PER11 CENTAGES FOR QUALITY AND RESOURCE

12 USE.— 

13 ‘‘(I) IN GENERAL.—Subject to 

14 subclause (II), the percentages de15 scribed in subclauses (I) and (II) of 

16 clause (i), including after application 

17 of clause (ii), shall be equal. 

18 ‘‘(II) EXCEPTION.—For the first 

19 2 years for which the VBP program 

20 applies, after application of clause (ii), 

21 the Secretary may increase the per22 centage applicable under subclause (I) 

23 or (II) of clause (i) as long as the 

24 Secretary decreases the percentage 

25 applicable under the other subclause 


smartinez on DSK6TPTVN1PROD with BILLS
36 

•S 1871 PCS

1 by an equal number of percentage 

2 points and the number of percentage 

3 points applicable under each of sub4 clauses (I) and (II) is not less than 

5 15. 

6 ‘‘(H) RESOURCE USE.—Analysis of the 

7 performance category described in paragraph 

8 (2)(A)(ii) shall include results from the method9 ology described in subsection (r)(5), as appro10 priate. 

11 ‘‘(I) INCLUSION OF QUALITY MEASURE

12 DATA FROM MULTIPLE PAYERS.—In applying 

13 subsections (k), (m), and (p) with respect to 

14 measures described in paragraph (2)(B)(i), 

15 analysis of the performance category described 

16 in paragraph (2)(A)(i) may include data sub17 mitted by VBP eligible professionals with re18 spect to multiple payers. 

19 ‘‘(J) USE OF VOLUNTARY VIRTUAL

20 GROUPS FOR CERTAIN ASSESSMENT PUR21 POSES.— 

22 ‘‘(i) IN GENERAL.—In the case of 

23 VBP eligible professionals electing to be a 

24 virtual group under clause (ii) with respect 

25 to a performance period for a year, for 


smartinez on DSK6TPTVN1PROD with BILLS
37 

•S 1871 PCS

1 purposes of applying the methodology 

2 under subparagraph (A)— 

3 ‘‘(I) the assessment of perform4 ance provided under such methodology 

5 with respect to the performance cat6 egories described in clauses (i) and 

7 (ii) of paragraph (2)(A) that is to be 

8 applied to each such professional in 

9 such group for such performance pe10 riod shall be with respect to the com11 bined performance of all such profes12 sionals in such group for such period; 

13 and 

14 ‘‘(II) the composite score pro15 vided under this paragraph for such 

16 performance period with respect to 

17 each such performance category for 

18 each such VBP eligible professional in 

19 such virtual group shall be based on 

20 the assessment of the combined per21 formance under subclause (I) for the 

22 performance category and perform23 ance period. 

24 ‘‘(ii) ELECTION OF PRACTICES TO BE

25 A VIRTUAL GROUP.—The Secretary shall, 


smartinez on DSK6TPTVN1PROD with BILLS
38 

•S 1871 PCS

1 in accordance with clause (iii), establish 

2 and have in place a process to allow an in3 dividual VBP eligible professional or a 

4 group practice consisting of not more than 

5 10 VBP eligible professionals to elect, with 

6 respect to a performance period for a year, 

7 for such individual VBP eligible profes8 sional or all such VBP eligible profes9 sionals in such group practice, respectively, 

10 to be a virtual group under this subpara11 graph with at least one other such indi12 vidual VBP eligible professional or group 

13 practice making such an election. 

14 ‘‘(iii) REQUIREMENTS.—The process 

15 under clause (ii) shall provide that— 

16 ‘‘(I) an election under such 

17 clause, with respect to a performance 

18 period, shall be made before the be19 ginning of such performance period 

20 and may not be changed during such 

21 performance period; and 

22 ‘‘(II) a practice described in such 

23 clause, and each VBP eligible profes24 sional in such practice, may elect to 


smartinez on DSK6TPTVN1PROD with BILLS
39 

•S 1871 PCS

1 be in no more than one virtual group 

2 for a performance period. 

3 ‘‘(6) FUNDING FOR VBP PROGRAM INCENTIVE

4 PAYMENTS.— 

5 ‘‘(A) TOTAL AMOUNT FOR INCENTIVE PAY6 MENTS.—The total amount for VBP program 

7 incentive payments under paragraph (7) for all 

8 VBP eligible professionals for a year shall be 

9 equal to the total amount of the performance 

10 funding pool for all VBP eligible professionals 

11 under subparagraph (B) for such year, as esti12 mated by the Secretary. 

13 ‘‘(B) PERFORMANCE FUNDING POOL.— 

14 ‘‘(i) IN GENERAL.—In the case of 

15 items and services furnished by a VBP eli16 gible professional during a year (beginning 

17 with 2017), the otherwise applicable fee 

18 schedule amount (as defined in clause (iii)) 

19 with respect to such items and services and 

20 eligible professional for such year shall be 

21 reduced by the applicable percent under 

22 clause (ii). The total amount of such re23 ductions for a year shall be referred to in 

24 this subsection as the ‘performance fund25 ing pool’ for such year. 


smartinez on DSK6TPTVN1PROD with BILLS
40 

•S 1871 PCS

1 ‘‘(ii) APPLICABLE PERCENT DE2 FINED.—For purposes of clause (i), the 

3 term ‘applicable percent’ means— 

4 ‘‘(I) for 2017, 4 percent; 

5 ‘‘(II) for 2018, 6 percent; 

6 ‘‘(III) for 2019, 8 percent; 

7 ‘‘(IV) for 2020, 10 percent; and 

8 ‘‘(V) for 2021 and subsequent 

9 years, a percent specified by the Sec10 retary (but in no case less than 10 

11 percent or more than 12 percent). 

12 ‘‘(iii) OTHERWISE APPLICABLE FEE

13 SCHEDULE AMOUNT.—For purposes of this 

14 subparagraph and paragraph (7), the term 

15 ‘otherwise applicable fee schedule amount’ 

16 means, with respect to items and services 

17 furnished by a VBP eligible professional 

18 during a year, the fee schedule amount for 

19 such items and services and year that 

20 would otherwise apply (without application 

21 of this subparagraph or paragraph (7)) 

22 with respect to such eligible professional 

23 under subsection (b), after application of 

24 subsection (a)(3), or under another fee 

25 schedule under this part. 


smartinez on DSK6TPTVN1PROD with BILLS
41 

•S 1871 PCS

1 ‘‘(7) VBP PROGRAM INCENTIVE PAYMENTS.— 

2 ‘‘(A) VBP PROGRAM INCENTIVE PAYMENT

3 ADJUSTMENT FACTOR.—The Secretary shall 

4 specify a VBP program incentive payment ad5 justment factor for each VBP eligible profes6 sional for a year. Such VBP program incentive 

7 payment adjustment factor for a VBP eligible 

8 professional for a year shall be determined— 

9 ‘‘(i) by the composite performance 

10 score of the eligible professional for such 

11 year; 

12 ‘‘(ii) in a manner such that the ad13 justment factors specified under this sub14 paragraph for a year results in differential 

15 payments under this paragraph reflecting 

16 the full range of the distribution of com17 posite performance scores of VBP eligible 

18 professionals determined under paragraph 

19 (5)(E) for such year, with such profes20 sionals having higher composite perform21 ance scores receiving higher payment; and 

22 ‘‘(iii) in a manner such that the ad23 justment factors specified under this sub24 paragraph for a year— 


smartinez on DSK6TPTVN1PROD with BILLS
42 

•S 1871 PCS

1 ‘‘(I) do not result in a payment 

2 reduction for such year by an amount 

3 that exceeds the applicable percent de4 scribed in paragraph (6)(B)(ii) for 

5 such year; and 

6 ‘‘(II) do not result in a payment 

7 increase for such year by an amount 

8 that exceeds the applicable percent de9 scribed in paragraph (6)(B)(ii) for 

10 such year. 

11 ‘‘(B) CALCULATION OF VBP PROGRAM IN12 CENTIVE PAYMENT AMOUNTS.—The VBP pro13 gram incentive payment amount with respect to 

14 items and services furnished by a VBP eligible 

15 professional during a year shall be equal to the 

16 difference between— 

17 ‘‘(i) the product of— 

18 ‘‘(I) the VBP program incentive 

19 payment adjustment factor deter20 mined under subparagraph (A) for 

21 such VBP eligible professional for 

22 such year; and 

23 ‘‘(II) the otherwise applicable fee 

24 schedule amount (as defined in para25 graph (6)(B)(iii)) with respect to such 


smartinez on DSK6TPTVN1PROD with BILLS
43 

•S 1871 PCS

1 items and services and eligible profes2 sional for such year; and 

3 ‘‘(ii) the otherwise applicable fee 

4 schedule amount, as reduced under para5 graph (6)(B), with respect to such items 

6 and services, eligible professional, and 

7 year. 

8 The application of the preceding sentence may 

9 result in the VBP program incentive payment 

10 amount being 0.0 with respect to an item or 

11 service furnished by a VBP eligible professional. 

12 ‘‘(C) APPLICATION OF VBP PROGRAM IN13 CENTIVE PAYMENT AMOUNT.—In the case of 

14 items and services furnished by a VBP eligible 

15 professional during a year (beginning with 

16 2017), the otherwise applicable fee schedule 

17 amount, as reduced under paragraph (6)(B), 

18 with respect to such items and services and eli19 gible professional for such year shall be in20 creased, if applicable, by the VBP program in21 centive payment amount determined under sub22 paragraph (B) with respect to such items and 

23 services, professional, and year. 

24 ‘‘(D) BUDGET NEUTRALITY.—In specifying 

25 the VBP program incentive payment adjustVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00043 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
44 

•S 1871 PCS

1 ment factor for each VBP eligible professional 

2 for a year under subparagraph (A), the Sec3 retary shall ensure that the total amount of 

4 VBP program incentive payment amounts 

5 under this paragraph for all VBP eligible pro6 fessionals in a year shall be equal to the per7 formance funding pool for such year under 

8 paragraph (6), as estimated by the Secretary. 

9 ‘‘(8) ANNOUNCEMENT OF RESULT OF ADJUST10 MENTS.—Under the VBP program, the Secretary 

11 shall, not later than 60 days prior to the year in12 volved, make available to each VBP eligible profes13 sional the VBP program incentive payment adjust14 ment factor under paragraph (7) and the payment 

15 reduction under paragraph (6) applicable to the eli16 gible professional for items and services furnished by 

17 the professional in such year. The Secretary may in18 clude such information in the confidential feedback 

19 under paragraph (13). 

20 ‘‘(9) NO EFFECT IN SUBSEQUENT YEARS.—The 

21 VBP program incentive payment under paragraph 

22 (7) and the payment reduction under paragraph (6) 

23 shall each apply only with respect to the year in24 volved, and the Secretary shall not take into account 

25 such VBP program incentive payment or payment 


smartinez on DSK6TPTVN1PROD with BILLS
45 

•S 1871 PCS

1 reduction in making payments to a VBP eligible pro2 fessional under this part in a subsequent year. 

3 ‘‘(10) PUBLIC REPORTING.— 

4 ‘‘(A) IN GENERAL.—The Secretary shall, 

5 in an easily understandable format, make avail6 able on the Physician Compare Internet website 

7 under subsection (t) the following: 

8 ‘‘(i) Information regarding the per9 formance of VBP eligible professionals 

10 under the VBP program, which— 

11 ‘‘(I) shall include the composite 

12 score for each such VBP eligible pro13 fessional and the performance of each 

14 such VBP eligible professional with 

15 respect to each performance category; 

16 and 

17 ‘‘(II) may include the perform18 ance of each such VBP eligible profes19 sional with respect to each measure or 

20 activity specified in paragraph (2)(B). 

21 ‘‘(ii) The names of eligible profes22 sionals in eligible alternative payment mod23 els (as defined in section 1833(z)(3)(D)) 

24 and, to the extent feasible, the names of 


smartinez on DSK6TPTVN1PROD with BILLS
46 

•S 1871 PCS

1 such eligible alternative payment models 

2 and performance of such models. 

3 ‘‘(B) OPPORTUNITY TO REVIEW AND SUB4 MIT CORRECTIONS.—The Secretary shall pro5 vide for an opportunity for a professional de6 scribed in subparagraph (A) to review, and sub7 mit corrections for, the information to be made 

8 public with respect to the professional under 

9 such subparagraph prior to such information 

10 being made public. 

11 ‘‘(C) AGGREGATE INFORMATION.—The 

12 Secretary shall periodically post on the Physi13 cian Compare Internet website aggregate infor14 mation on the VBP program, including the 

15 range of composite scores for all VBP eligible 

16 professionals and the range of the performance 

17 of all VBP eligible professionals with respect to 

18 each performance category. 

19 ‘‘(11) CONSULTATION.—The Secretary shall 

20 consult with stakeholders in carrying out the VBP 

21 program, including for the identification of measures 

22 and activities under paragraph (2)(B) and the meth23 odologies developed under paragraphs (5)(A) and 

24 (7). Such consultation shall include the use of a reVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00046 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
47 

•S 1871 PCS

1 quest for information or other mechanisms deter2 mined appropriate. 

3 ‘‘(12) TECHNICAL ASSISTANCE TO SMALL PRAC4 TICES AND PRACTICES IN HEALTH PROFESSIONAL

5 SHORTAGE AREAS.— 

6 ‘‘(A) IN GENERAL.—The Secretary shall 

7 enter into contracts or agreements with appro8 priate entities (such as quality improvement or9 ganizations, regional extension centers (as de10 scribed in section 3012(c) of the Public Health 

11 Service Act), or regional health collaboratives) 

12 to offer guidance and assistance to VBP eligible 

13 professionals in practices of 10 or fewer profes14 sionals (with priority given to such practices lo15 cated in rural areas, health professional short16 age areas (as designated in section 

17 332(a)(1)(A) of the Public Health Service Act), 

18 medically underserved areas, or practices with 

19 low composite scores) with respect to— 

20 ‘‘(i) the performance categories de21 scribed in clauses (i) through (iv) of para22 graph (2)(A); or 

23 ‘‘(ii) how to transition to the imple24 mentation of and participation in an alterVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00047 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
48 

•S 1871 PCS

1 native payment model as described in sec2 tion 1833(z)(3)(C). 

3 ‘‘(B) FUNDING FOR IMPLEMENTATION.— 

4 For purposes of implementing subparagraph 

5 (A), the Secretary shall provide for the transfer 

6 from the Federal Supplementary Medical Insur7 ance Trust Fund established under section 

8 1841 to the Centers for Medicare & Medicaid 

9 Services Program Management Account of 

10 $25,000,000 for each of fiscal years 2014 

11 through 2018. Of amounts transferred under 

12 the preceding sentence, not less than 

13 $10,000,000 shall be available for technical as14 sistance to small practices (consisting of 10 or 

15 fewer professionals) in health professional 

16 shortage areas (as so designated). Amounts 

17 transferred under this subparagraph for a fiscal 

18 year shall be available until expended. 

19 ‘‘(13) FEEDBACK AND INFORMATION TO IM20 PROVE PERFORMANCE.— 

21 ‘‘(A) PERFORMANCE FEEDBACK.— 

22 ‘‘(i) IN GENERAL.—Beginning July 1, 

23 2015, the Secretary— 

24 ‘‘(I) shall make available timely 

25 (such as quarterly) confidential feedVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00048 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
49 

•S 1871 PCS

1 back to each VBP eligible professional 

2 on the performance of such profes3 sional with respect to the performance 

4 categories under clauses (i) and (ii) of 

5 paragraph (2)(A); and 

6 ‘‘(II) may make available con7 fidential feedback to each such profes8 sional on the performance of such 

9 professional with respect to the per10 formance categories under clauses (iii) 

11 and (iv) of such paragraph. 

12 ‘‘(ii) MECHANISMS.—The Secretary 

13 may use one or more mechanisms to make 

14 feedback available under clause (i), which 

15 may include use of a web-based portal or 

16 other mechanisms determined appropriate 

17 by the Secretary. The Secretary shall en18 courage provision of feedback through 

19 qualified clinical data registries, as de20 scribed in subsection (m)(3)(E). 

21 ‘‘(iii) USE OF DATA.—For purposes of 

22 clause (i), the Secretary may use data, 

23 with respect to a VBP eligible professional, 

24 from periods prior to the current perform25 ance period and may use rolling periods in 


smartinez on DSK6TPTVN1PROD with BILLS
50 

•S 1871 PCS

1 order to make illustrative calculations 

2 about the performance of such profes3 sional. 

4 ‘‘(iv) DISCLOSURE EXEMPTION.— 

5 Feedback made available under this sub6 paragraph shall be exempt from disclosure 

7 under section 552 of title 5, United States 

8 Code. 

9 ‘‘(v) RECEIPT OF INFORMATION.— 

10 The Secretary may use the mechanisms es11 tablished under clause (ii) to receive infor12 mation from professionals, such as infor13 mation with respect to this subsection. 

14 ‘‘(B) ADDITIONAL INFORMATION.— 

15 ‘‘(i) IN GENERAL.—Beginning July 1, 

16 2016, the Secretary shall make available to 

17 each VBP eligible professional information, 

18 with respect to individuals who are pa19 tients of such VBP eligible professional, 

20 about items and services for which pay21 ment is made under this title that are fur22 nished to such individuals by other sup23 pliers and providers of services, which may 

24 include information described in clause (ii). 

25 Such information shall be made available 


smartinez on DSK6TPTVN1PROD with BILLS
51 

•S 1871 PCS

1 under the previous sentence to such VBP 

2 eligible professionals by mechanisms deter3 mined appropriate by the Secretary, which 

4 may include use of a web-based portal. 

5 Such information shall be made available 

6 in accordance with the same or similar 

7 terms as data are made available to ac8 countable care organizations under section 

9 1899, including a beneficiary opt-out. 

10 ‘‘(ii) TYPE OF INFORMATION.—For 

11 purposes of clause (i), the information de12 scribed in this clause, is the following: 

13 ‘‘(I) With respect to selected 

14 items and services (as determined ap15 propriate by the Secretary) for which 

16 payment is made under this title and 

17 that are furnished to individuals, who 

18 are patients of a VBP eligible profes19 sional, by another supplier or provider 

20 of services during the most recent pe21 riod for which data are available (such 

22 as the most recent three-month pe23 riod), the name of such providers fur24 nishing such items and services to 

25 such patients during such period, the 


smartinez on DSK6TPTVN1PROD with BILLS
52 

•S 1871 PCS

1 types of such items and services so 

2 furnished, and the dates such items 

3 and services were so furnished. 

4 ‘‘(II) Historical averages (and 

5 other measures of the distribution if 

6 appropriate) of the total, and compo7 nents of, allowed charges (and other 

8 figures as determined appropriate by 

9 the Secretary) for care episodes for 

10 such period. 

11 ‘‘(14) REVIEW.— 

12 ‘‘(A) TARGETED REVIEW.—The Secretary 

13 shall establish a process under which a VBP eli14 gible professional may seek an informal review 

15 of the calculation of the VBP program incentive 

16 payment adjustment factor applicable to such 

17 eligible professional under this subsection for a 

18 year. The results of a review conducted pursu19 ant to the previous sentence shall not be taken 

20 into account for purposes of paragraph (7) with 

21 respect to a year (other than with respect to the 

22 calculation of such eligible professional’s VBP 

23 program incentive payment adjustment factor 

24 for such year) after the factors determined in 


smartinez on DSK6TPTVN1PROD with BILLS
53 

•S 1871 PCS

1 subparagraph (A) of such paragraph have been 

2 determined for such year. 

3 ‘‘(B) LIMITATION.—Except as provided for 

4 in subparagraph (A), there shall be no adminis5 trative or judicial review under section 1869, 

6 section 1878, or otherwise of the following: 

7 ‘‘(i) The methodology used to deter8 mine the amount of the VBP program in9 centive payment adjustment factor under 

10 paragraph (7) and the determination of 

11 such amount. 

12 ‘‘(ii) The determination of the amount 

13 of funding available for such VBP program 

14 incentive payments under paragraph 

15 (6)(A) and the payment reduction under 

16 paragraph (6)(B)(i). 

17 ‘‘(iii) The establishment of the per18 formance standards under paragraph (3) 

19 and the performance period under para20 graph (4). 

21 ‘‘(iv) The identification of measures 

22 and activities specified under paragraph 

23 (2)(B) and information made public or 

24 posted on the Physician Compare Internet 


smartinez on DSK6TPTVN1PROD with BILLS
54 

•S 1871 PCS

1 website of the Centers for Medicare & 

2 Medicaid Services under paragraph (10). 

3 ‘‘(v) The methodology developed under 

4 paragraph (5) that is used to calculate per5 formance scores and the calculation of 

6 such scores, including the weighting of 

7 measures and activities under such meth8 odology.’’. 

9 (2) GAO REPORTS.— 

10 (A) EVALUATION OF ELIGIBLE PROFES11 SIONAL VBP PROGRAM.—Not later than October 

12 1, 2018, and October 1, 2021, the Comptroller 

13 General of the United States shall submit to 

14 Congress a report evaluating the eligible profes15 sional value-based performance incentive pro16 gram under subsection (q) of section 1848 of 

17 the Social Security Act (42 U.S.C. 1395w–4), 

18 as added by paragraph (1). Such report shall— 

19 (i) examine the distribution of the 

20 performance and incentive payments for 

21 VBP eligible professionals (as defined in 

22 subsection (q)(1)(C) of such section) under 

23 such program, and patterns relating to 

24 such performance and incentive payments, 

25 including those based on type of provider, 


smartinez on DSK6TPTVN1PROD with BILLS
55 

•S 1871 PCS

1 practice size, geographic location, and pa2 tient mix; 

3 (ii) provide recommendations for im4 proving such program; 

5 (iii) evaluate the impact of technical 

6 assistance funding under section 

7 1848(q)(12) of the Social Security Act, as 

8 added by paragraph (1), on the ability of 

9 professionals to improve within such pro10 gram or successfully transition to an alter11 native payment model (as defined in sec12 tion 1833(z)(3) of the Social Security Act, 

13 as added by subsection (e)(1)), with pri14 ority for such evaluation given to practices 

15 located in rural areas, health professional 

16 shortage areas (as designated in section 

17 332(a)(1)(A) of the Public Health Service 

18 Act), and medically underserved areas; and 

19 (iv) provide recommendations for opti20 mizing the use of such technical assistance 

21 funds. 

22 (B) STUDY TO EXAMINE ALIGNMENT OF

23 QUALITY MEASURES USED IN PUBLIC AND PRI24 VATE PROGRAMS.— 


smartinez on DSK6TPTVN1PROD with BILLS
56 

•S 1871 PCS

1 (i) IN GENERAL.—Not later than 18 

2 months after the date of the enactment of 

3 this Act, the Comptroller General of the 

4 United States shall submit to Congress a 

5 report that— 

6 (I) compares the similarities and 

7 differences in the use of quality meas8 ures under the original medicare fee9 for-service program under parts A and 

10 B of title XVIII of the Social Security 

11 Act, the Medicare Advantage program 

12 under part C of such title, selected 

13 State Medicaid programs under title 

14 XIX of such Act, and private payer 

15 arrangements; and 

16 (II) makes recommendations on 

17 how to reduce the administrative bur18 den involved in applying such quality 

19 measures. 

20 (ii) REQUIREMENTS.—The report 

21 under clause (i) shall— 

22 (I) consider those measures ap23 plicable to individuals entitled to, or 

24 enrolled for, benefits under such part 


smartinez on DSK6TPTVN1PROD with BILLS
57 

•S 1871 PCS

1 A, or enrolled under such part B and 

2 individuals under the age of 65; and 

3 (II) focus on those measures that 

4 comprise the most significant compo5 nent of the quality performance cat6 egory of the eligible professional 

7 value-based performance incentive 

8 program under subsection (q) of sec9 tion 1848 of the Social Security Act 

10 (42 U.S.C. 1395w–4), as added by 

11 paragraph (1). 

12 (C) STUDY TO EXAMINE RURAL AND

13 HEALTH PROFESSIONAL SHORTAGE AREA AL14 TERNATIVE PAYMENT MODELS.—Not later than 

15 October 1, 2019, and October 1, 2021, the 

16 Comptroller General of the United States shall 

17 submit to Congress a report that examines the 

18 transition of professionals in rural areas, health 

19 professional shortage areas (as designated in 

20 section 332(a)(1)(A) of the Public Health Serv21 ice Act), or medically underserved areas to an 

22 alternative payment model (as defined in sec23 tion 1833(z)(3) of the Social Security Act, as 

24 added by subsection (e)(1)). Such report shall 

25 make recommendations for removing adminisVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00057 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
58 

•S 1871 PCS

1 trative barriers to practices in rural areas, 

2 health professional shortage areas, and medi3 cally underserved areas to participation in such 

4 models. 

5 (3) FUNDING FOR IMPLEMENTATION.—For 

6 purposes of implementing the provisions of and the 

7 amendments made by this section, the Secretary of 

8 Health and Human Services shall provide for the 

9 transfer of $50,000,000 from the Supplementary 

10 Medical Insurance Trust Fund established under 

11 section 1841 of the Social Security Act (42 U.S.C. 

12 1395t) to the Centers for Medicare & Medicaid Pro13 gram Management Account for each of the fiscal 

14 years 2014 through 2017. Amounts transferred 

15 under this paragraph shall be available until ex16 pended. 

17 (d) IMPROVING QUALITY REPORTING FOR COM18 POSITE SCORES.— 

19 (1) CHANGES FOR GROUP REPORTING OP20 TION.— 

21 (A) IN GENERAL.—Section 

22 1848(m)(3)(C)(ii) of the Social Security Act 

23 (42 U.S.C. 1395w–4(m)(3)(C)(ii)) is amended 

24 by inserting ‘‘and, for 2014 and subsequent 

25 years, may provide’’ after ‘‘shall provide’’. 


smartinez on DSK6TPTVN1PROD with BILLS
59 

•S 1871 PCS

1 (B) CLARIFICATION OF QUALIFIED CLIN2 ICAL DATA REGISTRY REPORTING TO GROUP

3 PRACTICES.—Section 1848(m)(3)(D) of the So4 cial Security Act (42 U.S.C. 1395w– 

5 4(m)(3)(D)) is amended by inserting ‘‘and, for 

6 2015 and subsequent years, subparagraph (A) 

7 or (C)’’ after ‘‘subparagraph (A)’’. 

8 (2) CHANGES FOR MULTIPLE REPORTING PERI9 ODS AND ALTERNATIVE CRITERIA FOR SATISFAC10 TORY REPORTING.—Section 1848(m)(5)(F) of the 

11 Social Security Act (42 U.S.C. 1395w–4(m)(5)(F)) 

12 is amended— 

13 (A) by striking ‘‘and subsequent years’’ 

14 and inserting ‘‘through reporting periods occur15 ring in 2013’’; and 

16 (B) by inserting ‘‘and, for reporting peri17 ods occurring in 2014 and subsequent years, 

18 the Secretary may establish’’ following ‘‘shall 

19 establish’’. 

20 (3) PHYSICIAN FEEDBACK PROGRAM REPORTS

21 SUCCEEDED BY REPORTS UNDER VBP PROGRAM.— 

22 Section 1848(n) of the Social Security Act (42 

23 U.S.C. 1395w–4(n)) is amended by adding at the 

24 end the following new paragraph: 


smartinez on DSK6TPTVN1PROD with BILLS
60 

•S 1871 PCS

1 ‘‘(11) REPORTS ENDING WITH 2016.—Reports 

2 under the Program shall not be provided after De3 cember 31, 2016. See subsection (q)(13) for reports 

4 beginning with 2017.’’. 

5 (4) COORDINATION WITH SATISFYING MEANING6 FUL EHR USE CLINICAL QUALITY MEASURE REPORT7 ING REQUIREMENT.—Section 1848(o)(2)(A)(iii) of 

8 the Social Security Act (42 U.S.C. 1395w– 

9 4(o)(2)(A)(iii)) is amended by inserting ‘‘and sub10 section (q)(5)(C)(ii)(II)’’ after ‘‘Subject to subpara11 graph (B)(ii)’’. 

12 (e) PROMOTING ALTERNATIVE PAYMENT MODELS.— 

13 (1) INCENTIVE PAYMENTS FOR PARTICIPATION

14 IN ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

15 Section 1833 of the Social Security Act (42 U.S.C. 

16 1395l) is amended by adding at the end the fol17 lowing new subsection: 

18 ‘‘(z) INCENTIVE PAYMENTS FOR PARTICIPATION IN

19 ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

20 ‘‘(1) PAYMENT INCENTIVE.— 

21 ‘‘(A) IN GENERAL.—In the case of covered 

22 professional services furnished by an eligible 

23 professional during a year that is in the period 

24 beginning with 2017 and ending with 2022 and 

25 for which the professional is a qualifying APM 


smartinez on DSK6TPTVN1PROD with BILLS
61 

•S 1871 PCS

1 participant, in addition to the amount of pay2 ment that would otherwise be made for such 

3 covered professional services under this part for 

4 such year, there also shall be paid to such pro5 fessional an amount equal to 5 percent of the 

6 payment amount for the covered professional 

7 services under this part for the preceding year. 

8 For purposes of the previous sentence, the pay9 ment amount for the preceding year may be an 

10 estimation for the full preceding year based on 

11 a period of such preceding year that is less than 

12 the full year. The Secretary shall establish poli13 cies to implement this subparagraph in cases 

14 where payment for covered professional services 

15 furnished by a qualifying APM participant in 

16 an alternative payment model is made to an en17 tity participating in the alternative payment 

18 model rather than directly to the qualifying 

19 APM participant. 

20 ‘‘(B) FORM OF PAYMENT.—Payments 

21 under this subsection shall be made in a lump 

22 sum, on an annual basis, as soon as practicable. 

23 ‘‘(C) TREATMENT OF PAYMENT INCEN24 TIVE.—Payments under this subsection shall 

25 not be taken into account for purposes of deterVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00061 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
62 

•S 1871 PCS

1 mining actual expenditures under an alternative 

2 payment model and for purposes of determining 

3 or rebasing any benchmarks used under the al4 ternative payment model. 

5 ‘‘(D) COORDINATION.—The amount of the 

6 additional payment for an item or service under 

7 this subsection or subsection (m) shall be deter8 mined without regard to any additional pay9 ment for the item or service under subsection 

10 (m) and this subsection, respectively. The 

11 amount of the additional payment for an item 

12 or service under this subsection or subsection 

13 (x) shall be determined without regard to any 

14 additional payment for the item or service 

15 under subsection (x) and this subsection, re16 spectively. The amount of the additional pay17 ment for an item or service under this sub18 section or subsection (y) shall be determined 

19 without regard to any additional payment for 

20 the item or service under subsection (y) and 

21 this subsection, respectively. 

22 ‘‘(2) QUALIFYING APM PARTICIPANT.—For pur23 poses of this subsection, the term ‘qualifying APM 

24 participant’ means the following: 


smartinez on DSK6TPTVN1PROD with BILLS
63 

•S 1871 PCS

1 ‘‘(A) 2017 AND 2018.—With respect to 

2 2017 and 2018, an eligible professional for 

3 whom the Secretary determines that at least 25 

4 percent of payments under this part for covered 

5 professional services furnished by such profes6 sional during the most recent period for which 

7 data are available (which may be less than a 

8 year) were attributable to such services fur9 nished under this part through an entity that 

10 participates in an eligible alternative payment 

11 model with respect to such services. 

12 ‘‘(B) 2019 AND 2020.—With respect to 

13 2019 and 2020, an eligible professional de14 scribed in either of the following clauses: 

15 ‘‘(i) MEDICARE REVENUE THRESHOLD

16 OPTION.—An eligible professional for 

17 whom the Secretary determines that at 

18 least 50 percent of payments under this 

19 part for covered professional services fur20 nished by such professional during the 

21 most recent period for which data are 

22 available (which may be less than a year) 

23 were attributable to such services furnished 

24 under this part through an entity that parVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00063 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
64 

•S 1871 PCS

1 ticipates in an eligible alternative payment 

2 model with respect to such services. 

3 ‘‘(ii) COMBINATION ALL-PAYER AND

4 MEDICARE REVENUE THRESHOLD OP5 TION.—An eligible professional— 

6 ‘‘(I) for whom the Secretary de7 termines, with respect to items and 

8 services furnished by such professional 

9 during the most recent period for 

10 which data are available (which may 

11 be less than a year), that at least 50 

12 percent of the sum of— 

13 ‘‘(aa) payments described in 

14 clause (i); and 

15 ‘‘(bb) all other payments, re16 gardless of payer (other than 

17 payments made by the Secretary 

18 of Defense or the Secretary of 

19 Veterans Affairs under chapter 

20 55 of title 10, United States 

21 Code, or title 38, United States 

22 Code, or any other provision of 

23 law, and other than payments 

24 made under title XIX in a State 

25 in which no medical home or alVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00064 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
65 

•S 1871 PCS

1 ternative payment model is avail2 able under the State program 

3 under that title). 

4 meet the requirement described in 

5 clause (iii)(I) with respect to pay6 ments described in item (aa) and meet 

7 the requirement described in clause 

8 (iii)(II) with respect to payments de9 scribed in item (bb); 

10 ‘‘(II) for whom the Secretary de11 termines at least 25 percent of pay12 ments under this part for covered pro13 fessional services furnished by such 

14 professional during the most recent 

15 period for which data are available 

16 (which may be less than a year) were 

17 attributable to such services furnished 

18 under this part through an entity that 

19 participates in an eligible alternative 

20 payment model with respect to such 

21 services; and 

22 ‘‘(III) who provides to the Sec23 retary such information as is nec24 essary for the Secretary to make a deVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00065 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
66 

•S 1871 PCS

1 termination under subclause (I), with 

2 respect to such professional. 

3 ‘‘(iii) REQUIREMENT.—For purposes 

4 of clause (ii)(I)— 

5 ‘‘(I) the requirement described in 

6 this subclause, with respect to pay7 ments described in item (aa) of such 

8 clause, is that such payments are 

9 made under an eligible alternative 

10 payment model; and 

11 ‘‘(II) the requirement described 

12 in this subclause, with respect to pay13 ments described in item (bb) of such 

14 clause, is that such payments are 

15 made under an arrangement in 

16 which— 

17 ‘‘(aa) quality measures com18 parable to measures under the 

19 performance category described 

20 in section 1848(q)(2)(B)(i) apply; 

21 ‘‘(bb) certified EHR tech22 nology is used; and 

23 ‘‘(cc) the eligible profes24 sional (AA) bears more than 

25 nominal financial risk if actual 


smartinez on DSK6TPTVN1PROD with BILLS
67 

•S 1871 PCS

1 aggregate expenditures exceeds 

2 expected aggregate expenditures; 

3 or (BB) is a medical home (with 

4 respect to beneficiaries under 

5 title XIX) that meets criteria 

6 comparable to medical homes ex7 panded under section 1115A(c). 

8 ‘‘(C) BEGINNING IN 2021.—With respect to 

9 2021 and each subsequent year, an eligible pro10 fessional described in either of the following 

11 clauses: 

12 ‘‘(i) MEDICARE REVENUE THRESHOLD

13 OPTION.—An eligible professional for 

14 whom the Secretary determines that at 

15 least 75 percent of payments under this 

16 part for covered professional services fur17 nished by such professional during the 

18 most recent period for which data are 

19 available (which may be less than a year) 

20 were attributable to such services furnished 

21 under this part through an entity that par22 ticipates in an eligible alternative payment 

23 model with respect to such services. 


smartinez on DSK6TPTVN1PROD with BILLS
68 

•S 1871 PCS

1 ‘‘(ii) COMBINATION ALL-PAYER AND

2 MEDICARE REVENUE THRESHOLD OP3 TION.—An eligible professional— 

4 ‘‘(I) for whom the Secretary de5 termines, with respect to items and 

6 services furnished by such professional 

7 during the most recent period for 

8 which data are available (which may 

9 be less than a year), that at least 75 

10 percent of the sum of— 

11 ‘‘(aa) payments described in 

12 clause (i); and 

13 ‘‘(bb) all other payments, re14 gardless of payer (other than 

15 payments made by the Secretary 

16 of Defense or the Secretary of 

17 Veterans Affairs under chapter 

18 55 of title 10, United States 

19 Code, or title 38, United States 

20 Code, or any other provision of 

21 law, and other than payments 

22 made under title XIX in a State 

23 in which no medical home or al24 ternative payment model is availVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00068 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
69 

•S 1871 PCS

1 able under the State program 

2 under that title. 

3 meet the requirement described in 

4 clause (iii)(I) with respect to pay5 ments described in item (aa) and meet 

6 the requirement described in clause 

7 (iii)(II) with respect to payments de8 scribed in item (bb); 

9 ‘‘(II) for whom the Secretary de10 termines at least 25 percent of pay11 ments under this part for covered pro12 fessional services furnished by such 

13 professional during the most recent 

14 period for which data are available 

15 (which may be less than a year) were 

16 attributable to such services furnished 

17 under this part through an entity that 

18 participates in an eligible alternative 

19 payment model with respect to such 

20 services; and 

21 ‘‘(III) who provides to the Sec22 retary such information as is nec23 essary for the Secretary to make a de24 termination under subclause (I), with 

25 respect to such professional. 


smartinez on DSK6TPTVN1PROD with BILLS
70 

•S 1871 PCS

1 ‘‘(iii) REQUIREMENT.—For purposes 

2 of clause (ii)(I)— 

3 ‘‘(I) the requirement described in 

4 this subclause, with respect to pay5 ments described in item (aa) of such 

6 clause, is that such payments are 

7 made under an eligible alternative 

8 payment model; and 

9 ‘‘(II) the requirement described 

10 in this subclause, with respect to pay11 ments described in item (bb) of such 

12 clause, is that such payments are 

13 made under an arrangement in 

14 which— 

15 ‘‘(aa) quality measures com16 parable to measures under the 

17 performance category described 

18 in section 1848(q)(2)(B)(i) apply; 

19 ‘‘(bb) certified EHR tech20 nology is used; and 

21 ‘‘(cc) the eligible profes22 sional (AA) bears more than 

23 nominal financial risk if actual 

24 aggregate expenditures exceeds 

25 expected aggregate expenditures; 


smartinez on DSK6TPTVN1PROD with BILLS
71 

•S 1871 PCS

1 or (BB) is a medical home (with 

2 respect to beneficiaries under 

3 title XIX) that meets criteria 

4 comparable to medical homes ex5 panded under section 1115A(c). 

6 ‘‘(3) ADDITIONAL DEFINITIONS.—In this sub7 section: 

8 ‘‘(A) COVERED PROFESSIONAL SERV9 ICES.—The term ‘covered professional services’ 

10 has the meaning given that term in section 

11 1848(k)(3)(A). 

12 ‘‘(B) ELIGIBLE PROFESSIONAL.—The term 

13 ‘eligible professional’ has the meaning given 

14 that term in section 1848(k)(3)(B). 

15 ‘‘(C) ALTERNATIVE PAYMENT MODEL

16 (APM).—The term ‘alternative payment model’ 

17 means any of the following: 

18 ‘‘(i) A model under section 1115A 

19 (other than a health care innovation 

20 award). 

21 ‘‘(ii) An accountable care organization 

22 under section 1899. 

23 ‘‘(iii) A demonstration under section 

24 1866C. 


smartinez on DSK6TPTVN1PROD with BILLS
72 

•S 1871 PCS

1 ‘‘(iv) A demonstration required by 

2 Federal law. 

3 ‘‘(D) ELIGIBLE ALTERNATIVE PAYMENT

4 MODEL (APM).— 

5 ‘‘(i) IN GENERAL.—The term ‘eligible 

6 alternative payment model’ means, with re7 spect to a year, an alternative payment 

8 model— 

9 ‘‘(I) that requires use of certified 

10 EHR technology (as defined in sub11 section (o)(4)); 

12 ‘‘(II) that provides for payment 

13 for covered professional services based 

14 on quality measures comparable to 

15 measures under the performance cat16 egory described in section 

17 1848(q)(2)(B)(i); and 

18 ‘‘(III) that satisfies the require19 ment described in clause (ii). 

20 ‘‘(ii) ADDITIONAL REQUIREMENT.— 

21 For purposes of clause (i)(III), the require22 ment described in this clause, with respect 

23 to a year and an alternative payment 

24 model, is that the alternative payment 

25 model— 


smartinez on DSK6TPTVN1PROD with BILLS
73 

•S 1871 PCS

1 ‘‘(I) is one in which one or more 

2 entities bear financial risk for mone3 tary losses under such model that are 

4 in excess of a nominal amount; or 

5 ‘‘(II) is a medical home expanded 

6 under section 1115A(c). 

7 ‘‘(4) LIMITATION.—There shall be no adminis8 trative or judicial review under section 1869, 1878, 

9 or otherwise, of the following: 

10 ‘‘(A) The determination that an eligible 

11 professional is a qualifying APM participant 

12 under paragraph (2) and the determination 

13 that an alternative payment model is an eligible 

14 alternative payment model under paragraph 

15 (3)(D). 

16 ‘‘(B) The determination of the amount of 

17 the 5 percent payment incentive under para18 graph (1)(A), including any estimation as part 

19 of such determination.’’. 

20 (2) COORDINATION CONFORMING AMEND21 MENTS.—Section 1833 of the Social Security Act 

22 (42 U.S.C. 1395l) is further amended— 

23 (A) in subsection (x)(3), by adding at the 

24 end the following new sentence: ‘‘The amount 

25 of the additional payment for a service under 


smartinez on DSK6TPTVN1PROD with BILLS
74 

•S 1871 PCS

1 this subsection and subsection (z) shall be de2 termined without regard to any additional pay3 ment for the service under subsection (z) and 

4 this subsection, respectively.’’; and 

5 (B) in subsection (y)(3), by adding at the 

6 end the following new sentence: ‘‘The amount 

7 of the additional payment for a service under 

8 this subsection and subsection (z) shall be de9 termined without regard to any additional pay10 ment for the service under subsection (z) and 

11 this subsection, respectively.’’. 

12 (3) ENCOURAGING DEVELOPMENT AND TEST13 ING OF CERTAIN MODELS.—Section 1115A(b)(2) of 

14 the Social Security Act (42 U.S.C. 1315a(b)(2)) is 

15 amended— 

16 (A) in subparagraph (B), by adding at the 

17 end the following new clauses: 

18 ‘‘(xxi) Focusing primarily on physi19 cians’ services (as defined in section 

20 1848(j)(3)) furnished by physicians who 

21 are not primary care practitioners. 

22 ‘‘(xxii) Focusing on practices of 10 or 

23 fewer professionals. 

24 ‘‘(xxiii) Focusing primarily on title 

25 XIX, working in conjunction with the CenVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00074 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
75 

•S 1871 PCS

1 ter for Medicaid and CHIP Services within 

2 the Centers for Medicare & Medicaid Serv3 ices.’’; and 

4 (B) in subparagraph (C)(viii), by striking 

5 ‘‘other public sector or private sector payers’’ 

6 and inserting ‘‘other public sector payers, pri7 vate sector payers, or Statewide payment mod8 els’’. 

9 (4) CONSTRUCTION REGARDING TELEHEALTH

10 SERVICES.—Nothing in the provisions of, or amend11 ments made by, this Act shall be construed as pre12 cluding an alternative payment model or a qualifying 

13 APM participant (as those terms are defined in sec14 tion 1833(z) of the Social Security Act, as added by 

15 paragraph (1)) from furnishing a telehealth service 

16 for which payment is not made under section 

17 1834(m) of the Social Security Act (42 U.S.C. 

18 1395m(m)). 

19 (5) PLAN FOR INTEGRATING MEDICARE ADVAN20 TAGE ALTERNATIVE PAYMENT MODELS.—Not later 

21 than July 1, 2015, the Secretary of Health and 

22 Human Services shall submit to Congress a plan to 

23 integrate Medicare Advantage alternative payment 

24 models that take into account a budget neutral 

25 value-based modifier. 


smartinez on DSK6TPTVN1PROD with BILLS
76 

•S 1871 PCS

1 (f) STUDY AND REPORT ON FRAUD RELATED TO AL2 TERNATIVE PAYMENT MODELS UNDER THE MEDICARE

3 PROGRAM.— 

4 (1) STUDY.—The Secretary of Health and 

5 Human Services, in consultation with the Inspector 

6 General of the Department of Health and Human 

7 Services, shall conduct a study that— 

8 (A) examines the applicability of the Fed9 eral fraud prevention laws to items and services 

10 furnished under title XVIII of the Social Secu11 rity Act for which payment is made under an 

12 alternative payment model (as defined in sec13 tion 1833(z)(3)(C) of such Act (42 U.S.C. 

14 1395l(z)(3)(C))); 

15 (B) identifies aspects of such alternative 

16 payment models that are vulnerable to fraudu17 lent activity; and 

18 (C) examines the implications of waivers to 

19 such laws granted in support of such alternative 

20 payment models, including under any potential 

21 expansion of such models. 

22 (2) REPORT.—Not later than 2 years after the 

23 date of the enactment of this Act, the Secretary 

24 shall submit to Congress a report containing the re25 sults of the study conducted under paragraph (1). 


smartinez on DSK6TPTVN1PROD with BILLS
77 

•S 1871 PCS

1 Such report shall include recommendations for ac2 tions to be taken to reduce the vulnerability of such 

3 alternative payment models to fraudulent activity. 

4 Such report also shall include, as appropriate, rec5 ommendations of the Inspector General for changes 

6 in Federal fraud prevention laws to reduce such vul7 nerability. 

8 (g) IMPROVING PAYMENT ACCURACY.— 

9 (1) STUDIES AND REPORTS OF EFFECT OF CER10 TAIN INFORMATION ON QUALITY AND RESOURCE

11 USE .— 

12 (A) STUDY USING EXISTING MEDICARE

13 DATA.— 

14 (i) STUDY.—The Secretary of Health 

15 and Human Services (in this subsection re16 ferred to as the ‘‘Secretary’’) shall conduct 

17 a study that examines the effect of individ18 uals’ socioeconomic status on quality and 

19 resource use outcome measures for individ20 uals under the Medicare program. The 

21 study shall use information collected on 

22 such individuals in carrying out such pro23 gram, such as urban and rural location, 

24 eligibility for Medicaid (recognizing and ac25 counting for varying Medicaid eligibility 


smartinez on DSK6TPTVN1PROD with BILLS
78 

•S 1871 PCS

1 across States), and eligibility for benefits 

2 under the supplemental security income 

3 (SSI) program. The Secretary shall carry 

4 out this paragraph acting through the As5 sistant Secretary for Planning and Evalua6 tion. 

7 (ii) REPORT.—Not later than 2 years 

8 after the date of the enactment of this Act, 

9 the Secretary shall submit to Congress a 

10 report on the study conducted under clause 

11 (i). 

12 (B) STUDY USING OTHER DATA.— 

13 (i) STUDY.—The Secretary shall con14 duct a study that examines the impact of 

15 risk factors, such as those described in sec16 tion 1848(p)(3) of the Social Security Act 

17 (42 U.S.C. 1395w–4(p)(3)), race, health 

18 literacy, limited English proficiency (LEP), 

19 and patient activation, on quality and re20 source use outcome measures under the 

21 Medicare program. In conducting such 

22 study the Secretary may use existing Fed23 eral data and collect such additional data 

24 as may be necessary to complete the study. 


smartinez on DSK6TPTVN1PROD with BILLS
79 

•S 1871 PCS

1 (ii) REPORT.—Not later than 5 years 

2 after the date of the enactment of this Act, 

3 the Secretary shall submit to Congress a 

4 report on the study conducted under clause 

5 (i). 

6 (C) EXAMINATION OF DATA IN CON7 DUCTING STUDIES.—In conducting the studies 

8 under subparagraphs (A) and (B), the Sec9 retary shall examine what non-Medicare data 

10 sets, such as data from the American Commu11 nity Survey (ACS), can be useful in conducting 

12 the types of studies under such paragraphs and 

13 how such data sets that are identified as useful 

14 can be coordinated with Medicare administra15 tive data in order to improve the overall data 

16 set available to do such studies and for the ad17 ministration of the Medicare program. 

18 (D) RECOMMENDATIONS TO ACCOUNT FOR

19 INFORMATION IN PAYMENT ADJUSTMENT

20 MECHANISMS.—If the studies conducted under 

21 subparagraphs (A) and (B) find a relationship 

22 between the factors examined in the studies and 

23 quality and resource use outcome measures, 

24 then the Secretary shall also provide recVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00079 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
80 

•S 1871 PCS

1 ommendations for how the Centers for Medicare 

2 & Medicaid Services should— 

3 (i) obtain access to the necessary data 

4 (if such data is not already being collected) 

5 on such factors, including recommenda6 tions on how to address barriers to the 

7 Centers in accessing such data; and 

8 (ii) account for such factors in deter9 mining payment adjustments based on 

10 quality and resource use outcome measures 

11 under the eligible professional value-based 

12 performance incentive program under sec13 tion 1848(q) of the Social Security Act (42 

14 U.S.C. 1395w–4(q)) and, as the Secretary 

15 determines appropriate, other similar pro16 visions of title XVIII of such Act. 

17 (E) FUNDING.—There are hereby appro18 priated from the Federal Supplemental Medical 

19 Insurance Trust Fund to the Secretary to carry 

20 out this paragraph $6,000,000, to remain avail21 able until expended. 

22 (2) CMS ACTIVITIES.— 

23 (A) HIERARCHAL CONDITION CATEGORY

24 (HCC) IMPROVEMENT.—Taking into account the 

25 relevant studies conducted and recommendaVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00080 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
81 

•S 1871 PCS

1 tions made in reports under paragraph (1), the 

2 Secretary, on an ongoing basis, shall estimate 

3 how an individual’s health status and other risk 

4 factors affect quality and resource use outcome 

5 measures and, as feasible, shall incorporate in6 formation from quality and resource use out7 come measurement (including care episode and 

8 patient condition groups) into the eligible pro9 fessional value-based performance incentive pro10 gram under section 1848(q) of the Social Secu11 rity Act and, as the Secretary determines ap12 propriate, other similar provisions of title XVIII 

13 of such Act. 

14 (B) ACCOUNTING FOR OTHER FACTORS IN

15 PAYMENT ADJUSTMENT MECHANISMS.— 

16 (i) IN GENERAL.—Taking into ac17 count the studies conducted and rec18 ommendations made in reports under para19 graph (1), the Secretary shall account for 

20 identified factors (other than those applied 

21 under subparagraph (A)) with an effect on 

22 quality and resource use outcome measures 

23 when determining payment adjustments 

24 under the eligible professional value-based 

25 performance incentive program under secVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00081 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
82 

•S 1871 PCS

1 tion 1848(q) of the Social Security Act 

2 and, as the Secretary determines appro3 priate, other similar provisions of title 

4 XVIII of such Act. 

5 (ii) ACCESSING DATA.—The Secretary 

6 shall collect or otherwise obtain access to 

7 the data necessary to carry out this para8 graph through existing and new data 

9 sources. 

10 (iii) PERIODIC ANALYSES.—The Sec11 retary shall carry out periodic analyses, at 

12 least every 3 years, based on the factors 

13 referred to in clause (i) so as to monitor 

14 changes in possible relationships. 

15 (C) FUNDING.—There are hereby appro16 priated from the Federal Supplemental Medical 

17 Insurance Trust Fund to the Secretary to carry 

18 out this paragraph $10,000,000, to remain 

19 available until expended. 

20 (3) STRATEGIC PLAN FOR ACCESSING RACE

21 AND ETHNICITY DATA.—Not later than 18 months 

22 after the date of the enactment of this Act, the Sec23 retary shall develop and report to Congress on a 

24 strategic plan for collecting or otherwise accessing 


smartinez on DSK6TPTVN1PROD with BILLS
83 

•S 1871 PCS

1 data on race and ethnicity for purposes of carrying 

2 out the Medicare program. 

3 (h) COLLABORATING WITH THE PHYSICIAN, PRACTI4 TIONER, AND OTHER STAKEHOLDER COMMUNITIES TO

5 IMPROVE RESOURCE USE MEASUREMENT.—Section 1848 

6 of the Social Security Act (42 U.S.C. 1395w–4), as 

7 amended by subsection (c), is further amended by adding 

8 at the end the following new subsection: 

9 ‘‘(r) COLLABORATING WITH THE PHYSICIAN, PRAC10 TITIONER, AND OTHER STAKEHOLDER COMMUNITIES TO

11 IMPROVE RESOURCE USE MEASUREMENT.— 

12 ‘‘(1) IN GENERAL.—In order to involve the phy13 sician, practitioner, and other stakeholder commu14 nities in enhancing the infrastructure for resource 

15 use measurement, including for purposes of the 

16 value-based performance incentive program under 

17 subsection (q) and alternative payment models under 

18 section 1833(z), the Secretary shall undertake the 

19 steps described in the succeeding provisions of this 

20 subsection. 

21 ‘‘(2) DEVELOPMENT OF CARE EPISODE AND PA22 TIENT CONDITION GROUPS AND CLASSIFICATION

23 CODES.— 

24 ‘‘(A) IN GENERAL.—In order to classify 

25 similar patients into distinct care episode 


smartinez on DSK6TPTVN1PROD with BILLS
84 

•S 1871 PCS

1 groups and distinct patient condition groups, 

2 the Secretary shall undertake the steps de3 scribed in the succeeding provisions of this 

4 paragraph. 

5 ‘‘(B) PUBLIC AVAILABILITY OF EXISTING

6 EFFORTS TO DESIGN AN EPISODE GROUPER.— 

7 Not later than 60 days after the date of the en8 actment of this subsection, the Secretary shall 

9 post on the Internet website of the Centers for 

10 Medicare & Medicaid Services a list of the epi11 sode groups developed pursuant to subsection 

12 (n)(9)(A) and related descriptive information. 

13 ‘‘(C) STAKEHOLDER INPUT.—The Sec14 retary shall accept, through the date that is 60 

15 days after the day the Secretary posts the list 

16 pursuant to subparagraph (B), suggestions 

17 from physician specialty societies, applicable 

18 practitioner organizations, and other stake19 holders for episode groups in addition to those 

20 posted pursuant to such subparagraph, and 

21 specific clinical criteria and patient characteris22 tics to classify patients into— 

23 ‘‘(i) distinct care episode groups; and 

24 ‘‘(ii) distinct patient condition groups. 


smartinez on DSK6TPTVN1PROD with BILLS
85 

•S 1871 PCS

1 ‘‘(D) DEVELOPMENT OF PROPOSED CLAS2 SIFICATION CODES.— 

3 ‘‘(i) IN GENERAL.—Taking into ac4 count the information described in sub5 paragraph (B) and the information re6 ceived under subparagraph (C), the Sec7 retary shall— 

8 ‘‘(I) establish distinct care epi9 sode groups and distinct patient con10 dition groups, which account for at 

11 least an estimated two-thirds of ex12 penditures under parts A and B; and 

13 ‘‘(II) assign codes to such 

14 groups. 

15 ‘‘(ii) CARE EPISODE GROUPS.—In es16 tablishing the care episode groups under 

17 clause (i), the Secretary shall take into ac18 count— 

19 ‘‘(I) the patient’s clinical prob20 lems at the time items and services 

21 are furnished during an episode of 

22 care, such as the clinical conditions or 

23 diagnoses, whether or not inpatient 

24 hospitalization is anticipated or ocVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00085 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
86 

•S 1871 PCS

1 curs, and the principal procedures or 

2 services planned or furnished; and 

3 ‘‘(II) other factors determined 

4 appropriate by the Secretary. 

5 ‘‘(iii) PATIENT CONDITION GROUPS.— 

6 In establishing the patient condition 

7 groups under clause (i), the Secretary shall 

8 take into account— 

9 ‘‘(I) the patient’s clinical history 

10 at the time of each medical visit, such 

11 as the patient’s combination of chron12 ic conditions, current health status, 

13 and recent significant history (such as 

14 hospitalization and major surgery dur15 ing a previous period, such as 3 

16 months); and 

17 ‘‘(II) other factors determined 

18 appropriate by the Secretary, such as 

19 eligibility status under this title (in20 cluding eligibility under section 

21 226(a), 226(b), or 226A, and dual eli22 gibility under this title and title XIX). 

23 ‘‘(E) DRAFT CARE EPISODE AND PATIENT

24 CONDITION GROUPS AND CLASSIFICATION

25 CODES.—Not later than 120 days after the end 


smartinez on DSK6TPTVN1PROD with BILLS
87 

•S 1871 PCS

1 of the comment period described in subpara2 graph (C), the Secretary shall post on the 

3 Internet website of the Centers for Medicare & 

4 Medicaid Services a draft list of the care epi5 sode and patient condition codes established 

6 under subparagraph (D) (and the criteria and 

7 characteristics assigned to such code). 

8 ‘‘(F) SOLICITATION OF INPUT.—The Sec9 retary shall seek, through the date that is 60 

10 days after the Secretary posts the list pursuant 

11 to subparagraph (E), comments from physician 

12 specialty societies, applicable practitioner orga13 nizations, and other stakeholders, including in14 dividuals entitled to benefits under part A or 

15 enrolled under this part, regarding the care epi16 sode and patient condition groups (and codes) 

17 posted under subparagraph (E). In seeking 

18 such comments, the Secretary shall use one or 

19 more mechanisms (other than notice and com20 ment rulemaking) that may include use of open 

21 door forums, town hall meetings, or other ap22 propriate mechanisms. 

23 ‘‘(G) OPERATIONAL LIST OF CARE EPI24 SODE AND PATIENT CONDITION GROUPS AND

25 CODES.—Not later than 120 days after the end 


smartinez on DSK6TPTVN1PROD with BILLS
88 

•S 1871 PCS

1 of the comment period described in subpara2 graph (F), taking into account the comments 

3 received under such subparagraph, the Sec4 retary shall post on the Internet website of the 

5 Centers for Medicare & Medicaid Services an 

6 operational list of care episode and patient con7 dition codes (and the criteria and characteris8 tics assigned to such code). 

9 ‘‘(H) SUBSEQUENT REVISIONS.—Not later 

10 than November 1 of each year (beginning with 

11 2016), the Secretary shall, through rulemaking, 

12 make revisions to the operational lists of care 

13 episode and patient condition codes as the Sec14 retary determines may be appropriate. Such re15 visions may be based on experience, new infor16 mation developed pursuant to subsection 

17 (n)(9)(A), and input from the physician spe18 cialty societies, applicable practitioner organiza19 tions, and other stakeholders, including individ20 uals entitled to benefits under part A or en21 rolled under this part. 

22 ‘‘(3) ATTRIBUTION OF PATIENTS TO PHYSI23 CIANS OR PRACTITIONERS.— 

24 ‘‘(A) IN GENERAL.—In order to facilitate 

25 the attribution of patients and episodes (in 


smartinez on DSK6TPTVN1PROD with BILLS
89 

•S 1871 PCS

1 whole or in part) to one or more physicians or 

2 applicable practitioners furnishing items and 

3 services, the Secretary shall undertake the steps 

4 described in the succeeding provisions of this 

5 paragraph. 

6 ‘‘(B) DEVELOPMENT OF PATIENT RELA7 TIONSHIP CATEGORIES AND CODES.—The Sec8 retary shall develop patient relationship cat9 egories and codes that define and distinguish 

10 the relationship and responsibility of a physi11 cian or applicable practitioner with a patient at 

12 the time of furnishing an item or service. Such 

13 patient relationship categories shall include dif14 ferent relationships of the physician or applica15 ble practitioner to the patient (and the codes 

16 may reflect combinations of such categories), 

17 such as a physician or applicable practitioner 

18 who— 

19 ‘‘(i) considers themself to have the 

20 primary responsibility for the general and 

21 ongoing care for the patient over extended 

22 periods of time; 

23 ‘‘(ii) considers themself to be the lead 

24 physician or practitioner and who furnishes 

25 items and services and coordinates care 


smartinez on DSK6TPTVN1PROD with BILLS
90 

•S 1871 PCS

1 furnished by other physicians or practi2 tioners for the patient during an acute epi3 sode; 

4 ‘‘(iii) furnishes items and services to 

5 the patient on a continuing basis during an 

6 acute episode of care, but in a supportive 

7 rather than a lead role; 

8 ‘‘(iv) furnishes items and services to 

9 the patient on an occasional basis, usually 

10 at the request of another physician or 

11 practitioner; or 

12 ‘‘(v) furnishes items and services only 

13 as ordered by another physician or practi14 tioner. 

15 ‘‘(C) DRAFT LIST OF PATIENT RELATION16 SHIP CATEGORIES AND CODES.—Not later than 

17 180 days after the date of the enactment of this 

18 subsection, the Secretary shall post on the 

19 Internet website of the Centers for Medicare & 

20 Medicaid Services a draft list of the patient re21 lationship categories and codes developed under 

22 subparagraph (B). 

23 ‘‘(D) STAKEHOLDER INPUT.—The Sec24 retary shall seek, through the date that is 60 

25 days after the Secretary posts the list pursuant 


smartinez on DSK6TPTVN1PROD with BILLS
91 

•S 1871 PCS

1 to subparagraph (C), comments from physician 

2 specialty societies, applicable practitioner orga3 nizations, and other stakeholders, including in4 dividuals entitled to benefits under part A or 

5 enrolled under this part, regarding the patient 

6 relationship categories and codes posted under 

7 subparagraph (C). In seeking such comments, 

8 the Secretary shall use one or more mechanisms 

9 (other than notice and comment rulemaking) 

10 that may include open door forums, town hall 

11 meetings, or other appropriate mechanisms. 

12 ‘‘(E) OPERATIONAL LIST OF PATIENT RE13 LATIONSHIP CATEGORIES AND CODES.—Not 

14 later than 120 days after the end of the com15 ment period described in subparagraph (D), 

16 taking into account the comments received 

17 under such subparagraph, the Secretary shall 

18 post on the Internet website of the Centers for 

19 Medicare & Medicaid Services an operational 

20 list of patient relationship categories and codes. 

21 ‘‘(F) SUBSEQUENT REVISIONS.—Not later 

22 than November 1 of each year (beginning with 

23 2016), the Secretary shall, through rulemaking, 

24 make revisions to the operational list of patient 

25 relationship categories and codes as the SecVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00091 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
92 

•S 1871 PCS

1 retary determines appropriate. Such revisions 

2 may be based on experience, new information 

3 developed pursuant to subsection (n)(9)(A), and 

4 input from the physician specialty societies, ap5 plicable practitioner organizations, and other 

6 stakeholders, including individuals entitled to 

7 benefits under part A or enrolled under this 

8 part. 

9 ‘‘(4) REPORTING OF INFORMATION FOR RE10 SOURCE USE MEASUREMENT.—Claims submitted for 

11 items and services furnished by a physician or appli12 cable practitioner on or after January 1, 2016, shall, 

13 as determined appropriate by the Secretary, in14 clude— 

15 ‘‘(A) applicable codes established under 

16 paragraphs (2) and (3); and 

17 ‘‘(B) the national provider identifier of the 

18 ordering physician or applicable practitioner (if 

19 different from the billing physician or applicable 

20 practitioner). 

21 ‘‘(5) METHODOLOGY FOR RESOURCE USE ANAL22 YSIS.— 

23 ‘‘(A) IN GENERAL.—In order to evaluate 

24 the resources used to treat patients (with reVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00092 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
93 

•S 1871 PCS

1 spect to care episode and patient condition 

2 groups), the Secretary shall— 

3 ‘‘(i) use the patient relationship codes 

4 reported on claims pursuant to paragraph 

5 (4) to attribute patients (in whole or in 

6 part) to one or more physicians and appli7 cable practitioners; 

8 ‘‘(ii) use the care episode and patient 

9 condition codes reported on claims pursu10 ant to paragraph (4) as a basis to compare 

11 similar patients and care episodes and pa12 tient condition groups; and 

13 ‘‘(iii) conduct an analysis of resource 

14 use (with respect to care episodes and pa15 tient condition groups of such patients), as 

16 the Secretary determines appropriate. 

17 ‘‘(B) ANALYSIS OF PATIENTS OF PHYSI18 CIANS AND PRACTITIONERS.—In conducting the 

19 analysis described in subparagraph (A)(iii) with 

20 respect to patients attributed to physicians and 

21 applicable practitioners, the Secretary shall, as 

22 feasible— 

23 ‘‘(i) use the claims data experience of 

24 such patients by patient condition codes 


smartinez on DSK6TPTVN1PROD with BILLS
94 

•S 1871 PCS

1 during a common period, such as 12 

2 months; and 

3 ‘‘(ii) use the claims data experience of 

4 such patients by care episode codes— 

5 ‘‘(I) in the case of episodes with6 out a hospitalization, during periods 

7 of time (such as the number of days) 

8 determined appropriate by the Sec9 retary; and 

10 ‘‘(II) in the case of episodes with 

11 a hospitalization, during periods of 

12 time (such as the number of days) be13 fore, during, and after the hospitaliza14 tion. 

15 ‘‘(C) MEASUREMENT OF RESOURCE USE.— 

16 In measuring such resource use, the Sec17 retary— 

18 ‘‘(i) shall use per patient total allowed 

19 amounts for all services under part A and 

20 this part (and, if the Secretary determines 

21 appropriate, part D) for the analysis of pa22 tient resource use, by care episode codes 

23 and by patient condition codes; and 

24 ‘‘(ii) may, as determined appropriate, 

25 use other measures of allowed amounts 


smartinez on DSK6TPTVN1PROD with BILLS
95 

•S 1871 PCS

1 (such as subtotals for categories of items 

2 and services) and measures of utilization of 

3 items and services (such as frequency of 

4 specific items and services and the ratio of 

5 specific items and services among attrib6 uted patients or episodes). 

7 ‘‘(D) STAKEHOLDER INPUT.—The Sec8 retary shall seek comments from the physician 

9 specialty societies, applicable practitioner orga10 nizations, and other stakeholders, including in11 dividuals entitled to benefits under part A or 

12 enrolled under this part, regarding the resource 

13 use methodology established pursuant to this 

14 paragraph. In seeking comments the Secretary 

15 shall use one or more mechanisms (other than 

16 notice and comment rulemaking) that may in17 clude open door forums, town hall meetings, or 

18 other appropriate mechanisms. 

19 ‘‘(6) LIMITATION.—There shall be no adminis20 trative or judicial review under section 1869, section 

21 1878, or otherwise of— 

22 ‘‘(A) care episode and patient condition 

23 groups and codes established under paragraph 

24 (2); 


smartinez on DSK6TPTVN1PROD with BILLS
96 

•S 1871 PCS

1 ‘‘(B) patient relationship categories and 

2 codes established under paragraph (3); and 

3 ‘‘(C) measurement of, and analyses of re4 source use with respect to, care episode and pa5 tient condition codes and patient relationship 

6 codes pursuant to paragraph (5). 

7 ‘‘(7) ADMINISTRATION.—Chapter 35 of title 44, 

8 United States Code, shall not apply to this section. 

9 ‘‘(8) DEFINITIONS.—In this section: 

10 ‘‘(A) PHYSICIAN.—The term ‘physician’ 

11 has the meaning given such term in section 

12 1861(r). 

13 ‘‘(B) APPLICABLE PRACTITIONER.—The 

14 term ‘applicable practitioner’ means— 

15 ‘‘(i) a physician assistant, nurse prac16 titioner, and clinical nurse specialist (as 

17 such terms are defined in section 

18 1861(aa)(5)); and 

19 ‘‘(ii) beginning January 1, 2017, such 

20 other eligible professionals (as defined in 

21 subsection (k)(3)(B)) as specified by the 

22 Secretary. 

23 ‘‘(9) CLARIFICATION.—The provisions of sec24 tions 1890A(b)(2) and 1890B shall not apply to this 

25 subsection.’’. 


smartinez on DSK6TPTVN1PROD with BILLS
97 

•S 1871 PCS

1 SEC. 102. PRIORITIES AND FUNDING FOR QUALITY MEAS2 URE DEVELOPMENT. 

3 Section 1848 of the Social Security Act (42 U.S.C. 

4 1395w–4), as amended by subsections (c) and (h) of sec5 tion 101, is further amended by inserting at the end the 

6 following new subsection: 

7 ‘‘(s) PRIORITIES AND FUNDING FOR QUALITY MEAS8 URE DEVELOPMENT.— 

9 ‘‘(1) PLAN IDENTIFYING MEASURE DEVELOP10 MENT PRIORITIES AND TIMELINES.— 

11 ‘‘(A) DRAFT MEASURE DEVELOPMENT

12 PLAN.— 

13 ‘‘(i) DRAFT PLAN.— 

14 ‘‘(I) IN GENERAL.—Not later 

15 than October 1, 2014, the Secretary 

16 shall develop, and post on the Internet 

17 website of the Centers for Medicare & 

18 Medicaid Services, a draft plan for the 

19 development of quality measures for 

20 application under the applicable provi21 sions. 

22 ‘‘(II) REQUIREMENT.—Such plan 

23 shall address how measures used by 

24 private payers and integrated delivery 

25 systems could be incorporated under 

26 such subsection. 


smartinez on DSK6TPTVN1PROD with BILLS
98 

•S 1871 PCS

1 ‘‘(ii) CONSIDERATION.—In developing 

2 the draft plan under subparagraph (A), the 

3 Secretary shall consider— 

4 ‘‘(I) gap analyses conducted by 

5 the entity with a contract under sec6 tion 1890(a) or other contractors or 

7 entities; and 

8 ‘‘(II) whether measures are appli9 cable across health care settings. 

10 ‘‘(iii) PRIORITIES.—In developing the 

11 draft plan under subparagraph (A), the 

12 Secretary shall give priority to the fol13 lowing types of measures: 

14 ‘‘(I) Outcome measures including 

15 patient reported outcome and func16 tional status measures. 

17 ‘‘(II) Patient experience meas18 ures. 

19 ‘‘(III) Care coordination meas20 ures. 

21 ‘‘(IV) Measures of appropriate 

22 use of services, including measures of 

23 over use. 

24 ‘‘(iv) DEFINITION OF APPLICABLE

25 PROVISIONS.—In this subsection, the term 


smartinez on DSK6TPTVN1PROD with BILLS
99 

•S 1871 PCS

1 ‘applicable provisions’ means the following 

2 provisions: 

3 ‘‘(I) Subsection (q)(2)(B)(i). 

4 ‘‘(II) Section 1833(z)(2)(C). 

5 ‘‘(B) STAKEHOLDER INPUT.—The Sec6 retary shall accept through December 1, 2014, 

7 comments on the draft plan posted under para8 graph (1)(A) from the public, including health 

9 care providers, payers, consumers, and other 

10 stakeholders. 

11 ‘‘(C) OPERATIONAL MEASURE DEVELOP12 MENT PLAN.—Not later than February 1, 2015, 

13 taking into account the comments received 

14 under subparagraph (B), the Secretary shall 

15 post on the Internet website of the Centers for 

16 Medicare & Medicaid Services an operational 

17 plan for the development of quality measures 

18 for use under subsection (q)(2)(A)(i). 

19 ‘‘(2) CONTRACTS AND OTHER ARRANGEMENTS

20 FOR QUALITY MEASURE DEVELOPMENT.— 

21 ‘‘(A) IN GENERAL.—The Secretary shall 

22 enter into contracts or other arrangements with 

23 entities for the purpose of developing, improv24 ing, updating, or expanding quality measures 

25 for application under the applicable provisions. 


smartinez on DSK6TPTVN1PROD with BILLS
100 

•S 1871 PCS

1 Such entities may include physician specialty 

2 societies and other practitioner organizations. 

3 ‘‘(B) PRIORITIZATION.— 

4 ‘‘(i) IN GENERAL.—In entering into 

5 contracts or other arrangements under 

6 subparagraph (A), the Secretary shall give 

7 priority to the development of the types of 

8 measures described in paragraph 

9 (1)(A)(iii). 

10 ‘‘(ii) CONSIDERATION.—In selecting 

11 measures for development under this sub12 section, the Secretary shall consider wheth13 er such measures would be electronically 

14 specified. 

15 ‘‘(3) ANNUAL REPORT BY THE SECRETARY.— 

16 ‘‘(A) IN GENERAL.—Not later than Feb17 ruary 1, 2016, and annually thereafter, the Sec18 retary shall post on the Internet website of the 

19 Centers for Medicare & Medicaid Services a re20 port on the progress made in developing quality 

21 measures for application under the applicable 

22 provisions. 

23 ‘‘(B) REQUIREMENTS.—Each report sub24 mitted pursuant to paragraph (1) shall include 

25 the following: 


smartinez on DSK6TPTVN1PROD with BILLS
101 

•S 1871 PCS

1 ‘‘(i) A description of the Secretary’s 

2 efforts to implement this subsection. 

3 ‘‘(ii) With respect to the measures de4 veloped during the previous year— 

5 ‘‘(I) a description of the total 

6 number of quality measures developed 

7 and the types of such measures, such 

8 as an outcome or patient experience 

9 measure; 

10 ‘‘(II) the name of each measure 

11 developed; 

12 ‘‘(III) the name of the developer 

13 and steward of each measure; 

14 ‘‘(IV) with respect to each type 

15 of measure, an estimate of the total 

16 amount expended under this title to 

17 develop all measures of such type; and 

18 ‘‘(V) whether the measure would 

19 be electronically specified. 

20 ‘‘(iii) With respect to measures in de21 velopment at the time of the report— 

22 ‘‘(I) the information described in 

23 clause (ii), if available; and 

24 ‘‘(II) a timeline for completion of 

25 the development of such measures. 


smartinez on DSK6TPTVN1PROD with BILLS
102 

•S 1871 PCS

1 ‘‘(iv) An update on the progress in de2 veloping the types of measures described in 

3 paragraph (1)(A)(iii), including a descrip4 tion of issues affecting such progress. 

5 ‘‘(v) A list of quality topics and con6 cepts that are being considered for develop7 ment of measures and the rationale for the 

8 selection of topics and concepts including 

9 their relationship to gap analyses. 

10 ‘‘(vi) A description of any updates to 

11 the plan under paragraph (1) (including 

12 newly identified gaps and the status of pre13 viously identified gaps) and the inventory 

14 of measures applicable under the applicable 

15 provisions. 

16 ‘‘(vii) Other information the Secretary 

17 determines to be appropriate. 

18 ‘‘(4) STAKEHOLDER INPUT.—With respect to 

19 measures applicable under the applicable provisions, 

20 the Secretary shall seek stakeholder input with re21 spect to— 

22 ‘‘(A) the identification of gaps where no 

23 quality measures exist, particularly with respect 

24 to the types of measures described in paragraph 

25 (1)(A)(iii); 


smartinez on DSK6TPTVN1PROD with BILLS
103 

•S 1871 PCS

1 ‘‘(B) prioritizing quality measure develop2 ment to address such gaps; and 

3 ‘‘(C) other areas related to quality measure 

4 development determined appropriate by the Sec5 retary. 

6 ‘‘(5) FUNDING.—For purposes of carrying out 

7 this subsection, the Secretary shall provide for the 

8 transfer, from the Federal Supplementary Medical 

9 Insurance Trust Fund under section 1841, of 

10 $15,000,000 to the Centers for Medicare & Medicaid 

11 Services Program Management Account for each of 

12 fiscal years 2014 through 2018. Amounts trans13 ferred under this paragraph shall remain available 

14 through the end of fiscal year 2021.’’. 

15 SEC. 103. ENCOURAGING CARE MANAGEMENT FOR INDI16 VIDUALS WITH CHRONIC CARE NEEDS. 

17 (a) IN GENERAL.—Section 1848(b) of the Social Se18 curity Act (42 U.S.C. 1395w–4(b)) is amended by adding 

19 at the end the following new paragraph: 

20 ‘‘(8) ENCOURAGING CARE MANAGEMENT FOR

21 INDIVIDUALS WITH CHRONIC CARE NEEDS.— 

22 ‘‘(A) IN GENERAL.—In order to encourage 

23 the management of care by an applicable pro24 vider (as defined in subparagraph (B)) for indiVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00103 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
104 

•S 1871 PCS

1 viduals with chronic care needs the Secretary 

2 shall— 

3 ‘‘(i) establish one or more HCPCS 

4 codes for chronic care management serv5 ices for such individuals; and 

6 ‘‘(ii) subject to subparagraph (D), 

7 make payment (as the Secretary deter8 mines to be appropriate) under this section 

9 for such management services furnished on 

10 or after January 1, 2015, by an applicable 

11 provider. 

12 ‘‘(B) APPLICABLE PROVIDER DEFINED.— 

13 For purposes of this paragraph, the term ‘ap14 plicable provider’ means a physician (as defined 

15 in section 1861(r)(1)), physician assistant or 

16 nurse practitioner (as defined in section 

17 1861(aa)(5)(A)), or clinical nurse specialist (as 

18 defined in section 1861(aa)(5)(B)) who fur19 nishes services as part of a patient-centered 

20 medical home or a comparable specialty practice 

21 that— 

22 ‘‘(i) is recognized as such a medical 

23 home or comparable specialty practice by 

24 an organization that is recognized by the 


smartinez on DSK6TPTVN1PROD with BILLS
105 

•S 1871 PCS

1 Secretary for purposes of such recognition 

2 as such a medical home or practice; or 

3 ‘‘(ii) meets such other comparable 

4 qualifications as the Secretary determines 

5 to be appropriate. 

6 ‘‘(C) BUDGET NEUTRALITY.—The budget 

7 neutrality provision under subsection 

8 (c)(2)(B)(ii)(II) shall apply in establishing the 

9 payment under subparagraph (A)(ii). 

10 ‘‘(D) POLICIES RELATING TO PAYMENT.— 

11 In carrying out this paragraph, with respect to 

12 chronic care management services, the Sec13 retary shall— 

14 ‘‘(i) make payment to only one appli15 cable provider for such services furnished 

16 to an individual during a period; 

17 ‘‘(ii) not make payment under sub18 paragraph (A) if such payment would be 

19 duplicative of payment that is otherwise 

20 made under this title for such services 

21 (such as in the case of hospice care or 

22 home health services); and 

23 ‘‘(iii) not require that an annual 

24 wellness visit (as defined in section 

25 1861(hhh)) or an initial preventive physVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00105 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
106 

•S 1871 PCS

1 ical examination (as defined in section 

2 1861(ww)) be furnished as a condition of 

3 payment for such management services.’’. 

4 (b) EDUCATION AND OUTREACH.— 

5 (1) CAMPAIGN.— 

6 (A) IN GENERAL.—The Secretary of 

7 Health and Human Services (in this subsection 

8 referred to as the ‘‘Secretary’’) shall conduct an 

9 education and outreach campaign to inform 

10 professionals who furnish items and services 

11 under part B of title XVIII of the Social Secu12 rity Act and individuals enrolled under such 

13 part of the benefits of chronic care management 

14 services described in section 1848(b)(8) of the 

15 Social Security Act, as added by subsection (a), 

16 and encourage such individuals with chronic 

17 care needs to receive such services. 

18 (B) REQUIREMENTS.—Such campaign 

19 shall— 

20 (i) be directed by the Office of Rural 

21 Health Policy of the Department of Health 

22 and Human Services and the Office of Mi23 nority Health of the Centers for Medicare 

24 & Medicaid Services; and 


smartinez on DSK6TPTVN1PROD with BILLS
107 

•S 1871 PCS

1 (ii) focus on encouraging participation 

2 by underserved rural populations and ra3 cial and ethnic minority populations. 

4 (2) REPORT.— 

5 (A) IN GENERAL.—Not later than Decem6 ber 31, 2017, the Secretary shall submit to 

7 Congress a report on the use of chronic care 

8 management services described in such section 

9 1848(b)(8) by individuals living in rural areas 

10 and by racial and ethnic minority populations. 

11 Such report shall— 

12 (i) identify barriers to receiving chron13 ic care management services; and 

14 (ii) make recommendations for in15 creasing the appropriate use of chronic 

16 care management services. 

17 SEC. 104. ENSURING ACCURATE VALUATION OF SERVICES 

18 UNDER THE PHYSICIAN FEE SCHEDULE. 

19 (a) AUTHORITY TO COLLECT AND USE INFORMA20 TION ON PHYSICIANS’ SERVICES IN THE DETERMINATION

21 OF RELATIVE VALUES.— 

22 (1) IN GENERAL.—Section 1848(c)(2) of the 

23 Social Security Act (42 U.S.C. 1395w–4(c)(2)) is 

24 amended by adding at the end the following new 

25 subparagraph: 


smartinez on DSK6TPTVN1PROD with BILLS
108 

•S 1871 PCS

1 ‘‘(M) AUTHORITY TO COLLECT AND USE

2 INFORMATION ON PHYSICIANS’ SERVICES IN

3 THE DETERMINATION OF RELATIVE VALUES.— 

4 ‘‘(i) COLLECTION OF INFORMATION.— 

5 Notwithstanding any other provision of 

6 law, the Secretary may collect or obtain in7 formation on the resources directly or indi8 rectly related to furnishing services for 

9 which payment is made under the fee 

10 schedule established under subsection (b). 

11 Such information may be collected or ob12 tained from any eligible professional or any 

13 other source. 

14 ‘‘(ii) USE OF INFORMATION.—Not15 withstanding any other provision of law, 

16 subject to clause (v), the Secretary may 

17 (as the Secretary determines appropriate) 

18 use information collected or obtained pur19 suant to clause (i) in the determination of 

20 relative values for services under this sec21 tion. 

22 ‘‘(iii) TYPES OF INFORMATION.—The 

23 types of information described in clauses 

24 (i) and (ii) may, at the Secretary’s discre25 tion, include any or all of the following: 


smartinez on DSK6TPTVN1PROD with BILLS
109 

•S 1871 PCS

1 ‘‘(I) Time involved in furnishing 

2 services. 

3 ‘‘(II) Amounts and types of prac4 tice expense inputs involved with fur5 nishing services. 

6 ‘‘(III) Prices (net of any dis7 counts) for practice expense inputs, 

8 which may include paid invoice prices 

9 or other documentation or records. 

10 ‘‘(IV) Overhead and accounting 

11 information for practices of physicians 

12 and other suppliers. 

13 ‘‘(V) Any other element that 

14 would improve the valuation of serv15 ices under this section. 

16 ‘‘(iv) INFORMATION COLLECTION

17 MECHANISMS.—Information may be col18 lected or obtained pursuant to this sub19 paragraph from any or all of the following: 

20 ‘‘(I) Surveys of physicians, other 

21 suppliers, providers of services, manu22 facturers, and vendors. 

23 ‘‘(II) Surgical logs, billing sys24 tems, or other practice or facility 

25 records. 


smartinez on DSK6TPTVN1PROD with BILLS
110 

•S 1871 PCS

1 ‘‘(III) Electronic health records. 

2 ‘‘(IV) Any other mechanism de3 termined appropriate by the Sec4 retary. 

5 ‘‘(v) TRANSPARENCY OF USE OF IN6 FORMATION.— 

7 ‘‘(I) IN GENERAL.—Subject to 

8 subclauses (II) and (III), if the Sec9 retary uses information collected or 

10 obtained under this subparagraph in 

11 the determination of relative values 

12 under this subsection, the Secretary 

13 shall disclose the information source 

14 and discuss the use of such informa15 tion in such determination of relative 

16 values through notice and comment 

17 rulemaking. 

18 ‘‘(II) THRESHOLDS FOR USE.— 

19 The Secretary may establish thresh20 olds in order to use such information, 

21 including the exclusion of information 

22 collected or obtained from eligible pro23 fessionals who use very high resources 

24 (as determined by the Secretary) in 

25 furnishing a service. 


smartinez on DSK6TPTVN1PROD with BILLS
111 

•S 1871 PCS

1 ‘‘(III) DISCLOSURE OF INFORMA2 TION.—The Secretary shall make ag3 gregate information available under 

4 this subparagraph but shall not dis5 close information in a form or manner 

6 that identifies an eligible professional 

7 or a group practice, or information 

8 collected or obtained pursuant to a 

9 nondisclosure agreement. 

10 ‘‘(vi) INCENTIVE TO PARTICIPATE.— 

11 The Secretary may provide for such pay12 ments under this part to an eligible profes13 sional that submits such solicited informa14 tion under this subparagraph as the Sec15 retary determines appropriate in order to 

16 compensate such eligible professional for 

17 such submission. Such payments shall be 

18 provided in a form and manner specified 

19 by the Secretary. 

20 ‘‘(vii) ADMINISTRATION.—Chapter 35 

21 of title 44, United States Code, shall not 

22 apply to information collected or obtained 

23 under this subparagraph. 

24 ‘‘(viii) DEFINITION OF ELIGIBLE PRO25 FESSIONAL.—In this subparagraph, the 


smartinez on DSK6TPTVN1PROD with BILLS
112 

•S 1871 PCS

1 term ‘eligible professional’ has the meaning 

2 given such term in subsection (k)(3)(B). 

3 ‘‘(ix) FUNDING.—For purposes of car4 rying out this subparagraph, in addition to 

5 funds otherwise appropriated, the Sec6 retary shall provide for the transfer, from 

7 the Federal Supplementary Medical Insur8 ance Trust Fund under section 1841, of 

9 $2,000,000 to the Centers for Medicare & 

10 Medicaid Services Program Management 

11 Account for each fiscal year beginning with 

12 fiscal year 2014. Amounts transferred 

13 under the preceding sentence for a fiscal 

14 year shall be available until expended.’’. 

15 (2) LIMITATION ON REVIEW.—Section 

16 1848(i)(1) of the Social Security Act (42 U.S.C. 

17 1395w–4(i)(1)) is amended— 

18 (A) in subparagraph (D), by striking 

19 ‘‘and’’ at the end; 

20 (B) in subparagraph (E), by striking the 

21 period at the end and inserting ‘‘, and’’; and 

22 (C) by adding at the end the following new 

23 subparagraph: 


smartinez on DSK6TPTVN1PROD with BILLS
113 

•S 1871 PCS

1 ‘‘(F) the collection and use of information 

2 in the determination of relative values under 

3 subsection (c)(2)(M).’’. 

4 (b) AUTHORITY FOR ALTERNATIVE APPROACHES TO

5 ESTABLISHING PRACTICE EXPENSE RELATIVE VAL6 UES.—Section 1848(c)(2) of the Social Security Act (42 

7 U.S.C. 1395w–4(c)(2)), as amended by subsection (a), is 

8 amended by adding at the end the following new subpara9 graph: 

10 ‘‘(N) AUTHORITY FOR ALTERNATIVE AP11 PROACHES TO ESTABLISHING PRACTICE EX12 PENSE RELATIVE VALUES.—The Secretary may 

13 establish or adjust practice expense relative val14 ues under this subsection using cost, charge, or 

15 other data from suppliers or providers of serv16 ices, including information collected or obtained 

17 under subparagraph (M).’’. 

18 (c) REVISED AND EXPANDED IDENTIFICATION OF

19 POTENTIALLY MISVALUED CODES.—Section 

20 1848(c)(2)(K)(ii) of the Social Security Act (42 U.S.C. 

21 1395w–4(c)(2)(K)(ii)) is amended to read as follows: 

22 ‘‘(ii) IDENTIFICATION OF POTEN23 TIALLY MISVALUED CODES.—For purposes 

24 of identifying potentially misvalued codes 

25 pursuant to clause (i)(I), the Secretary 


smartinez on DSK6TPTVN1PROD with BILLS
114 

•S 1871 PCS

1 shall examine codes (and families of codes 

2 as appropriate) based on any or all of the 

3 following criteria: 

4 ‘‘(I) Codes that have experienced 

5 the fastest growth. 

6 ‘‘(II) Codes that have experi7 enced substantial changes in practice 

8 expenses. 

9 ‘‘(III) Codes that describe new 

10 technologies or services within an ap11 propriate time period (such as 3 

12 years) after the relative values are ini13 tially established for such codes. 

14 ‘‘(IV) Codes which are multiple 

15 codes that are frequently billed in con16 junction with furnishing a single serv17 ice. 

18 ‘‘(V) Codes with low relative val19 ues, particularly those that are often 

20 billed multiple times for a single treat21 ment. 

22 ‘‘(VI) Codes that have not been 

23 subject to review since implementation 

24 of the fee schedule. 


smartinez on DSK6TPTVN1PROD with BILLS
115 

•S 1871 PCS

1 ‘‘(VII) Codes that account for 

2 the majority of spending under the 

3 physician fee schedule. 

4 ‘‘(VIII) Codes for services that 

5 have experienced a substantial change 

6 in the hospital length of stay or proce7 dure time. 

8 ‘‘(IX) Codes for which there may 

9 be a change in the typical site of serv10 ice since the code was last valued. 

11 ‘‘(X) Codes for which there is a 

12 significant difference in payment for 

13 the same service between different 

14 sites of service. 

15 ‘‘(XI) Codes for which there may 

16 be anomalies in relative values within 

17 a family of codes. 

18 ‘‘(XII) Codes for services where 

19 there may be efficiencies when a serv20 ice is furnished at the same time as 

21 other services. 

22 ‘‘(XIII) Codes with high intra23 service work per unit of time. 

24 ‘‘(XIV) Codes with high practice 

25 expense relative value units. 


smartinez on DSK6TPTVN1PROD with BILLS
116 

•S 1871 PCS

1 ‘‘(XV) Codes with high cost sup2 plies. 

3 ‘‘(XVI) Codes as determined ap4 propriate by the Secretary.’’. 

5 (d) TARGET FOR RELATIVE VALUE ADJUSTMENTS

6 FOR MISVALUED SERVICES.— 

7 (1) IN GENERAL.—Section 1848(c)(2) of the 

8 Social Security Act (42 U.S.C. 1395w–4(c)(2)), as 

9 amended by subsections (a) and (b), is amended by 

10 adding at the end the following new subparagraph: 

11 ‘‘(O) TARGET FOR RELATIVE VALUE AD12 JUSTMENTS FOR MISVALUED SERVICES.—With 

13 respect to fee schedules established for each of 

14 2015 through 2018, the following shall apply: 

15 ‘‘(i) DETERMINATION OF NET REDUC16 TION IN EXPENDITURES.—For each year, 

17 the Secretary shall determine the esti18 mated net reduction in expenditures under 

19 the fee schedule under this section with re20 spect to the year as a result of adjust21 ments to the relative values established 

22 under this paragraph for misvalued codes. 

23 ‘‘(ii) BUDGET NEUTRAL REDISTRIBU24 TION OF FUNDS IF TARGET MET AND

25 COUNTING OVERAGES TOWARDS THE TARVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00116 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
117 

•S 1871 PCS

1 GET FOR THE SUCCEEDING YEAR.—If the 

2 estimated net reduction in expenditures de3 termined under clause (i) for the year is 

4 equal to or greater than the target for the 

5 year— 

6 ‘‘(I) reduced expenditures attrib7 utable to such adjustments shall be 

8 redistributed for the year in a budget 

9 neutral manner in accordance with 

10 subparagraph (B)(ii)(II); and 

11 ‘‘(II) the amount by which such 

12 reduced expenditures exceeds the tar13 get for the year shall be treated as a 

14 reduction in expenditures described in 

15 clause (i) for the succeeding year, for 

16 purposes of determining whether the 

17 target has or has not been met under 

18 this subparagraph with respect to that 

19 year. 

20 ‘‘(iii) EXEMPTION FROM BUDGET

21 NEUTRALITY IF TARGET NOT MET.—If the 

22 estimated net reduction in expenditures de23 termined under clause (i) for the year is 

24 less than the target for the year, reduced 

25 expenditures in an amount equal to the 


smartinez on DSK6TPTVN1PROD with BILLS
118 

•S 1871 PCS

1 target recapture amount shall not be taken 

2 into account in applying subparagraph 

3 (B)(ii)(II) with respect to fee schedules be4 ginning with 2015. 

5 ‘‘(iv) TARGET RECAPTURE AMOUNT.— 

6 For purposes of clause (iii), the target re7 capture amount is, with respect to a year, 

8 an amount equal to the difference be9 tween— 

10 ‘‘(I) the target for the year; and 

11 ‘‘(II) the estimated net reduction 

12 in expenditures determined under 

13 clause (i) for the year. 

14 ‘‘(v) TARGET.—For purposes of this 

15 subparagraph, with respect to a year, the 

16 target is calculated as 0.5 percent of the 

17 estimated amount of expenditures under 

18 the fee schedule under this section for the 

19 year.’’. 

20 (2) CONFORMING AMENDMENT.—Section 

21 1848(c)(2)(B)(v) of the Social Security Act (42 

22 U.S.C. 1395w–4(c)(2)(B)(v)) is amended by adding 

23 at the end the following new subclause: 

24 ‘‘(VIII) REDUCTIONS FOR

25 MISVALUED SERVICES IF TARGET NOT


smartinez on DSK6TPTVN1PROD with BILLS
119 

•S 1871 PCS

1 MET.—Effective for fee schedules be2 ginning with 2015, reduced expendi3 tures attributable to the application of 

4 the target recapture amount described 

5 in subparagraph (O)(iii).’’. 

6 (e) PHASE-IN OF SIGNIFICANT RELATIVE VALUE

7 UNIT (RVU) REDUCTIONS.— 

8 (1) IN GENERAL.—Section 1848(c) of the So9 cial Security Act (42 U.S.C. 1395w–4(c)) is amend10 ed by adding at the end the following new para11 graph: 

12 ‘‘(7) PHASE-IN OF SIGNIFICANT RELATIVE

13 VALUE UNIT (RVU) REDUCTIONS.—Effective for fee 

14 schedules established beginning with 2015, if the 

15 total relative value units for a service for a year 

16 would otherwise be decreased by an estimated 

17 amount equal to or greater than 20 percent as com18 pared to the total relative value units for the pre19 vious year, the applicable adjustments in work, prac20 tice expense, and malpractice relative value units 

21 shall be phased-in over a 2-year period.’’. 

22 (2) CONFORMING AMENDMENTS.—Section 

23 1848(c)(2) of the Social Security Act (42 U.S.C. 

24 1395w–4(c)(2)) is amended— 


smartinez on DSK6TPTVN1PROD with BILLS
120 

•S 1871 PCS

1 (A) in subparagraph (B)(ii)(I), by striking 

2 ‘‘subclause (II)’’ and inserting ‘‘subclause (II) 

3 and paragraph (7)’’; and 

4 (B) in subparagraph (K)(iii)(VI)— 

5 (i) by striking ‘‘provisions of subpara6 graph (B)(ii)(II)’’ and inserting ‘‘provi7 sions of subparagraph (B)(ii)(II) and para8 graph (7)’’; and 

9 (ii) by striking ‘‘under subparagraph 

10 (B)(ii)(II)’’ and inserting ‘‘under subpara11 graph (B)(ii)(I)’’. 

12 (f) AUTHORITY TO SMOOTH RELATIVE VALUES

13 WITHIN GROUPS OF SERVICES.—Section 1848(c)(2)(C) of 

14 the Social Security Act (42 U.S.C. 1395w–4(c)(2)(C)) is 

15 amended— 

16 (1) in each of clauses (i) and (iii), by striking 

17 ‘‘the service’’ and inserting ‘‘the service or group of 

18 services’’ each place it appears; and 

19 (2) in the first sentence of clause (ii), by insert20 ing ‘‘or group of services’’ before the period. 

21 (g) GAO STUDY AND REPORT ON RELATIVE VALUE

22 SCALE UPDATE COMMITTEE.— 

23 (1) STUDY.—The Comptroller General of the 

24 United States (in this subsection referred to as the 

25 ‘‘Comptroller General’’) shall conduct a study of the 


smartinez on DSK6TPTVN1PROD with BILLS
121 

•S 1871 PCS

1 processes used by the Relative Value Scale Update 

2 Committee (RUC) to provide recommendations to 

3 the Secretary of Health and Human Services regard4 ing relative values for specific services under the 

5 Medicare physician fee schedule under section 1848 

6 of the Social Security Act (42 U.S.C. 1395w–4). 

7 (2) REPORT.—Not later than 1 year after the 

8 date of the enactment of this Act, the Comptroller 

9 General shall submit to Congress a report containing 

10 the results of the study conducted under paragraph 

11 (1). 

12 SEC. 105. PROMOTING EVIDENCE-BASED CARE. 

13 (a) RECOGNIZING APPROPRIATE USE CRITERIA FOR

14 CERTAIN IMAGING SERVICES.— 

15 (1) IN GENERAL.—Section 1834 of the Social 

16 Security Act (42 U.S.C. 1395m) is amended by add17 ing at the end the following new subsection: 

18 ‘‘(p) RECOGNIZING APPROPRIATE USE CRITERIA FOR

19 CERTAIN IMAGING SERVICES.— 

20 ‘‘(1) PROGRAM ESTABLISHED.— 

21 ‘‘(A) IN GENERAL.—The Secretary shall 

22 establish a program to promote the use of ap23 propriate use criteria (as defined in subpara24 graph (B)) for applicable imaging services (as 

25 defined in subparagraph (C)) furnished in an 


smartinez on DSK6TPTVN1PROD with BILLS
122 

•S 1871 PCS

1 applicable setting (as defined in subparagraph 

2 (D)) by ordering professionals and furnishing 

3 professionals (as defined in subparagraphs (E) 

4 and (F), respectively). 

5 ‘‘(B) APPROPRIATE USE CRITERIA DE6 FINED.—In this subsection, the term ‘appro7 priate use criteria’ means criteria, only devel8 oped or endorsed by national professional med9 ical specialty societies or other provider-led enti10 ties, to assist ordering professionals and fur11 nishing professionals in making the most appro12 priate treatment decision for a specific clinical 

13 condition. To the extent feasible, such criteria 

14 shall be evidence-based. 

15 ‘‘(C) APPLICABLE IMAGING SERVICE DE16 FINED.—In this subsection, the term ‘applicable 

17 imaging service’ means an advanced diagnostic 

18 imaging service (as defined in subsection 

19 (e)(1)(B)) for which the Secretary determines— 

20 ‘‘(i) one or more applicable appro21 priate use criteria specified under para22 graph (2) apply; 

23 ‘‘(ii) there are one or more qualified 

24 clinical decision support mechanisms listed 

25 under paragraph (3)(C); and 


smartinez on DSK6TPTVN1PROD with BILLS
123 

•S 1871 PCS

1 ‘‘(iii) one or more of such mechanisms 

2 is available free of charge. 

3 ‘‘(D) APPLICABLE SETTING DEFINED.—In 

4 this subsection, the term ‘applicable setting’ 

5 means a physician’s office, a hospital outpatient 

6 department (including an emergency depart7 ment), an ambulatory surgical center, and any 

8 other provider-led outpatient setting determined 

9 appropriate by the Secretary. 

10 ‘‘(E) ORDERING PROFESSIONAL DE11 FINED.—In this subsection, the term ‘ordering 

12 professional’ means a physician (as defined in 

13 section 1861(r)) or a practitioner described in 

14 section 1842(b)(18)(C) who orders an applica15 ble imaging service for an individual. 

16 ‘‘(F) FURNISHING PROFESSIONAL DE17 FINED.—In this subsection, the term ‘fur18 nishing professional’ means a physician (as de19 fined in section 1861(r)) or a practitioner de20 scribed in section 1842(b)(18)(C) who furnishes 

21 an applicable imaging service for an individual. 

22 ‘‘(2) ESTABLISHMENT OF APPLICABLE APPRO23 PRIATE USE CRITERIA.— 

24 ‘‘(A) IN GENERAL.—Not later than No25 vember 15, 2015, the Secretary shall through 


smartinez on DSK6TPTVN1PROD with BILLS
124 

•S 1871 PCS

1 rulemaking, and in consultation with physi2 cians, practitioners, and other stakeholders, 

3 specify applicable appropriate use criteria for 

4 applicable imaging services only from among 

5 appropriate use criteria developed or endorsed 

6 by national professional medical specialty soci7 eties or other provider-led entities. 

8 ‘‘(B) CONSIDERATIONS.—In specifying ap9 plicable appropriate use criteria under subpara10 graph (A), the Secretary shall take into account 

11 whether the criteria— 

12 ‘‘(i) have stakeholder consensus; 

13 ‘‘(ii) have been determined to be sci14 entifically valid and are evidence based; 

15 and 

16 ‘‘(iii) are based on studies that are 

17 published and reviewable by stakeholders. 

18 ‘‘(C) REVISIONS.—The Secretary shall pe19 riodically update and revise (as appropriate) 

20 such specification of applicable appropriate use 

21 criteria. 

22 ‘‘(D) TREATMENT OF MULTIPLE APPLICA23 BLE APPROPRIATE USE CRITERIA.—In the case 

24 where the Secretary determines that more than 

25 one appropriate use criteria applies with respect 


smartinez on DSK6TPTVN1PROD with BILLS
125 

•S 1871 PCS

1 to an applicable imaging service, the Secretary 

2 shall specify one or more applicable appropriate 

3 use criteria under this paragraph for the serv4 ice. 

5 ‘‘(3) MECHANISMS FOR CONSULTATION WITH

6 APPLICABLE APPROPRIATE USE CRITERIA.— 

7 ‘‘(A) IDENTIFICATION OF MECHANISMS TO

8 CONSULT WITH APPLICABLE APPROPRIATE USE

9 CRITERIA.— 

10 ‘‘(i) IN GENERAL.—The Secretary 

11 shall specify one or more qualified clinical 

12 decision support mechanisms that could be 

13 used by ordering professionals to consult 

14 with applicable appropriate use criteria for 

15 applicable imaging services. 

16 ‘‘(ii) CONSULTATION.—The Secretary 

17 shall consult with physicians, practitioners, 

18 and other stakeholders in specifying mech19 anisms under this paragraph. 

20 ‘‘(iii) INCLUSION OF CERTAIN MECHA21 NISMS.—Mechanisms specified under this 

22 paragraph may include any or all of the 

23 following that meet the requirements de24 scribed in subparagraph (B)(ii): 


smartinez on DSK6TPTVN1PROD with BILLS
126 

•S 1871 PCS

1 ‘‘(I) Use of clinical decision sup2 port modules in certified EHR tech3 nology (as defined in section 

4 1848(o)(4)). 

5 ‘‘(II) Use of private sector clin6 ical decision support mechanisms that 

7 are independent from certified EHR 

8 technology, which may include use of 

9 clinical decision support mechanisms 

10 available from medical specialty orga11 nizations. 

12 ‘‘(III) Use of a clinical decision 

13 support mechanism established by the 

14 Secretary. 

15 ‘‘(B) QUALIFIED CLINICAL DECISION SUP16 PORT MECHANISMS.— 

17 ‘‘(i) IN GENERAL.—For purposes of 

18 this subsection, a qualified clinical decision 

19 support mechanism is a mechanism that 

20 the Secretary determines meets the re21 quirements described in clause (ii). 

22 ‘‘(ii) REQUIREMENTS.—The require23 ments described in this clause are the fol24 lowing: 


smartinez on DSK6TPTVN1PROD with BILLS
127 

•S 1871 PCS

1 ‘‘(I) The mechanism makes avail2 able to the ordering professional appli3 cable appropriate use criteria specified 

4 under paragraph (2) and the sup5 porting documentation for the applica6 ble imaging service ordered. 

7 ‘‘(II) In the case where there are 

8 more than one applicable appropriate 

9 use criteria specified under such para10 graph for an applicable imaging serv11 ice, the mechanism indicates the cri12 teria that it uses for the service. 

13 ‘‘(III) The mechanism determines 

14 the extent to which an applicable im15 aging service ordered is consistent 

16 with the applicable appropriate use 

17 criteria so specified. 

18 ‘‘(IV) The mechanism generates 

19 and provides to the ordering profes20 sional a certification or documentation 

21 that documents that the qualified clin22 ical decision support mechanism was 

23 consulted by the ordering professional. 

24 ‘‘(V) The mechanism is updated 

25 on a timely basis to reflect revisions 


smartinez on DSK6TPTVN1PROD with BILLS
128 

•S 1871 PCS

1 to the specification of applicable ap2 propriate use criteria under such 

3 paragraph. 

4 ‘‘(VI) The mechanism meets pri5 vacy and security standards under ap6 plicable provisions of law. 

7 ‘‘(VII) The mechanism performs 

8 such other functions as specified by 

9 the Secretary, which may include a re10 quirement to provide aggregate feed11 back to the ordering professional. 

12 ‘‘(C) LIST OF MECHANISMS FOR CON13 SULTATION WITH APPLICABLE APPROPRIATE

14 USE CRITERIA.— 

15 ‘‘(i) INITIAL LIST.—Not later than 

16 April 1, 2016, the Secretary shall publish 

17 a list of mechanisms specified under this 

18 paragraph. 

19 ‘‘(ii) PERIODIC UPDATING OF LIST.— 

20 The Secretary shall periodically update the 

21 list of qualified clinical decision support 

22 mechanisms specified under this para23 graph. 

24 ‘‘(4) CONSULTATION WITH APPLICABLE APPRO25 PRIATE USE CRITERIA.— 


smartinez on DSK6TPTVN1PROD with BILLS
129 

•S 1871 PCS

1 ‘‘(A) CONSULTATION BY ORDERING PRO2 FESSIONAL.—Beginning with January 1, 2017, 

3 subject to subparagraph (C), with respect to an 

4 applicable imaging service ordered by an order5 ing professional that would be furnished in an 

6 applicable setting and paid for under an appli7 cable payment system (as defined in subpara8 graph (D)), an ordering professional shall— 

9 ‘‘(i) consult with a qualified decision 

10 support mechanism listed under paragraph 

11 (3)(C); and 

12 ‘‘(ii) provide to the furnishing profes13 sional the information described in clauses 

14 (i) through (iii) of subparagraph (B). 

15 ‘‘(B) REPORTING BY FURNISHING PROFES16 SIONAL.—Beginning with January 1, 2017, 

17 subject to subparagraph (C), with respect to an 

18 applicable imaging service furnished in an ap19 plicable setting and paid for under an applica20 ble payment system (as defined in subpara21 graph (D)), payment for such service may only 

22 be made if the claim for the service includes the 

23 following: 

24 ‘‘(i) Information about which qualified 

25 clinical decision support mechanism was 


smartinez on DSK6TPTVN1PROD with BILLS
130 

•S 1871 PCS

1 consulted by the ordering professional for 

2 the service. 

3 ‘‘(ii) Information regarding— 

4 ‘‘(I) whether the service ordered 

5 would adhere to the applicable appro6 priate use criteria specified under 

7 paragraph (2); 

8 ‘‘(II) whether the service ordered 

9 would not adhere to such criteria; or 

10 ‘‘(III) whether such criteria was 

11 not applicable to the service ordered. 

12 ‘‘(iii) The national provider identifier 

13 of the ordering professional (if different 

14 from the furnishing professional). 

15 ‘‘(C) EXCEPTIONS.—The provisions of sub16 paragraphs (A) and (B) and paragraph (6)(A) 

17 shall not apply to the following: 

18 ‘‘(i) EMERGENCY SERVICES.—An ap19 plicable imaging service ordered for an in20 dividual with an emergency medical condi21 tion (as defined in section 1867(e)(1)). 

22 ‘‘(ii) INPATIENT SERVICES.—An appli23 cable imaging service ordered for an inpa24 tient and for which payment is made under 

25 part A. 


smartinez on DSK6TPTVN1PROD with BILLS
131 

•S 1871 PCS

1 ‘‘(iii) ALTERNATIVE PAYMENT MOD2 ELS.—An applicable imaging service or3 dered by an ordering professional with re4 spect to an individual attributed to an al5 ternative payment model (as defined in 

6 section 1833(z)(3)(C)). 

7 ‘‘(iv) SIGNIFICANT HARDSHIP.—An 

8 applicable imaging service ordered by an 

9 ordering professional who the Secretary 

10 may, on a case-by-case basis, exempt from 

11 the application of such provisions if the 

12 Secretary determines, subject to annual re13 newal, that consultation with applicable ap14 propriate use criteria would result in a sig15 nificant hardship, such as in the case of a 

16 professional who practices in a rural area 

17 without sufficient Internet access. 

18 ‘‘(D) APPLICABLE PAYMENT SYSTEM DE19 FINED.—In this subsection, the term ‘applicable 

20 payment system’ means the following: 

21 ‘‘(i) The physician fee schedule estab22 lished under section 1848(b). 

23 ‘‘(ii) The prospective payment system 

24 for hospital outpatient department services 

25 under section 1833(t). 


smartinez on DSK6TPTVN1PROD with BILLS
132 

•S 1871 PCS

1 ‘‘(iii) The ambulatory surgical center 

2 payment systems under section 1833(i). 

3 ‘‘(5) IDENTIFICATION OF OUTLIER ORDERING

4 PROFESSIONALS.— 

5 ‘‘(A) IN GENERAL.—With respect to appli6 cable imaging services furnished beginning with 

7 2017, the Secretary shall determine, on a peri8 odic basis (which may be annually), ordering 

9 professionals who are outlier ordering profes10 sionals. 

11 ‘‘(B) OUTLIER ORDERING PROFES12 SIONALS.—The determination of an outlier or13 dering professional shall— 

14 ‘‘(i) be based on low adherence to ap15 plicable appropriate use criteria specified 

16 under paragraph (2), which may be based 

17 on comparison to other ordering profes18 sionals; and 

19 ‘‘(ii) include data for ordering profes20 sionals for whom prior authorization under 

21 paragraph (6)(A) applies. 

22 ‘‘(C) USE OF TWO YEARS OF DATA.—The 

23 Secretary shall use two years of data to identify 

24 outlier ordering professionals under this para25 graph. 


smartinez on DSK6TPTVN1PROD with BILLS
133 

•S 1871 PCS

1 ‘‘(D) CONSULTATION WITH STAKE2 HOLDERS.—The Secretary shall consult with 

3 physicians, practitioners and other stakeholders 

4 in developing methods to identify outlier order5 ing professionals under this paragraph. 

6 ‘‘(6) PRIOR AUTHORIZATION FOR ORDERING

7 PROFESSIONALS WHO ARE OUTLIERS.— 

8 ‘‘(A) IN GENERAL.—Beginning January 1, 

9 2020, subject to paragraph (4)(C), with respect 

10 to services furnished during a year, the Sec11 retary shall, for a period determined appro12 priate by the Secretary, apply prior authoriza13 tion for applicable imaging services that are or14 dered by an outlier ordering professional identi15 fied under paragraph (5). 

16 ‘‘(B) FUNDING.—For purposes of carrying 

17 out this paragraph, the Secretary shall provide 

18 for the transfer, from the Federal Supple19 mentary Medical Insurance Trust Fund under 

20 section 1841, of $5,000,000 to the Centers for 

21 Medicare & Medicaid Services Program Man22 agement Account for each of fiscal years 2019 

23 through 2021. Amounts transferred under the 

24 preceding sentence shall remain available until 

25 expended.’’. 


smartinez on DSK6TPTVN1PROD with BILLS
134 

•S 1871 PCS

1 (2) CONFORMING AMENDMENT.—Section 

2 1833(t)(16) of the Social Security Act (42 U.S.C. 

3 1395l(t)(16)) is amended by adding at the end the 

4 following new subparagraph: 

5 ‘‘(E) APPLICATION OF APPROPRIATE USE

6 CRITERIA FOR CERTAIN IMAGING SERVICES.— 

7 For provisions relating to the application of ap8 propriate use criteria for certain imaging serv9 ices, see section 1834(p).’’. 

10 (b) ESTABLISHMENT OF APPROPRIATE USE PRO11 GRAM FOR OTHER PART B SERVICES.—Section 1834 of 

12 the Social Security Act (42 U.S.C. 1395m), as amended 

13 by subsection (a), is amended by adding at the end the 

14 following new subsection: 

15 ‘‘(q) ESTABLISHMENT OF APPROPRIATE USE PRO16 GRAM FOR OTHER PART B SERVICES.— 

17 ‘‘(1) ESTABLISHMENT.— 

18 ‘‘(A) IN GENERAL.—The Secretary may es19 tablish an appropriate use program for services 

20 under this part (other than applicable imaging 

21 services under subsection (p)) using a process 

22 that is comparable to the process under such 

23 subsection. With respect to appropriate use cri24 teria, such process shall replicate the provider25 developed or provider-endorsed criteria frameVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00134 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
135 

•S 1871 PCS

1 work for appropriate use criteria for applicable 

2 imaging services under such subsection. 

3 ‘‘(B) REQUIREMENTS.—In determining 

4 whether to establish a program under subpara5 graph (A), the Secretary shall take into consid6 eration— 

7 ‘‘(i) the applicability of the provider8 developed or provider-endorsed criteria 

9 framework for appropriate use criteria for 

10 applicable imaging services under sub11 section (p); 

12 ‘‘(ii) the implementation of provider13 developed or provider-endorsed appropriate 

14 use criteria for such applicable imaging 

15 services; and 

16 ‘‘(iii) the report under paragraph (2). 

17 ‘‘(C) INPUT FROM STAKEHOLDERS IN AD18 VANCE OF RULEMAKING.—Before issuing a no19 tice of proposed rulemaking to establish a pro20 gram under subparagraph (A), the Secretary 

21 shall issue an advance notice of proposed rule22 making. 

23 ‘‘(2) REPORT ON EXPERIENCE OF IMAGING AP24 PROPRIATE USE CRITERIA PROGRAM.—Not later 

25 than 18 months after the date of the enactment of 


smartinez on DSK6TPTVN1PROD with BILLS
136 

•S 1871 PCS

1 this subsection, the Comptroller General of the 

2 United States shall submit to Congress a report that 

3 includes a description of the extent to which appro4 priate use criteria could be used for other services 

5 under this part, such as radiation therapy and clin6 ical diagnostic laboratory services.’’. 

7 SEC. 106. EMPOWERING BENEFICIARY CHOICES THROUGH 

8 ACCESS TO INFORMATION ON PHYSICIANS’ 

9 SERVICES. 

10 (a) TRANSFERRING FREESTANDING PHYSICIAN COM11 PARE PROVISION TO THE SOCIAL SECURITY ACT.— 

12 (1) IN GENERAL.—Section 10331 of Public 

13 Law 111–148 is transferred and redesignated as 

14 subsection (t) of section 1848 of the Social Security 

15 Act (42 U.S.C. 1395w–4), as amended by sub16 sections (c) and (h) of section 101 and by section 

17 102. 

18 (2) CONFORMING REDESIGNATIONS.—Section 

19 1848(t) of the Social Security Act (42 U.S.C. 

20 1395w–4(t)), as transferred and redesignated by 

21 paragraph (1), is further amended— 

22 (A) by striking the subsection heading and 

23 inserting the following new subsection heading: 

24 ‘‘PUBLIC REPORTING OF PERFORMANCE AND


smartinez on DSK6TPTVN1PROD with BILLS
137 

•S 1871 PCS

1 OTHER INFORMATION ON PHYSICIAN COM2 PARE’’; 

3 (B) by redesignating subsections (a) 

4 through (i) as paragraphs (1) through (9), re5 spectively, and indenting appropriately; 

6 (C) in paragraph (1), as redesignated by 

7 subparagraph (B)— 

8 (i) by redesignating paragraphs (1) 

9 and (2) as subparagraphs (A) and (B), re10 spectively, and indenting appropriately; 

11 (ii) in subparagraph (B), as redesig12 nated by clause (i), by redesignating sub13 paragraphs (A) through (G) as clauses (i) 

14 through (vii), respectively, and indenting 

15 appropriately; 

16 (D) in paragraph (2), as redesignated by 

17 subparagraph (B), by redesignating paragraphs 

18 (1) through (7) as subparagraphs (A) through 

19 (G), respectively, and indenting appropriately; 

20 and 

21 (E) in paragraph (9), as redesignated by 

22 subparagraph (B), by redesignating paragraphs 

23 (1) through (4) as subparagraphs (A) through 

24 (D), respectively, and indenting appropriately. 


smartinez on DSK6TPTVN1PROD with BILLS
138 

•S 1871 PCS

1 (3) CONFORMING AMENDMENTS.—Section 

2 1848(t) of the Social Security Act (42 U.S.C. 

3 1395w–4(t)), as amended by paragraph (2), is fur4 ther amended— 

5 (A) in paragraph (1)— 

6 (i) in subparagraph (A)— 

7 (I) by striking ‘‘the Medicare 

8 program under section 1866(j) of the 

9 Social Security Act (42 U.S.C. 

10 1395cc(j))’’ and inserting ‘‘the pro11 gram under this title under section 

12 1866(j)’’; and 

13 (II) by striking ‘‘of such Act (42 

14 U.S.C. 1395w–4)’’; and 

15 (ii) in subparagraph (B), in the mat16 ter preceding clause (i)— 

17 (I) by striking ‘‘subsection (c)’’ 

18 and inserting ‘‘paragraph (3)’’; 

19 (II) by striking ‘‘the Medicare 

20 program under such section 1866(j)’’ 

21 and inserting ‘‘the program under this 

22 title under section 1866(j)’’; and 

23 (III) by striking ‘‘this section’’ 

24 and inserting ‘‘this subsection’’; 

25 (B) in paragraph (2)— 


smartinez on DSK6TPTVN1PROD with BILLS
139 

•S 1871 PCS

1 (i) in the matter preceding subpara2 graph (A), by striking ‘‘subsection (a)(2)’’ 

3 and inserting ‘‘paragraph (1)(B)’’; 

4 (ii) in subparagraph (D), by striking 

5 ‘‘the Medicare program’’ and inserting 

6 ‘‘the program under this title’’; and 

7 (iii) in each of subparagraphs (F) and 

8 (G), by striking ‘‘this section’’ and insert9 ing ‘‘this subsection’’; 

10 (C) in paragraph (3), by striking ‘‘this sec11 tion’’ and inserting ‘‘this subsection’’; 

12 (D) in paragraph (4)— 

13 (i) by striking ‘‘of the Social Security 

14 Act, as added by section 3014 of this Act’’; 

15 and 

16 (ii) by striking ‘‘this section’’ and in17 serting ‘‘this subsection’’; 

18 (E) in paragraph (5)— 

19 (i) by striking ‘‘this subsection (a)(2)’’ 

20 and inserting ‘‘paragraph (1)(B)’’; and 

21 (ii) by striking ‘‘(Public Law 110– 

22 275)’’; 

23 (F) in paragraph (6), by striking ‘‘sub24 section (a)(1)’’ and inserting ‘‘paragraph 

25 (1)(A)’’; 


smartinez on DSK6TPTVN1PROD with BILLS
140 

•S 1871 PCS

1 (G) in paragraph (7)— 

2 (i) by striking ‘‘subsection (f)’’ and in3 serting ‘‘paragraph (6)’’; and 

4 (ii) by striking ‘‘title XVIII of the So5 cial Security Act’’ and inserting ‘‘this 

6 title’’; 

7 (H) in paragraph (8)— 

8 (i) by striking ‘‘subparagraphs (A) 

9 through (G) of subsection (a)(2)’’ and in10 serting ‘‘clauses (i) through (vii) of para11 graph (1)(B)’’; 

12 (ii) by striking ‘‘title XVIII of the So13 cial Security Act’’ and inserting ‘‘this 

14 title’’; and 

15 (iii) by striking ‘‘such title’’ and in16 serting ‘‘this title’’; and 

17 (I) in paragraph (9)— 

18 (i) in the matter preceding subpara19 graph (8), by striking ‘‘this section’’ and 

20 inserting ‘‘this subsection’’; 

21 (ii) in subparagraph (A), by striking 

22 ‘‘of the Social Security Act (42 U.S.C. 

23 1395w–4)’’; 

24 (iii) in subparagraph (B), by striking 

25 ‘‘of such Act (42 U.S.C. 1395x(r))’’; 


smartinez on DSK6TPTVN1PROD with BILLS
141 

•S 1871 PCS

1 (iv) in subparagraph (C), by striking 

2 ‘‘subsection (a)(1)’’ and inserting ‘‘para3 graph (1)(A)’’; and 

4 (v) by striking subparagraph (D). 

5 (b) PUBLIC AVAILABILITY OF MEDICARE DATA.— 

6 Section 1848(t) of the Social Security Act (42 U.S.C. 

7 1395w–4(t)), as amended by subsection (a), is further 

8 amended— 

9 (1) by redesignating paragraph (9) as para10 graph (10); 

11 (2) by inserting after paragraph (8) the fol12 lowing new paragraph: 

13 ‘‘(9) PUBLIC AVAILABILITY OF ELIGIBLE PRO14 FESSIONAL CLAIMS DATA.— 

15 ‘‘(A) IN GENERAL.—The Secretary shall 

16 make publicly available on Physician Compare 

17 the information described in subparagraph (B) 

18 with respect to eligible professionals. 

19 ‘‘(B) INFORMATION DESCRIBED.—The fol20 lowing information, with respect to an eligible 

21 professional, is described in this subparagraph: 

22 ‘‘(i) Information on the number of 

23 services furnished by the eligible profes24 sional, which may include information on 


smartinez on DSK6TPTVN1PROD with BILLS
142 

•S 1871 PCS

1 the most frequent services furnished or 

2 groupings of services. 

3 ‘‘(ii) Information on submitted 

4 charges and payments for services under 

5 this part. 

6 ‘‘(iii) A unique identifier for the eligi7 ble professional that is available to the 

8 public, such as a national provider identi9 fier. 

10 ‘‘(C) SEARCHABILITY.—The information 

11 made available under this paragraph shall be 

12 searchable by at least the following: 

13 ‘‘(i) The specialty or type of the eligi14 ble professional. 

15 ‘‘(ii) Characteristics of the services 

16 furnished, such as volume or groupings of 

17 services. 

18 ‘‘(iii) The location of the eligible pro19 fessional. 

20 ‘‘(D) DISCLOSURE.—The information 

21 made available under this paragraph shall indi22 cate, where appropriate, that publicized infor23 mation may not be representative of the eligible 

24 professional’s entire patient population, the va25 riety of services furnished by the eligible profesVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00142 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
143 

•S 1871 PCS

1 sional, or the health conditions of individuals 

2 treated. 

3 ‘‘(E) IMPLEMENTATION.— 

4 ‘‘(i) INITIAL IMPLEMENTATION.—Phy5 sician Compare shall include the informa6 tion described in subparagraph (B)— 

7 ‘‘(I) with respect to physicians, 

8 by not later than July 1, 2015; and 

9 ‘‘(II) with respect to other eligi10 ble professionals, by not later than 

11 July 1, 2016. 

12 ‘‘(ii) ANNUAL UPDATING.—The infor13 mation made available under this para14 graph shall be updated on Physician Com15 pare not less frequently than on an annual 

16 basis. 

17 ‘‘(F) OPPORTUNITY TO REVIEW AND SUB18 MIT CORRECTIONS.—The Secretary shall pro19 vide for an opportunity for an eligible profes20 sional to review, and submit corrections for, the 

21 information to be made public with respect to 

22 the eligible professional under this paragraph 

23 prior to such information being made public.’’; 

24 and 


smartinez on DSK6TPTVN1PROD with BILLS
144 

•S 1871 PCS

1 (3) in paragraph (10)(C), as redesignated by 

2 paragraph (1), by inserting ‘‘(or a successor 

3 website)’’ before the period at the end. 

4 SEC. 107. EXPANDING CLAIMS DATA AVAILABILITY TO IM5 PROVE CARE. 

6 (a) EXPANSION OF USES OF CLAIMS DATA BY

7 QUALIFIED ENTITIES.—Section 1874(e) of the Social Se8 curity Act (42 U.S.C. 1395kk(e)) is amended by adding 

9 at the end the following new paragraphs: 

10 ‘‘(5) EXPANSION OF USES OF CLAIMS DATA BY

11 QUALIFIED ENTITIES.— 

12 ‘‘(A) EXPANSION.—To the extent con13 sistent with applicable information, privacy, se14 curity, and disclosure laws, beginning July 1, 

15 2014, notwithstanding paragraph (4)(B) (other 

16 than clause (iii) of such paragraph) and the 

17 second sentence of paragraph (4)(D), a quali18 fied entity may, as determined appropriate by 

19 the Secretary, do any or all of the following: 

20 ‘‘(i)(I) Use the combined data de21 scribed in paragraph (4)(B)(iii) to conduct 

22 analyses, other than for reports described 

23 in paragraph (4), for entities described in 

24 subparagraph (B) for non-public uses, as 

25 determined appropriate by the Secretary, 


smartinez on DSK6TPTVN1PROD with BILLS
145 

•S 1871 PCS

1 such as for the purposes described in sub2 clause (II). 

3 ‘‘(II) The purposes described in this 

4 subclause are assisting providers of serv5 ices and suppliers in developing and par6 ticipating in quality and patient care im7 provement activities (including developing 

8 new models of care), population health 

9 management, and disease monitoring, and 

10 the purposes described in subparagraph 

11 (C). 

12 ‘‘(ii) Provide or sell such analyses to 

13 entities described in subparagraph (B). 

14 ‘‘(iii) Provide entities described in 

15 clauses (i), (ii), (v), and (vi) of subpara16 graph (B) with access to the combined 

17 data described in paragraph (4)(B)(iii) 

18 through a qualified data enclave (as de19 fined in subparagraph (F)) that is main20 tained by the qualified entity, or through 

21 an approved alternative method (as defined 

22 in subparagraph (G)), in order for entities 

23 described in such clauses to conduct anal24 yses for non-public uses, such as for the 

25 purposes described in clause (i)(II) (but 


smartinez on DSK6TPTVN1PROD with BILLS
146 

•S 1871 PCS

1 excluding the purposes described in sub2 paragraph (C)). 

3 ‘‘(B) ENTITIES DESCRIBED.—For the pur4 pose of subparagraph (A) clauses (i) and (ii), 

5 the entities described in this subparagraph are 

6 the following: 

7 ‘‘(i) A provider of services. 

8 ‘‘(ii) A supplier. 

9 ‘‘(iii) Subject to subparagraph (C), an 

10 employer (as defined in section 3(5) of the 

11 Employee Retirement Insurance Security 

12 Act of 1974). 

13 ‘‘(iv) A health insurance issuer (as de14 fined in section 2791 of the Public Health 

15 Service Act) that provides data under 

16 paragraph (4)(B)(iii). 

17 ‘‘(v) A medical society or hospital as18 sociation. 

19 ‘‘(vi) Other entities approved by the 

20 Secretary (other than an employer (as so 

21 defined) and a health insurance issuer (as 

22 so defined)). 

23 ‘‘(C) LIMITATION FOR EMPLOYERS WITH

24 RESPECT TO ANALYSES.—Any analyses pro25 vided or sold under this paragraph to an emVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00146 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
147 

•S 1871 PCS

1 ployer (as so defined) may only be used by such 

2 employer for purposes of providing health insur3 ance to employees and retirees of the employer. 

4 ‘‘(D) PROTECTION OF PATIENT IDENTI5 FICATION IN ANALYSES.— 

6 ‘‘(i) IN GENERAL.—Except as pro7 vided in clause (ii), an analysis provided or 

8 sold under this paragraph shall not contain 

9 information that individually identifies a 

10 patient. 

11 ‘‘(ii) INFORMATION ON PATIENTS OF

12 THE PROVIDER OF SERVICES OR SUP13 PLIER.—An analysis that is provided or 

14 sold under this paragraph to a provider of 

15 services or supplier may contain data that 

16 individually identifies a patient of such 

17 provider or supplier but only with respect 

18 to items and services furnished by such 

19 provider or supplier to such patient. 

20 ‘‘(iii) OPPORTUNITY FOR PROVIDERS

21 OF SERVICES AND SUPPLIERS TO RE22 VIEW.—Prior to a qualified entity pro23 viding or selling an analysis under this 

24 paragraph to an entity described in sub25 paragraph (B), to the extent that such 


smartinez on DSK6TPTVN1PROD with BILLS
148 

•S 1871 PCS

1 analysis would individually identify a pro2 vider of services or supplier who is not 

3 being provided or sold such analysis, such 

4 qualified entity shall provide an oppor5 tunity for such provider or supplier to re6 view and submit corrections to such anal7 ysis. 

8 ‘‘(E) NO REDISCLOSURE OF ANALYSES OR

9 DATA.—An entity described in subparagraph 

10 (B) that is provided or sold analyses under this 

11 paragraph, or an entity described in subpara12 graph (A)(iii) that receives data under this 

13 paragraph through a qualified data enclave or 

14 an approved alternative method, shall not redis15 close or make public such analyses, such data, 

16 or analyses using such data. 

17 ‘‘(F) REQUIREMENTS FOR A QUALIFIED

18 DATA ENCLAVE.— 

19 ‘‘(i) DEFINITION.—For purposes of 

20 this paragraph, the term ‘qualified data 

21 enclave’ means a data enclave that the 

22 Secretary determines meets the following: 

23 ‘‘(I) The data enclave is a virtual 

24 private network or comparable mecha25 nism. 


smartinez on DSK6TPTVN1PROD with BILLS
149 

•S 1871 PCS

1 ‘‘(II) Subject to the requirements 

2 described in clause (ii) and such other 

3 requirements as the Secretary may 

4 specify, the data enclave is capable of 

5 providing access to the combined data 

6 described in subparagraph (A)(iii). 

7 ‘‘(ii) ENCLAVE ACCESS REQUIRE8 MENTS.—The requirements described in 

9 this clause are the following: 

10 ‘‘(I) A qualified data enclave 

11 shall preclude any entity that obtains 

12 access to the data from removing or 

13 extracting the data from such enclave. 

14 ‘‘(II) Subject to the succeeding 

15 sentence, the enclave shall preclude 

16 access to data that individually identi17 fies a patient, including data on the 

18 patient’s name and date of birth and 

19 such other data as the Secretary shall 

20 specify. Such data enclave may pro21 vide providers of services and sup22 pliers with access to such individually 

23 identifiable patient data but only with 

24 respect to items and services furVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00149 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
150 

•S 1871 PCS

1 nished by such provider or supplier to 

2 such patient. 

3 ‘‘(III) Access to data in the en4 clave shall not be provided to any en5 tity unless the qualified entity and the 

6 entity have entered into a data use 

7 agreement, the terms of which contain 

8 the requirements of this paragraph 

9 and paragraph (6) and such other 

10 terms the Secretary may specify. 

11 ‘‘(G) APPROVED ALTERNATIVE METHOD.— 

12 For purposes of this paragraph, the term ‘ap13 proved alternative method’ means a method of 

14 providing access to the data described in sub15 paragraph (A)(iii) (other than through a quali16 fied data enclave) to entities described in such 

17 paragraph that the Secretary determines meets 

18 the following: 

19 ‘‘(i) The method is as secure as a 

20 qualified data enclave. 

21 ‘‘(ii) The method meets the require22 ments applicable to a qualified data en23 clave under subclauses (II) and (III) of 

24 subparagraph (F)(ii). 


smartinez on DSK6TPTVN1PROD with BILLS
151 

•S 1871 PCS

1 ‘‘(iii) The method meets other require2 ments determined appropriate by the Sec3 retary. 

4 ‘‘(H) ANNUAL REPORTS.—Any qualified 

5 entity that provides or sells analyses pursuant 

6 to subparagraph (A)(ii), or provides access to a 

7 data through an approved data enclave or an 

8 approved alternative method, shall annually 

9 submit to the Secretary a report that in10 cludes— 

11 ‘‘(i) a summary of the analyses pro12 vided or sold, including the number of such 

13 analyses, the number of purchasers of such 

14 analyses, and the total amount of fees re15 ceived for such analyses; 

16 ‘‘(ii) a description of the topics and 

17 purposes of such analyses; 

18 ‘‘(iii) information on the entities who 

19 obtained access to data pursuant to sub20 paragraph (A)(iii), the uses of the data, 

21 and the total amount of fees received for 

22 providing such access; and 

23 ‘‘(iv) other information determined 

24 appropriate by the Secretary. 


smartinez on DSK6TPTVN1PROD with BILLS
152 

•S 1871 PCS

1 ‘‘(6) CIVIL MONETARY PENALTIES FOR A

2 BREACH OF A DATA USE AGREEMENT.—A data use 

3 agreement under this subsection shall provide for 

4 civil monetary penalties (as determined appropriate 

5 by the Secretary) for a breach of such agreement.’’. 

6 (b) EXPANSION OF DATA AVAILABLE TO QUALIFIED

7 ENTITIES.—Section 1874(e) of the Social Security Act 

8 (42 U.S.C. 1395kk(e)) is amended— 

9 (1) in the subsection heading, by striking 

10 ‘‘Medicare’’; and 

11 (2) in paragraph (3)— 

12 (A) by inserting after the first sentence the 

13 following new sentence: ‘‘Effective July 1, 

14 2014, if the Secretary determines appropriate, 

15 the data described in this paragraph may also 

16 include standardized extracts (as determined by 

17 the Secretary) of claims data under titles XIX 

18 and XXI for assistance provided under such ti19 tles for one or more specified geographic areas 

20 and time periods requested by a qualified enti21 ty.’’; and 

22 (B) in the last sentence, by inserting ‘‘or 

23 under titles XIX or XXI’’ before the period at 

24 the end. 


smartinez on DSK6TPTVN1PROD with BILLS
153 

•S 1871 PCS

1 (c) ACCESS TO MEDICARE DATA BY QUALIFIED

2 CLINICAL DATA REGISTRIES TO FACILITATE QUALITY

3 IMPROVEMENT.—Section 1848(m)(3)(E) of the Social Se4 curity Act (42 U.S.C. 1395w–4(m)(3)(E)) is amended by 

5 adding at the end the following new clause: 

6 ‘‘(vi) ACCESS TO MEDICARE DATA TO

7 FACILITATE QUALITY IMPROVEMENT.— 

8 ‘‘(I) IN GENERAL.—To the extent 

9 consistent with applicable information, 

10 privacy, security, and disclosure laws, 

11 and subject to other requirements as 

12 the Secretary may specify, beginning 

13 July 1, 2014, the Secretary shall, if 

14 requested by a qualified clinical data 

15 registry under this subparagraph, sub16 ject to subclauses (II) and (III), pro17 vide data as described in section 

18 1874(e)(3) (in a form and manner de19 termined to be appropriate) to such 

20 registry for purposes of linking such 

21 data with clinical data and performing 

22 analyses and research to support qual23 ity improvement or patient safety. 

24 ‘‘(II) PROTECTION.—A qualified 

25 clinical data registry may not publicly 


smartinez on DSK6TPTVN1PROD with BILLS
154 

•S 1871 PCS

1 report any data made available under 

2 subclause (I) (or any analyses or re3 search described in such subclause) 

4 that individually identifies a provider 

5 of services, supplier, or individual un6 less the registry obtains the consent of 

7 such provider, supplier, or individual 

8 prior to such reporting. 

9 ‘‘(III) FEE.—The data described 

10 in subclause (I) shall be made avail11 able to qualified clinical data reg12 istries at a fee equal to the cost of 

13 making such data available. Any fee 

14 collected pursuant to the preceding 

15 sentence shall be deposited in the 

16 Centers for Medicare & Medicaid 

17 Services Program Management Ac18 count.’’. 

19 (d) REVISION OF PLACEMENT OF FEES.—Section 

20 1874(e)(4)(A) of the Social Security Act (42 U.S.C. 

21 1395kk(e)(4)(A)) is amended, in the second sentence— 

22 (1) by inserting ‘‘, for periods prior to July 1, 

23 2014,’’ after ‘‘deposited’’; and 

24 (2) by inserting the following before the period 

25 at the end: ‘‘, and, beginning July 1, 2014, into the 


smartinez on DSK6TPTVN1PROD with BILLS
155 

•S 1871 PCS

1 Centers for Medicare & Medicaid Services Program 

2 Management Account’’. 

3 TITLE II—EXTENSIONS AND 

4 OTHER PROVISIONS 

5 Subtitle A—Medicare Extensions 

6 SEC. 201. WORK GEOGRAPHIC ADJUSTMENT. 

7 Section 1848(e)(1)(E) of the Social Security Act (42 

8 U.S.C. 1395w–4(e)(1)(E)) is amended by striking ‘‘and 

9 before January 1, 2014,’’. 

10 SEC. 202. MEDICARE PAYMENT FOR THERAPY SERVICES. 

11 (a) REPEAL OF THERAPY CAP AND 1-YEAR EXTEN12 SION OF THRESHOLD FOR MANUAL MEDICAL REVIEW.— 

13 Section 1833(g) of the Social Security Act (42 U.S.C. 

14 1395l(g)) is amended— 

15 (1) in paragraph (4)— 

16 (A) by striking ‘‘This subsection’’ and in17 serting ‘‘Except as provided in paragraph 

18 (5)(C), this subsection’’; and 

19 (B) by inserting the following before the 

20 period at the end: ‘‘or with respect to services 

21 furnished on or after the date of enactment of 

22 the SGR Repeal and Medicare Beneficiary Ac23 cess Act of 2013’’. 

24 (2) in paragraph (5)(C)— 


smartinez on DSK6TPTVN1PROD with BILLS
156 

•S 1871 PCS

1 (A) in clause (i), by inserting ‘‘and before 

2 January 1, 2015,’’ after ‘‘2012,’’; and 

3 (B) by adding at the end the following new 

4 clause: 

5 ‘‘(iii) With respect to services furnished during the 

6 period beginning on the date of enactment of the SGR 

7 Repeal and Medicare Beneficiary Access Act of 2013, and 

8 ending on December 31, 2014, the provisions of this para9 graph shall only apply to the extent necessary to carry 

10 out the manual medical review process under this subpara11 graph.’’. 

12 (b) MEDICAL REVIEW OF OUTPATIENT THERAPY

13 SERVICES.— 

14 (1) MEDICAL REVIEW OF OUTPATIENT THER15 APY SERVICES.—Section 1833 of the Social Security 

16 Act (42 U.S.C. 1395l), as amended by section 

17 101(e), is amended by adding at the end the fol18 lowing new subsection: 

19 ‘‘(aa) MEDICAL REVIEW OF OUTPATIENT THERAPY

20 SERVICES.— 

21 ‘‘(1) IN GENERAL.— 

22 ‘‘(A) PROCESS FOR MEDICAL REVIEW.— 

23 The Secretary shall implement a process for the 

24 medical review (as described in paragraph (2)) 

25 of outpatient therapy services (as defined in 


smartinez on DSK6TPTVN1PROD with BILLS
157 

•S 1871 PCS

1 paragraph (10)) and, subject to paragraph 

2 (12), apply such process to such services fur3 nished on or after January 1, 2015, focusing on 

4 services identified under subparagraph (B). 

5 ‘‘(B) IDENTIFICATION OF SERVICES FOR

6 REVIEW.—Under the process, the Secretary 

7 shall identify services for medical review, using 

8 such factors as the Secretary determines appro9 priate, which may include the following: 

10 ‘‘(i) Services furnished by a therapy 

11 provider (as defined in paragraph (10)) 

12 whose pattern of billing is higher compared 

13 to peers. 

14 ‘‘(ii) Services furnished by a therapy 

15 provider who, in a prior period, has a high 

16 claims denial percentage or is least compli17 ant with other applicable requirements 

18 under this title. 

19 ‘‘(iii) Services furnished by a therapy 

20 provider that is newly enrolled under this 

21 title. 

22 ‘‘(iv) Services furnished by a therapy 

23 provider who has questionable billing prac24 tices, such as billing medically unlikely 

25 units of services in a day. 


smartinez on DSK6TPTVN1PROD with BILLS
158 

•S 1871 PCS

1 ‘‘(v) Services furnished to treat a type 

2 of medical condition. 

3 ‘‘(vi) Services identified by use of the 

4 standardized data elements required to be 

5 reported under section 1834(p). 

6 ‘‘(vii) Services furnished by a single 

7 therapy provider or a group that includes 

8 a therapy provider identified by factors de9 scribed in this subparagraph. 

10 ‘‘(viii) Other services as determined 

11 appropriate by the Secretary. 

12 ‘‘(2) MEDICAL REVIEW.— 

13 ‘‘(A) PRIOR AUTHORIZATION MEDICAL RE14 VIEW.— 

15 ‘‘(i) IN GENERAL.—Subject to the 

16 succeeding provisions of this subparagraph, 

17 the Secretary shall use prior authorization 

18 medical review for outpatient therapy serv19 ices furnished to an individual above one 

20 or more thresholds established by the Sec21 retary, such as a dollar threshold or a 

22 threshold based on factors such as the type 

23 of outpatient therapy service or setting. 

24 ‘‘(ii) ENDING APPLICATION OF PRIOR

25 AUTHORIZATION FOR A THERAPY PROVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00158 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
159 

•S 1871 PCS

1 VIDER.—The Secretary shall end the appli2 cation of prior authorization medical re3 view to outpatient therapy services fur4 nished by a therapy provider if the Sec5 retary determines that the provider has a 

6 low denial rate under such prior authoriza7 tion. The Secretary may subsequently re8 apply prior authorization medical review to 

9 such therapy provider if the Secretary de10 termines it to be appropriate. 

11 ‘‘(iii) PRIOR AUTHORIZATION OF MUL12 TIPLE SERVICES.—The Secretary shall, 

13 where practicable, provide for prior author14 ization medical review for multiple services 

15 at a single time, such as services in a ther16 apy plan of care described in section 

17 1861(p)(2). 

18 ‘‘(B) OTHER TYPES OF MEDICAL RE19 VIEW.—The Secretary may use pre-payment re20 view or post-payment review for services identi21 fied under paragraph (1)(B) that are not sub22 ject to prior authorization medical review under 

23 subparagraph (A). 

24 ‘‘(C) LIMITATION FOR LAW ENFORCEMENT

25 ACTIVITIES.—The Secretary may determine 


smartinez on DSK6TPTVN1PROD with BILLS
160 

•S 1871 PCS

1 that medical review under this subsection does 

2 not apply in the case where fraud may be in3 volved. 

4 ‘‘(3) REVIEW CONTRACTORS.—The Secretary 

5 shall conduct prior authorization medical review of 

6 outpatient therapy services under this subsection 

7 using medicare administrative contractors (as de8 scribed in section 1874A) or other review contrac9 tors (other than contractors under section 1893(h) 

10 or contractors paid on a contingent basis). 

11 ‘‘(4) NO PAYMENT WITHOUT PRIOR AUTHORIZA12 TION.—With respect to an outpatient therapy service 

13 for which prior authorization medical review under 

14 this subsection applies, no payment shall be made 

15 under this part for the service unless a prior author16 ization determination is made, in advance of fur17 nishing such service, that such service would meet 

18 the applicable requirements of section 

19 1862(a)(1)(A). 

20 ‘‘(5) SUBMISSION OF INFORMATION.—A ther21 apy provider may submit the information necessary 

22 for medical review by fax, by mail, or by electronic 

23 means. The Secretary shall make available the elec24 tronic means described in the preceding sentence as 


smartinez on DSK6TPTVN1PROD with BILLS
161 

•S 1871 PCS

1 soon as practicable, but not later than 24 months 

2 after the date of enactment of this subsection. 

3 ‘‘(6) TIMELINESS.—The Secretary shall make a 

4 prior authorization determination under this sub5 section within 10 business days of the date of the 

6 Secretary’s receipt of medical documentation needed 

7 to make such determination or the Secretary shall 

8 be deemed to have found the services to meet the ap9 plicable requirements of section 1862(a)(1)(A). 

10 ‘‘(7) CONSTRUCTION.—With respect to an out11 patient therapy service that has been affirmed by 

12 medical review under this subsection, nothing in this 

13 subsection shall be construed to preclude the subse14 quent denial of a claim for such service that does 

15 not meet other applicable requirements under this 

16 Act. 

17 ‘‘(8) BENEFICIARY PROTECTIONS.—With re18 spect to services furnished on or after January 1, 

19 2015, where payment may not be made as a result 

20 of application of medical review under this sub21 section, section 1879 shall apply in the same manner 

22 as such section applies to a denial that is made by 

23 reason of section 1862(a)(1). 

24 ‘‘(9) IMPLEMENTATION.— 


smartinez on DSK6TPTVN1PROD with BILLS
162 

•S 1871 PCS

1 ‘‘(A) AUTHORITY.—The Secretary may im2 plement the provisions of this subsection by in3 terim final rule with comment period. 

4 ‘‘(B) ADMINISTRATION.—Chapter 35 of 

5 title 44, United States Code, shall not apply to 

6 medical review under this subsection. 

7 ‘‘(10) DEFINITIONS.—For purposes of this sub8 section: 

9 ‘‘(A) OUTPATIENT THERAPY SERVICES.— 

10 The term ‘outpatient therapy services’ means 

11 the following services for which payment is 

12 made under section 1848, 1834(g), or 1834(k): 

13 ‘‘(i) Physical therapy services of the 

14 type described in section 1861(p). 

15 ‘‘(ii) Speech-language pathology serv16 ices of the type described in such section 

17 though the application of section 

18 1861(ll)(2). 

19 ‘‘(iii) Occupational therapy services of 

20 the type described in section 1861(p) 

21 through the operation of section 1861(g). 

22 ‘‘(B) THERAPY PROVIDER.—The term 

23 ‘therapy provider’ means a provider of services 

24 (as defined in section 1861(u)) or a supplier (as 


smartinez on DSK6TPTVN1PROD with BILLS
163 

•S 1871 PCS

1 defined in section 1861(d)) who submits a claim 

2 for outpatient therapy services. 

3 ‘‘(11) FUNDING.—For purposes of imple4 menting this subsection, the Secretary shall provide 

5 for the transfer, from the Federal Supplementary 

6 Medical Insurance Trust Fund under section 1841, 

7 of $35,000,000 to the Centers for Medicare & Med8 icaid Services Program Management Account for 

9 each fiscal year (beginning with fiscal year 2014). 

10 Amounts transferred under this paragraph shall re11 main available until expended. 

12 ‘‘(12) SCALING BACK.— 

13 ‘‘(A) PERIODIC DETERMINATIONS.—Begin14 ning with 2017, and every two years thereafter, 

15 the Secretary shall— 

16 ‘‘(i) make a determination of the im17 proper payment rate for outpatient therapy 

18 services for a 12-month period; and 

19 ‘‘(ii) make such determination publicly 

20 available. 

21 ‘‘(B) SCALING BACK.—If the improper 

22 payment rate for outpatient therapy services de23 termined for a 12-month period under subpara24 graph (A) is 50 percent or less of the Medicare 


smartinez on DSK6TPTVN1PROD with BILLS
164 

•S 1871 PCS

1 fee-for-service improper payment rate for such 

2 period, the Secretary shall— 

3 ‘‘(i) reduce the amount and extent of 

4 medical review conducted for a prospective 

5 year under the process established in this 

6 subsection; and 

7 ‘‘(ii) return an appropriate portion of 

8 the funding provided for such year under 

9 paragraph (11).’’. 

10 (2) GAO STUDY AND REPORT.— 

11 (A) STUDY.—The Comptroller General of 

12 the United States shall conduct a study on the 

13 effectiveness of medical review of outpatient 

14 therapy services under section 1833(aa) of the 

15 Social Security Act, as added by paragraph (2). 

16 Such study shall include an analysis of— 

17 (i) aggregate data on— 

18 (I) the number of individuals, 

19 therapy providers, and claims subject 

20 to such review; and 

21 (II) the number of reviews con22 ducted under such section; and 

23 (ii) the outcomes of such reviews. 

24 (B) REPORT.—Not later than 3 years after 

25 the date of enactment of this Act, the CompVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00164 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
165 

•S 1871 PCS

1 troller General shall submit to Congress a re2 port containing the results of the study under 

3 subparagraph (A), together with recommenda4 tions for such legislation and administrative ac5 tion as the Comptroller General determines ap6 propriate. 

7 (c) COLLECTION OF STANDARDIZED DATA ELE8 MENTS FOR OUTPATIENT THERAPY SERVICES.— 

9 (1) COLLECTION OF STANDARDIZED DATA ELE10 MENTS FOR OUTPATIENT THERAPY SERVICES.—Sec11 tion 1834 of the Social Security Act (42 U.S.C. 

12 1395m) is amended by adding at the end the fol13 lowing new subsection: 

14 ‘‘(p) COLLECTION OF STANDARDIZED DATA ELE15 MENTS FOR OUTPATIENT THERAPY SERVICES.— 

16 ‘‘(1) STANDARDIZED DATA ELEMENTS.— 

17 ‘‘(A) IN GENERAL.—Not later than 6 

18 months after the date of enactment of this sub19 section, the Secretary shall post on the Internet 

20 website of the Centers for Medicare & Medicaid 

21 Services a draft list of standardized data ele22 ments for individuals receiving outpatient ther23 apy services. 

24 ‘‘(B) DOMAINS.—Such standardized data 

25 elements shall include information with respect 


smartinez on DSK6TPTVN1PROD with BILLS
166 

•S 1871 PCS

1 to the following domains, as determined appro2 priate by the Secretary: 

3 ‘‘(i) Demographic information. 

4 ‘‘(ii) Diagnosis. 

5 ‘‘(iii) Severity. 

6 ‘‘(iv) Affected body structures and 

7 functions. 

8 ‘‘(v) Limitations with activities of 

9 daily living and participation. 

10 ‘‘(vi) Functional status. 

11 ‘‘(vii) Other domains determined to be 

12 appropriate by the Secretary. 

13 ‘‘(C) SOLICITATION OF INPUT.—The Sec14 retary shall accept comments from stakeholders 

15 through the date that is 60 days after the date 

16 the Secretary posts the draft list of standard17 ized data elements pursuant to subparagraph 

18 (A). In seeking such comments, the Secretary 

19 shall use one or more mechanisms to solicit 

20 input from stakeholders that may include use of 

21 open door forums, town hall meetings, requests 

22 for information, or other mechanisms deter23 mined appropriate by the Secretary. 

24 ‘‘(D) OPERATIONAL LIST OF STANDARD25 IZED DATA ELEMENTS.—Not later than 120 


smartinez on DSK6TPTVN1PROD with BILLS
167 

•S 1871 PCS

1 days after the end of the comment period de2 scribed in subparagraph (C), the Secretary, tak3 ing into account such comments, shall post on 

4 the Internet website of the Centers for Medi5 care & Medicaid Services an operational list of 

6 standardized data elements. 

7 ‘‘(E) SUBSEQUENT REVISIONS.—Subse8 quent revisions to the operational list of stand9 ardized data elements shall be made through 

10 rulemaking. Such revisions may be based on ex11 perience and input from stakeholders. 

12 ‘‘(2) SYSTEM TO REPORT STANDARDIZED DATA

13 ELEMENTS.— 

14 ‘‘(A) IN GENERAL.—Not later than 18 

15 months after the date the Secretary posts the 

16 operational list of standardized data elements 

17 pursuant to paragraph (1)(D), the Secretary 

18 shall develop and implement an electronic sys19 tem (which may be a web portal) for therapy 

20 providers to report the standardized data ele21 ments for individuals with respect to outpatient 

22 therapy services. 

23 ‘‘(B) CONSULTATION.—The Secretary 

24 shall seek comments from stakeholders regardVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00167 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
168 

•S 1871 PCS

1 ing the best way to report the standardized 

2 data elements. 

3 ‘‘(3) REPORTING.— 

4 ‘‘(A) FREQUENCY OF REPORTING.—The 

5 Secretary shall specify the frequency of report6 ing standardized data elements. The Secretary 

7 shall seek comments from stakeholders regard8 ing the frequency of the reporting of such data 

9 elements. 

10 ‘‘(B) REPORTING REQUIREMENT.—Begin11 ning on the date the system to report standard12 ized data elements under this subsection is 

13 operational, no payment shall be made under 

14 this part for outpatient therapy services fur15 nished to an individual unless a therapy pro16 vider reports the standardized data elements for 

17 such individual. 

18 ‘‘(4) REPORT ON NEW PAYMENT SYSTEM FOR

19 OUTPATIENT THERAPY SERVICES.— 

20 ‘‘(A) IN GENERAL.—Not later than 18 

21 months after the date described in paragraph 

22 (3)(B), the Secretary shall submit to Congress 

23 a report on the design of a new payment system 

24 for outpatient therapy services. The report shall 

25 include an analysis of the standardized data eleVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00168 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
169 

•S 1871 PCS

1 ments collected and other appropriate data and 

2 information. 

3 ‘‘(B) FEATURES.—Such report shall con4 sider— 

5 ‘‘(i) appropriate adjustments to pay6 ment (such as case mix and outliers); 

7 ‘‘(ii) payments on an episode of care 

8 basis; and 

9 ‘‘(iii) reduced payment for multiple 

10 episodes. 

11 ‘‘(C) CONSULTATION.—The Secretary shall 

12 consult with stakeholders regarding the design 

13 of such a new payment system. 

14 ‘‘(5) IMPLEMENTATION.— 

15 ‘‘(A) FUNDING.—For purposes of imple16 menting this subsection, the Secretary shall 

17 provide for the transfer, from the Federal Sup18 plementary Medical Insurance Trust Fund 

19 under section 1841, of $7,000,000 to the Cen20 ters for Medicare & Medicaid Services Program 

21 Management Account for each of fiscal years 

22 2014 through 2018. Amounts transferred under 

23 this subparagraph shall remain available until 

24 expended. 


smartinez on DSK6TPTVN1PROD with BILLS
170 

•S 1871 PCS

1 ‘‘(B) ADMINISTRATION.—Chapter 35 of 

2 title 44, United States Code, shall not apply to 

3 specification of the standardized data elements 

4 and implementation of the system to report 

5 such standardized data elements under this 

6 subsection. 

7 ‘‘(C) LIMITATION.—There shall be no ad8 ministrative or judicial review under section 

9 1869, section 1878, or otherwise of the speci10 fication of standardized data elements required 

11 under this subsection or the system to report 

12 such standardized data elements. 

13 ‘‘(D) DEFINITION OF OUTPATIENT THER14 APY SERVICES AND THERAPY PROVIDER.—In 

15 this subsection, the terms ‘outpatient therapy 

16 services’ and ‘therapy provider’ have the mean17 ing given those term in section 1833(aa).’’. 

18 (2) SUNSET OF CURRENT CLAIMS-BASED COL19 LECTION OF THERAPY DATA.—Section 3005(g)(1) of 

20 the Middle Class Tax Extension and Job Creation 

21 Act of 2012 (42 U.S.C. 1395l note) is amended, in 

22 the first sentence, by inserting ‘‘and ending on the 

23 date the system to report standardized data ele24 ments under section 1834(p) of the Social Security 


smartinez on DSK6TPTVN1PROD with BILLS
171 

•S 1871 PCS

1 Act (42 U.S.C. 1395m(p)) is implemented,’’ after 

2 ‘‘January 1, 2013,’’. 

3 (d) REPORTING OF CERTAIN INFORMATION.—Sec4 tion 1842(t) of the Social Security Act (42 U.S.C. 

5 1395u(t)) is amended by adding at the end the following 

6 new paragraph: 

7 ‘‘(3) Each request for payment, or bill submitted, by 

8 a therapy provider (as defined in section 1833(aa)(10)) 

9 for an outpatient therapy service (as defined in such sec10 tion) furnished by a therapy assistant on or after January 

11 1, 2015, shall include (in a form and manner specified 

12 by the Secretary) an indication that the service was fur13 nished by a therapy assistant.’’. 

14 SEC. 203. MEDICARE AMBULANCE SERVICES. 

15 (a) EXTENSION OF CERTAIN AMBULANCE ADD-ON

16 PAYMENTS.— 

17 (1) GROUND AMBULANCE.—Section 

18 1834(l)(13)(A) of the Social Security Act (42 U.S.C. 

19 1395m(l)(13)(A)) is amended by striking ‘‘January 

20 1, 2014’’ and inserting ‘‘January 1, 2019’’ each 

21 place it appears. 

22 (2) SUPER RURAL AMBULANCE.—Section 

23 1834(l)(12)(A) of the Social Security Act (42 U.S.C. 

24 1395m(l)(12)(A)) is amended, in the first sentence, 


smartinez on DSK6TPTVN1PROD with BILLS
172 

•S 1871 PCS

1 by striking ‘‘January 1, 2014’’ and inserting ‘‘Janu2 ary 1, 2019’’. 

3 (b) REQUIRING AMBULANCE PROVIDERS TO SUBMIT

4 COST AND OTHER INFORMATION.—Section 1834(l) of the 

5 Social Security Act (42 U.S.C. 1395m(l)) is amended by 

6 adding at the end the following new paragraph: 

7 ‘‘(16) SUBMISSION OF COST AND OTHER INFOR8 MATION.— 

9 ‘‘(A) DEVELOPMENT OF DATA COLLECTION

10 SYSTEM.—The Secretary shall develop a data 

11 collection system (which may include use of a 

12 cost survey and standardized definitions) for 

13 providers and suppliers of ambulance services to 

14 collect cost, revenue, utilization, and other in15 formation determined appropriate by the Sec16 retary. Such system shall be designed to submit 

17 information— 

18 ‘‘(i) needed to evaluate the appro19 priateness of payment rates under this 

20 subsection; 

21 ‘‘(ii) on the utilization of capital 

22 equipment and ambulance capacity; and 

23 ‘‘(iii) on different types of ambulance 

24 services furnished in different geographic 

25 locations, including rural areas and low 


smartinez on DSK6TPTVN1PROD with BILLS
173 

•S 1871 PCS

1 population density areas described in para2 graph (12). 

3 ‘‘(B) SPECIFICATION OF DATA COLLEC4 TION SYSTEM.— 

5 ‘‘(i) IN GENERAL.—Not later than 

6 January 1, 2015, the Secretary shall— 

7 ‘‘(I) specify the data collection 

8 system under subparagraph (A); and 

9 ‘‘(II) identify the providers and 

10 suppliers of ambulance services who 

11 would be required to submit the infor12 mation under such data collection sys13 tem. 

14 ‘‘(ii) RESPONDENTS.—Subject to sub15 paragraph (D)(ii), the Secretary shall de16 termine an appropriate sample of providers 

17 and suppliers of ambulance services to sub18 mit information under the data collection 

19 system each year. 

20 ‘‘(C) REPORTING OF COST INFORMA21 TION.—Beginning July 1, 2015, a 5 percent re22 duction to payments under this part shall be 

23 made for a 1-year period to a provider or sup24 plier of ambulance services who— 


smartinez on DSK6TPTVN1PROD with BILLS
174 

•S 1871 PCS

1 ‘‘(i) is identified under subparagraph 

2 (B)(i)(II) as being required to submit the 

3 information under the data collection sys4 tem; and 

5 ‘‘(ii) does not submit such informa6 tion. 

7 ‘‘(D) ONGOING DATA COLLECTION.— 

8 ‘‘(i) REVISION OF DATA COLLECTION

9 SYSTEM.—The Secretary may revise, as 

10 the Secretary determines appropriate, the 

11 data collection system. The Secretary shall 

12 consult with providers and suppliers of am13 bulance services when revising such sys14 tem. 

15 ‘‘(ii) SUBSEQUENT DATA COLLEC16 TION.—In order to continue to evaluate 

17 the appropriateness of payment rates 

18 under this subsection, the Secretary shall 

19 require providers and suppliers of ambu20 lance services to submit information for 

21 years after 2015 as the Secretary deter22 mines appropriate, but in no case less 

23 often than once every 3 years. 

24 ‘‘(E) CONSULTATION.—The Secretary shall 

25 consult with stakeholders in carrying out the 


smartinez on DSK6TPTVN1PROD with BILLS
175 

•S 1871 PCS

1 development of the system and collection of in2 formation under this paragraph, including the 

3 activities described in subparagraphs (A) and 

4 (D). Such consultation shall include the use of 

5 requests for information and other mechanisms 

6 determined appropriate by the Secretary. 

7 ‘‘(F) ADMINISTRATION.—Chapter 35 of 

8 title 44, United States Code, shall not apply to 

9 the collection of information required under this 

10 subsection. 

11 ‘‘(G) LIMITATIONS ON REVIEW.—There 

12 shall be no administrative or judicial review 

13 under section 1869, section 1878, or otherwise 

14 of the data collection system or identification of 

15 respondents under this paragraph. 

16 ‘‘(H) FUNDING FOR IMPLEMENTATION.— 

17 For purposes of carrying out subparagraph (A), 

18 the Secretary shall provide for the transfer, 

19 from the Federal Supplementary Medical Insur20 ance Trust Fund under section 1841, of 

21 $1,000,000 to the Centers for Medicare & Med22 icaid Services Program Management Account 

23 for fiscal year 2014. Amounts transferred under 

24 this subparagraph shall remain available until 

25 expended.’’. 


smartinez on DSK6TPTVN1PROD with BILLS
176 

•S 1871 PCS

1 SEC. 204. REVISION OF THE MEDICARE-DEPENDENT HOS2 PITAL (MDH) PROGRAM. 

3 (a) PERMANENT EXTENSION OF PAYMENT METHOD4 OLOGY.— 

5 (1) IN GENERAL.—Section 1886(d)(5)(G) of 

6 the Social Security Act (42 U.S.C. 

7 1395ww(d)(5)(G)) is amended— 

8 (A) in clause (i), by striking ‘‘and before 

9 October 1, 2013,’’; and 

10 (B) in clause (ii)(II), by striking ‘‘and be11 fore October 1, 2013,’’. 

12 (2) CONFORMING AMENDMENTS.— 

13 (A) TARGET AMOUNT.—Section 

14 1886(b)(3)(D) of the Social Security Act (42 

15 U.S.C. 1395ww(b)(3)(D)) is amended— 

16 (i) in the matter preceding clause (i), 

17 by striking ‘‘and before October 1, 2013,’’; 

18 and 

19 (ii) in clause (iv), by striking 

20 ‘‘through fiscal year 2013’’ and inserting 

21 ‘‘or a subsequent fiscal year’’. 

22 (B) HOSPITAL VALUE-BASED PURCHASING

23 PROGRAM.—Section 1886(o)(7)(D)(ii)(I) of the 

24 Social Security Act (42 U.S.C. 

25 1395ww(o)(7)(D)(ii)(I)) is amended by striking 


smartinez on DSK6TPTVN1PROD with BILLS
177 

•S 1871 PCS

1 ‘‘(with respect to discharges occurring during 

2 fiscal year 2012 and 2013)’’. 

3 (C) HOSPITAL READMISSION REDUCTION

4 PROGRAM.—Section 1886(q)(2)(B)(i) of the So5 cial Security Act (42 U.S.C. 

6 1395ww(q)(2)(B)(i)) is amended by striking 

7 ‘‘(with respect to discharges occurring during 

8 fiscal years 2012 and 2013)’’. 

9 (D) PERMITTING HOSPITALS TO DECLINE

10 RECLASSIFICATION.—Section 13501(e)(2) of 

11 the Omnibus Budget Reconciliation Act of 1993 

12 (42 U.S.C. 1395ww note) is amended by strik13 ing ‘‘fiscal year 1998, fiscal year 1999, or fiscal 

14 year 2000 through fiscal year 2013’’ and insert15 ing ‘‘or fiscal year 1998 or a subsequent fiscal 

16 year’’. 

17 (b) GAO STUDY AND REPORT ON MEDICARE-DE18 PENDENT HOSPITALS.— 

19 (1) STUDY.—The Comptroller General of the 

20 United States shall conduct a study on the following: 

21 (A) The payor mix of medicare-dependent, 

22 small rural hospitals (as defined in section 

23 1886(d)(5)(G)(iv)), how such mix will trend in 

24 future years, and whether or not the requireVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00177 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
178 

•S 1871 PCS

1 ment under subclause (IV) of such section 

2 should be revised. 

3 (B) The characteristics of medicare-de4 pendent, small rural hospitals that meet the re5 quirement of such subclause (IV) through the 

6 application of paragraph (a)(iii)(A) or 

7 (a)(iii)(B) of section 412.108 of the Code of 

8 Federal Regulations, including Medicare inpa9 tient and outpatient utilization, payor mix, and 

10 financial status, including Medicare and total 

11 margins, and whether or not Medicare pay12 ments for such hospitals should be revised. 

13 (C) Such other items related to medicare14 dependent, small rural hospitals as the Comp15 troller General determines appropriate. 

16 (2) REPORT.—Not later than 12 months after 

17 the date of the enactment of this Act, the Comp18 troller General of the United States shall submit to 

19 Congress a report on the study conducted under 

20 paragraph (1), together with recommendations for 

21 such legislation and administrative action as the 

22 Comptroller General determines appropriate. 

23 (c) IMPLEMENTATION.—Notwithstanding any other 

24 provision of law, the Secretary of Health and Human 

25 Services may implement the provisions of, and the amendVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00178 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
179 

•S 1871 PCS

1 ments made by, this section through program instruction 

2 or otherwise. 

3 SEC. 205. REVISION OF MEDICARE INPATIENT HOSPITAL 

4 PAYMENT ADJUSTMENT FOR LOW-VOLUME 

5 HOSPITALS. 

6 (a) IN GENERAL.—Section 1886(d)(12) of the Social 

7 Security Act (42 U.S.C. 1395ww(d)(12)) is amended— 

8 (1) in subparagraph (B)— 

9 (A) in the subparagraph heading, by in10 serting ‘‘FOR FISCAL YEARS 2005 THROUGH

11 2010’’ after ‘‘INCREASE’’; and 

12 (B) in the matter preceding clause (i), by 

13 striking ‘‘and for discharges occurring in fiscal 

14 year 2014 and subsequent years’’; 

15 (2) in subparagraph (C)(i), by striking ‘‘fiscal 

16 years 2011, 2012, and 2013’’ and inserting ‘‘fiscal 

17 year 2011 and subsequent fiscal years’’ each place 

18 it appears; and 

19 (3) in subparagraph (D)— 

20 (A) in the heading, by striking ‘‘TEM21 PORARY APPLICABLE PERCENTAGE INCREASE’’ 

22 and inserting ‘‘APPLICABLE PERCENTAGE IN23 CREASE FOR FISCAL YEAR 2011 AND SUBSE24 QUENT FISCAL YEARS’’; and 


smartinez on DSK6TPTVN1PROD with BILLS
180 

•S 1871 PCS

1 (B) by striking ‘‘fiscal years 2011, 2012, 

2 and 2013’’ and inserting ‘‘fiscal year 2011 or 

3 a subsequent fiscal year’’; 

4 (b) IMPLEMENTATION.—Notwithstanding any other 

5 provision of law, the Secretary of Health and Human 

6 Services may implement the provisions of, and the amend7 ments made by, this section through program instruction 

8 or otherwise. 

9 SEC. 206. SPECIALIZED MEDICARE ADVANTAGE PLANS FOR 

10 SPECIAL NEEDS INDIVIDUALS. 

11 (a) EXTENSION.—Section 1859(f)(1) of the Social 

12 Security Act (42 U.S.C. 1395w–28(f)(1)) is amended— 

13 (1) by striking ‘‘ENROLLMENT.—In the case’’ 

14 and inserting ‘‘ENROLLMENT.— 

15 ‘‘(A) IN GENERAL.—Subject to subpara16 graphs (B) and (C), in the case’’; 

17 (2) in subparagraph (A), as added by para18 graph (1), by striking ‘‘and for periods before Janu19 ary 1, 2015’’; and 

20 (3) by adding at the end the following new sub21 paragraphs: 

22 ‘‘(B) APPLICATION TO DUAL SNPS.—Sub23 paragraph (A) shall only apply to a specialized 

24 MA plan for special needs individuals described 


smartinez on DSK6TPTVN1PROD with BILLS
181 

•S 1871 PCS

1 in subsection (b)(6)(B)(ii) for periods before 

2 January 1, 2021. 

3 ‘‘(C) APPLICATION TO SEVERE OR DIS4 ABLING CHRONIC CONDITION SNPS.—Subpara5 graph (A) shall only apply to a specialized MA 

6 plan for special needs individuals described in 

7 subsection (b)(6)(B)(iii) for periods before Jan8 uary 1, 2018.’’. 

9 (b) INCREASED INTEGRATION OF DUAL SNPS.— 

10 (1) IN GENERAL.—Section 1859(f) of the Social 

11 Security Act (42 U.S.C. 1395w–28(f)) is amended— 

12 (A) in paragraph (3), by adding at the end 

13 the following new subparagraph: 

14 ‘‘(F) The plan meets the requirements ap15 plicable under paragraph (8).’’; and 

16 (B) by adding at the end the following new 

17 paragraph: 

18 ‘‘(8) INCREASED INTEGRATION OF DUAL

19 SNPS.— 

20 ‘‘(A) DESIGNATED CONTACT.—The Sec21 retary, acting through the Federal Coordinated 

22 Health Care Office (Medicare-Medicaid Coordi23 nation Office) established under section 2602 of 

24 the Patient Protection and Affordable Care Act 

25 (in this paragraph referred to as the ‘MMCO’), 


smartinez on DSK6TPTVN1PROD with BILLS
182 

•S 1871 PCS

1 shall serve as a dedicated point of contact for 

2 States to address misalignments that arise with 

3 the integration of specialized MA plans for spe4 cial needs individuals described in subsection 

5 (b)(6)(B)(ii) under this paragraph. Consistent 

6 with such role, the MMCO shall— 

7 ‘‘(i) establish a uniform process for 

8 disseminating to State Medicaid agencies 

9 information under this title impacting con10 tracts between such agencies and such 

11 plans under this subsection; and 

12 ‘‘(ii) establish basic resources for 

13 States interested in exploring such plans 

14 as a platform for integration. 

15 ‘‘(B) UNIFIED APPEALS PROCESS.— 

16 ‘‘(i) IN GENERAL.—Not later than 

17 April 1, 2015, the Secretary shall establish 

18 procedures unifying the appeals procedures 

19 under sections 1852(g), 1902(a)(3), and 

20 1902(a)(5) for items and services provided 

21 by specialized MA plans for special needs 

22 individuals described in subsection 

23 (b)(6)(B)(ii) under this title and title XIX. 

24 The Secretary shall solicit comment in de25 veloping such procedures from States, 


smartinez on DSK6TPTVN1PROD with BILLS
183 

•S 1871 PCS

1 plans, beneficiary representatives, and 

2 other relevant stakeholders. 

3 ‘‘(ii) PROCEDURES.—To the extent 

4 compatible with a unified process, the pro5 cedures established under clause (i) shall— 

6 ‘‘(I) adopt the most protective 

7 provisions for the enrollee under cur8 rent law, including continuation of 

9 benefits under title XIX pending ap10 peal if an appeal is filed in a timely 

11 manner; 

12 ‘‘(II) take into account dif13 ferences in State plans under title 

14 XIX; 

15 ‘‘(III) be easily navigable by an 

16 enrollee; and 

17 ‘‘(IV) include the elements de18 scribed in clause (iii). 

19 ‘‘(iii) ELEMENTS DESCRIBED.—The 

20 following elements are described in this 

21 clause: 

22 ‘‘(I) Single notification of all ap23 plicable appeal rights under this title 

24 and title XIX. 


smartinez on DSK6TPTVN1PROD with BILLS
184 

•S 1871 PCS

1 ‘‘(II) Notices written in plain lan2 guage and available in a language and 

3 format that is accessible to the en4 rollee. 

5 ‘‘(III) Unified timeframes for in6 ternal and external appeals processes, 

7 such as an individual’s filing of ap8 peals, a plan’s acknowledgment and 

9 resolution of appeals, and notification 

10 of appeals decisions. 

11 ‘‘(IV) Mechanisms to allow the 

12 plan to track and resolve grievances. 

13 ‘‘(C) REQUIREMENT FOR UNIFIED AP14 PEALS.— 

15 ‘‘(i) IN GENERAL.—For 2016 and 

16 subsequent years, the contract of a special17 ized MA plan for special needs individuals 

18 described in subsection (b)(6)(B)(ii) with a 

19 State Medicaid agency under this sub20 section shall require the use of unified ap21 peals procedures as described in subpara22 graph (B). 

23 ‘‘(ii) CONSIDERATION OF APPLICA24 TION FOR OTHER SNPS.—The Secretary 

25 shall consider applying the unified appeals 


smartinez on DSK6TPTVN1PROD with BILLS
185 

•S 1871 PCS

1 process described in subparagraph (B) to 

2 specialized MA plans for special needs indi3 viduals described in subsection (b)(6)(B)(i) 

4 and subsection (b)(6)(B)(iii). 

5 ‘‘(D) REQUIREMENT FOR FULL INTEGRA6 TION FOR CERTAIN DUAL SNPS.— 

7 ‘‘(i) REQUIREMENT.—Subject to the 

8 succeeding provisions of this subparagraph, 

9 for 2018 and subsequent years, a special10 ized MA plan for special needs individuals 

11 described in subsection (b)(6)(B)(ii) 

12 shall— 

13 ‘‘(I) integrate all benefits under 

14 this title and title XIX; and 

15 ‘‘(II) meet the requirements of a 

16 fully integrated plan described in sec17 tion 1853(a)(1)(B)(iv)(II) (other than 

18 the requirement that the plan have 

19 similar average levels of frailty, as de20 termined by the Secretary, as the 

21 PACE program), including with re22 spect to long-term care services or be23 havioral health services to the extent 

24 State law permits capitation of those 

25 services under such plan. 


smartinez on DSK6TPTVN1PROD with BILLS
186 

•S 1871 PCS

1 ‘‘(ii) INITIAL SANCTIONS FOR FAIL2 URE TO MEET REQUIREMENT FOR 2018 OR

3 2019.—For each of 2018 and 2019, if the 

4 Secretary determines that a plan has failed 

5 to meet the requirement described in 

6 clause (i), the Secretary shall impose one 

7 of the following on the plan: 

8 ‘‘(I) A reduction in payments 

9 under this part. 

10 ‘‘(II) Closing enrollment in the 

11 plan. 

12 ‘‘(III) Sanctioning the plan in ac13 cordance with section 1857(g). 

14 ‘‘(IV) Other reasonable action 

15 (other than the sanction described in 

16 clause (iii)) the Secretary determines 

17 appropriate. 

18 ‘‘(iii) SANCTIONS FOR FAILURE TO

19 MEET REQUIREMENT FOR 2020 AND SUBSE20 QUENT YEARS.—For 2020 and subsequent 

21 years, if the Secretary determines that a 

22 plan has failed to meet the requirement de23 scribed in clause (i), the plan shall be 

24 deemed to no longer meet the definition of 

25 a specialized MA plan for special needs inVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00186 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
187 

•S 1871 PCS

1 dividuals described in subsection 

2 (b)(6)(B)(ii). 

3 ‘‘(iv) LIMITATION.—This subpara4 graph shall not apply to a specialized MA 

5 plan for special needs individuals described 

6 in subsection (b)(6)(B)(ii) that only enrolls 

7 individuals for whom the only medical as8 sistance to which the individuals are enti9 tled under the State plan is medicare cost 

10 sharing described in section 

11 1905(p)(3)(A)(ii).’’. 

12 (2) CONFORMING AMENDMENT TO RESPON13 SIBILITIES OF FEDERAL COORDINATED HEALTH

14 CARE OFFICE (MMCO).—Section 2602(d) of the Pa15 tient Protection and Affordable Care Act (42 U.S.C. 

16 1315b(d)) is amended by adding at the end the fol17 lowing new paragraph: 

18 ‘‘(6) To act as a designated contact for States 

19 under subsection (f)(8)(A) of section 1859 of the So20 cial Security Act (42 U.S.C. 1395w–28) with respect 

21 to the integration of specialized MA plans for special 

22 needs individuals described in subsection 

23 (b)(6)(B)(ii) of such section.’’. 

24 (c) IMPROVEMENTS TO CARE MANAGEMENT RE25 QUIREMENTS FOR SEVERE OR DISABLING CHRONIC CONVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00187 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
188 

•S 1871 PCS

1 DITION SNPS.—Section 1859(f)(5) of the Social Security 

2 Act (42 U.S.C. 1395w–28(f)(5)) is amended— 

3 (1) by striking ‘‘ALL SNPS.—The requirements’’ 

4 and inserting ‘‘ALL SNPS.— 

5 ‘‘(A) IN GENERAL.—Subject to subpara6 graph (B), the requirements’’; 

7 (2) by redesignating subparagraphs (A) and 

8 (B) as clauses (i) and (ii), respectively, and indent9 ing appropriately; 

10 (3) in clause (ii), as redesignated by paragraph 

11 (2), by redesignating clauses (i) through (iii) as sub12 clauses (I) through (III), respectively, and indenting 

13 appropriately; and 

14 (4) by adding at the end the following new sub15 paragraph: 

16 ‘‘(B) IMPROVEMENTS TO CARE MANAGE17 MENT REQUIREMENTS FOR SEVERE OR DIS18 ABLING CHRONIC CONDITION SNPS.—For 2016 

19 and subsequent years, in the case of a special20 ized MA plan for special needs individuals de21 scribed in subsection (b)(6)(B)(iii), the require22 ments described in this paragraph include the 

23 following: 

24 ‘‘(i) The interdisciplinary team under 

25 subparagraph (A)(ii)(III) includes a team 


smartinez on DSK6TPTVN1PROD with BILLS
189 

•S 1871 PCS

1 of providers with demonstrated expertise, 

2 including training in an applicable spe3 cialty, in treating individuals similar to the 

4 targeted population of the plan. 

5 ‘‘(ii) Requirements developed by the 

6 Secretary to provide face-to-face encoun7 ters with individuals enrolled in the plan. 

8 ‘‘(iii) As part of the model of care 

9 under clause (i) of subparagraph (A), the 

10 results of the initial assessment and an11 nual reassessment under clause (ii)(I) of 

12 such subparagraph of each individual en13 rolled in the plan are addressed in the indi14 vidual’s individualized care plan under 

15 clause (ii)(II) of such subparagraph. 

16 ‘‘(iv) As part of the annual evaluation 

17 and approval of such model of care, the 

18 Secretary shall take into account whether 

19 the plan fulfilled the previous year’s goals 

20 (as required under the model of care). 

21 ‘‘(v) The Secretary shall establish a 

22 minimum benchmark for each element of 

23 the model of care of a plan. The Secretary 

24 shall only approve a plan’s model of care 

25 under this paragraph if each element of 


smartinez on DSK6TPTVN1PROD with BILLS
190 

•S 1871 PCS

1 the model of care meets the minimum 

2 benchmark applicable under the preceding 

3 sentence.’’. 

4 (d) GAO STUDY ON QUALITY IMPROVEMENT.— 

5 (1) STUDY.—The Comptroller General of the 

6 United States shall conduct a study on how the Sec7 retary of Health and Human Services could change 

8 the quality measurement system under the Medicare 

9 Advantage program under part C of title XVIII of 

10 the Social Security Act (42 U.S.C. 1395w–21 et 

11 seq.) to allow an accurate comparison of the quality 

12 of care provided by specialized MA plans for special 

13 needs individuals (as defined in section 1859(b)(6) 

14 of such Act (42 U.S.C. 1395w–28(b)(6)), both for 

15 individual plans and such plans overall, compared to 

16 the quality of care delivered by the original Medicare 

17 fee-for-service program under parts A and B of such 

18 title and other Medicare Advantage plans under such 

19 part C across similar populations. 

20 (2) REPORT.—Not later than July 1, 2016, the 

21 Comptroller General shall submit to Congress a re22 port containing the results of the study under para23 graph (1), together with recommendations for such 

24 legislation and administrative action as the Comp25 troller General determines appropriate. 


smartinez on DSK6TPTVN1PROD with BILLS
191 

•S 1871 PCS

1 (e) CHANGES TO QUALITY RATINGS AND MEASURE2 MENT OF SNPS.—Section 1853(o) of the Social Security 

3 Act (42 U.S.C. 1395w–23(o)) is amended by adding at 

4 the end the following new paragraph: 

5 ‘‘(6) CHANGES TO QUALITY RATINGS OF

6 SNPS.— 

7 ‘‘(A) EMPHASIS ON IMPROVEMENT ACROSS

8 SNPS.—Subject to subparagraph (B), beginning 

9 in plan year 2016, in the case of a specialized 

10 MA plan for special needs individuals, the Sec11 retary shall increase the emphasis on the plan’s 

12 improvement or decline in performance when 

13 determining the star rating of the plan under 

14 this subsection for the year as follows: 

15 ‘‘(i) At least 25 percent, but not more 

16 than 33 percent, of the total star rating of 

17 the plan shall be based on improvement or 

18 decline in performance. 

19 ‘‘(ii) Improvement or decline in per20 formance under this subparagraph shall be 

21 measured based on net change in the indi22 vidual star rating measures of the plan, 

23 with appropriate weight given to specific 

24 individual star ratings measures, such as 


smartinez on DSK6TPTVN1PROD with BILLS
192 

•S 1871 PCS

1 readmission rates, as determined by the 

2 Secretary. 

3 ‘‘(iii) The Secretary shall make an ap4 propriate adjustment to the improvement 

5 rating of a plan under this subparagraph 

6 if the plan has achieved a 5-star rating or 

7 the highest rating possible overall or for an 

8 individual measure in order to ensure that 

9 the plan is not punished in cases where it 

10 is not possible to improve. 

11 ‘‘(B) NO APPLICATION TO CERTAIN

12 PLANS.—Subparagraph (A) shall not apply, 

13 with respect to a year, to a specialized MA plan 

14 for special needs individuals that has a rating 

15 that does not exceed two-and-one-half stars. 

16 ‘‘(C) QUALITY MEASUREMENT AT THE

17 PLAN LEVEL.— 

18 ‘‘(i) IN GENERAL.—The Secretary 

19 may require reporting for and apply under 

20 this subsection quality measures at the 

21 plan level for specialized MA plan for spe22 cial needs individuals instead of at the con23 tract level. 

24 ‘‘(ii) CONSIDERATION.—The Secretary 

25 shall take into consideration the minimum 


smartinez on DSK6TPTVN1PROD with BILLS
193 

•S 1871 PCS

1 number of enrollees in a specialized MA 

2 plan for special needs individuals in order 

3 to determine if a valid measurement of 

4 quality at the plan level is possible under 

5 clause (i). 

6 ‘‘(iii) APPLICATION.—If the Secretary 

7 applies quality measurement at the plan 

8 level under this subparagraph— 

9 ‘‘(I) such quality measurement 

10 shall include Medicare Health Out11 comes Survey (HOS), Healthcare Ef12 fectiveness Data and Information Set 

13 (HEDIS), and Consumer Assessment 

14 of Healthcare Providers and Systems 

15 (CAHPS) measures; and 

16 ‘‘(II) payment and other adminis17 trative actions linked to quality meas18 urement (including the 5-star rating 

19 system under this subsection) shall be 

20 applied at the plan level in accordance 

21 with this subparagraph.’’. 


smartinez on DSK6TPTVN1PROD with BILLS
194 

•S 1871 PCS

1 SEC. 207. REASONABLE COST REIMBURSEMENT CON2 TRACTS. 

3 (a) ONE-YEAR TRANSITION AND NOTICE REGARDING

4 TRANSITION.—Section 1876(h)(5)(C) of the Social Secu5 rity Act (42 U.S.C. 1395mm(h)(5)(C)) is amended— 

6 (1) in clause (ii), in the matter preceding sub7 clause (I), by striking ‘‘For any’’ and inserting 

8 ‘‘Subject to clause (iv), for any’’; and 

9 (2) by adding at the end the following new 

10 clauses: 

11 ‘‘(iv) In the case of an eligible organization that is 

12 offering a reasonable cost reimbursement contract that 

13 may no longer be extended or renewed because of the ap14 plication of clause (ii)— 

15 ‘‘(I) notwithstanding such clause, such contract 

16 may be extended or renewed for one last reasonable 

17 cost reimbursement contract year; 

18 ‘‘(II) the organization may not enroll any new 

19 enrollees under such contract during such last rea20 sonable cost reimbursement contract year; and 

21 ‘‘(III) on a date determined by the Secretary 

22 prior to the beginning of such last reasonable cost 

23 reimbursement contract year, the organization shall 

24 provide notice to the Secretary as to whether or not 

25 the organization will apply to have the contract con26 verted over and offered as a Medicare Advantage 


smartinez on DSK6TPTVN1PROD with BILLS
195 

•S 1871 PCS

1 plan under part C for the year following such last 

2 reasonable cost reimbursement contract year. 

3 ‘‘(v) If an eligible organization that is offering a rea4 sonable cost reimbursement contract that is extended or 

5 renewed pursuant to clause (iv) provides the notice de6 scribed in clause (iv)(III) that the contract will be con7 verted— 

8 ‘‘(I) the deemed enrollment under section 

9 1851(c)(4) shall apply; and 

10 ‘‘(II) the special rule for quality increases under 

11 1853(o)(3)(A)(iv) shall apply.’’. 

12 (b) DEEMED ENROLLMENT FROM REASONABLE

13 COST REIMBURSEMENT CONTRACTS CONVERTED TO

14 MEDICARE ADVANTAGE PLANS.— 

15 (1) IN GENERAL.—Section 1851(c) of the So16 cial Security Act (42 U.S.C. 1395w–21(c)) is 

17 amended— 

18 (A) in paragraph (1), by striking ‘‘Such 

19 elections’’ and inserting ‘‘Subject to paragraph 

20 (4), such elections’’; and 

21 (B) by adding at the end the following: 

22 ‘‘(4) DEEMED ENROLLMENT RELATING TO CON23 VERTED REASONABLE COST REIMBURSEMENT CON24 TRACTS.— 


smartinez on DSK6TPTVN1PROD with BILLS
196 

•S 1871 PCS

1 ‘‘(A) IN GENERAL.—On the first day of 

2 the annual, coordinated election period under 

3 subsection (e)(3) for plan years beginning on or 

4 after January 1, 2016, an MA eligible indi5 vidual described in clause (i) or (ii) of subpara6 graph (B) is deemed to have elected to receive 

7 benefits under this title through an applicable 

8 MA plan (and shall be enrolled in such plan) 

9 beginning with such plan year, if— 

10 ‘‘(i) the individual is enrolled in a rea11 sonable cost reimbursement contract under 

12 section 1876(h) in the previous plan year; 

13 ‘‘(ii) such reasonable cost reimburse14 ment contract was extended or renewed for 

15 one last reasonable cost reimbursement 

16 contract year pursuant to section 

17 1876(h)(5)(C)(iv); 

18 ‘‘(iii) the eligible organization that is 

19 offering such reasonable cost reimburse20 ment contract provided the notice de21 scribed in subclause (III) of such section 

22 that the contract was to be converted; 

23 ‘‘(iv) the applicable MA plan— 

24 ‘‘(I) is the plan that was con25 verted from the reasonable cost reimVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00196 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
197 

•S 1871 PCS

1 bursement contract described in 

2 clause (iii); 

3 ‘‘(II) is offered by the same enti4 ty (or an organization affiliated with 

5 such entity) that entered into such 

6 contract; and 

7 ‘‘(III) is offered in the service 

8 area where the individual resides; 

9 ‘‘(v) the amount of the MA monthly 

10 basic beneficiary premium for such appli11 cable MA plan with respect to the plan 

12 year does not exceed monthly premiums 

13 under such reasonable cost reimbursement 

14 contract for the previous plan year by 

15 more than 10 percent; 

16 ‘‘(vi) the applicable MA plan provides 

17 benefits, premiums, and access to providers 

18 that are comparable to the benefits, pre19 miums, and access to providers under such 

20 reasonable cost reimbursement contract for 

21 the previous plan year; and 

22 ‘‘(vii) the applicable MA plan— 

23 ‘‘(I) allows enrollees transitioning 

24 from the converted reasonable cost 

25 contract to such plan to maintain curVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00197 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
198 

•S 1871 PCS

1 rent providers and course of treat2 ment at the time of enrollment for at 

3 least 90 days after enrollment; and 

4 ‘‘(II) during such period, pays 

5 non-contracting providers for items 

6 and services furnished to the enrollee 

7 an amount that is not less than the 

8 amount of payment applicable for 

9 those items and services under the 

10 original medicare fee-for-service pro11 gram under parts A and B. 

12 ‘‘(B) MA ELIGIBLE INDIVIDUALS DE13 SCRIBED.— 

14 ‘‘(i) WITHOUT PRESCRIPTION DRUG

15 COVERAGE.—An MA eligible individual de16 scribed in this clause, with respect to a 

17 plan year, is an MA eligible individual who 

18 is enrolled in a reasonable cost reimburse19 ment contract under section 1876(h) in the 

20 previous plan year and who does not, for 

21 such previous plan year, receive any pre22 scription drug coverage under part D, in23 cluding coverage under section 1860D–22. 

24 ‘‘(ii) WITH PRESCRIPTION DRUG COV25 ERAGE.—An MA eligible individual deVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00198 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
199 

•S 1871 PCS

1 scribed in this clause, with respect to a 

2 plan year, is an MA eligible individual who 

3 is enrolled in a reasonable cost reimburse4 ment contract under section 1876(h) in the 

5 previous plan year and who, for such pre6 vious plan year, receives prescription drug 

7 coverage under part D— 

8 ‘‘(I) through such contract; or 

9 ‘‘(II) through a prescription drug 

10 plan, if the sponsor of such plan is the 

11 same entity (or an organization affili12 ated with such entity) that entered 

13 into such contract. 

14 ‘‘(C) APPLICABLE MA PLAN DEFINED.—In 

15 this paragraph, the term ‘applicable MA plan’ 

16 means, in the case of an individual described 

17 in— 

18 ‘‘(i) subparagraph (B)(i), an MA plan 

19 that is not an MA–PD plan; and 

20 ‘‘(ii) subparagraph (B)(ii), an MA– 

21 PD plan. 

22 ‘‘(D) IDENTIFICATION OF DEEMED INDI23 VIDUALS.—Not later than 30 days before the 

24 first day of the annual, coordinated election pe25 riod under subsection (e)(3) for plan years beVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00199 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
200 

•S 1871 PCS

1 ginning on or after January 1, 2016, the Sec2 retary shall identify the individuals who will be 

3 subject to deemed elections under subparagraph 

4 (A) on the first day of such period.’’. 

5 (2) BENEFICIARY OPTION TO DISCONTINUE OR

6 CHANGE MA PLAN OR MA–PD PLAN AFTER DEEMED

7 ENROLLMENT.— 

8 (A) IN GENERAL.—Section 1851(e)(2) of 

9 the Social Security Act (42 U.S.C. 1395w– 

10 21(e)(4)) is amended by adding at the end the 

11 following: 

12 ‘‘(F) SPECIAL PERIOD FOR CERTAIN

13 DEEMED ELECTIONS.— 

14 ‘‘(i) IN GENERAL.—At any time dur15 ing the period beginning after the last day 

16 of the annual, coordinated election period 

17 under paragraph (3) in which an individual 

18 is deemed to have elected to enroll in an 

19 MA plan or MA–PD plan under subsection 

20 (c)(4) and ending on the last day of Feb21 ruary of the first plan year for which the 

22 individual is enrolled in such plan, such in23 dividual may change the election under 

24 subsection (a)(1) (including changing the 


smartinez on DSK6TPTVN1PROD with BILLS
201 

•S 1871 PCS

1 MA plan or MA–PD plan in which the in2 dividual is enrolled). 

3 ‘‘(ii) LIMITATION OF ONE CHANGE.— 

4 An individual may exercise the right under 

5 clause (i) only once during the applicable 

6 period described in such clause. The limita7 tion under this clause shall not apply to 

8 changes in elections effected during an an9 nual, coordinated election period under 

10 paragraph (3) or during a special enroll11 ment period under paragraph (4).’’. 

12 (B) CONFORMING AMENDMENTS.— 

13 (i) PLAN REQUIREMENT FOR OPEN

14 ENROLLMENT.—Section 1851(e)(6)(A) of 

15 the Social Security Act (42 U.S.C. 1395w– 

16 21(e)(6)(A)) is amended by striking ‘‘para17 graph (1),’’ and inserting ‘‘paragraph (1), 

18 during the period described in paragraph 

19 (2)(F),’’. 

20 (ii) PART D.—Section 1860D– 

21 1(b)(1)(B) of such Act (42 U.S.C. 1395w– 

22 101(b)(1)(B)) is amended— 

23 (I) in clause (ii), by adding ‘‘and 

24 paragraph (4)’’ after ‘‘paragraph 

25 (3)(A)’’; and 


smartinez on DSK6TPTVN1PROD with BILLS
202 

•S 1871 PCS

1 (II) in clause (iii) by striking 

2 ‘‘and (E)’’ and inserting ‘‘(E), and 

3 (F)’’. 

4 (3) TREATMENT OF ESRD FOR DEEMED EN5 ROLLMENT.—Section 1851(a)(3)(B) of the Social 

6 Security Act (42 U.S.C. 1395w–21(a)(3)(B)) is 

7 amended by adding at the end the following flush 

8 sentence: 

9 ‘‘An individual who develops end-stage renal 

10 disease while enrolled in a reasonable cost reim11 bursement contract under section 1876(h) shall 

12 be treated as an MA eligible individual for pur13 poses of applying the deemed enrollment under 

14 subsection (c)(4).’’. 

15 (c) INFORMATION REQUIREMENTS.—Section 

16 1851(d)(2)(B) of the Social Security Act (42 U.S.C. 

17 1395w–21(d)(2)(B)) is amended— 

18 (1) by striking the subparagraph heading and 

19 inserting the following: ‘‘(i) NOTIFICATION TO

20 NEWLY ELIGIBLE MEDICARE ADVANTAGE ELIGIBLE

21 INDIVIDUALS.—’’; and 

22 (2) by adding at the end the following: 

23 ‘‘(ii) NOTIFICATION RELATED TO CERTAIN

24 DEEMED ELECTIONS.—The Secretary shall, not 

25 later than 15 days prior to the first day of the 


smartinez on DSK6TPTVN1PROD with BILLS
203 

•S 1871 PCS

1 annual, coordinated election period under sub2 section (e)(3) of a year, mail to any individual 

3 identified by the Secretary under subsection 

4 (c)(4)(D) for such year— 

5 ‘‘(I) a notification that such individual 

6 will, on such day, be deemed to have made 

7 an election to receive benefits under this 

8 title through an MA plan or MA–PD plan 

9 (and shall be enrolled in such plan) for the 

10 next plan year under subsection (c)(4)(A), 

11 but that the individual may make a dif12 ferent election during the annual, coordi13 nated election period for such year; 

14 ‘‘(II) the information described in 

15 subparagraph (A); 

16 ‘‘(III) a description of the differences 

17 between such MA plan or MA–PD plan 

18 and the reasonable cost reimbursement 

19 contract in which the individual was most 

20 recently enrolled with respect to benefits 

21 covered under such plans, including cost22 sharing, premiums, drug coverage, and 

23 provider networks; and 


smartinez on DSK6TPTVN1PROD with BILLS
204 

•S 1871 PCS

1 ‘‘(IV) information about the special 

2 period for elections under subsection 

3 (e)(2)(F).’’. 

4 (d) TREATMENT OF TRANSITION PLAN FOR QUALITY

5 RATING FOR PAYMENT PURPOSES.—Section 

6 1853(o)(3)(A) of the Social Security Act (42 U.S.C. 

7 1395w–23(o)(3)(A)) is amended by adding at the end the 

8 following new clause: 

9 ‘‘(iv) SPECIAL RULE FOR FIRST 2

10 PLAN YEARS FOR PLANS THAT WERE CON11 VERTED FROM A REASONABLE COST REIM12 BURSEMENT CONTRACT.—In applying 

13 paragraph (1) for the first 2 plan years 

14 under this part in the case of a plan that 

15 is a new MA plan (as defined in clause 

16 (iii)(II)) to which deemed enrollment ap17 plies under section 1851(e)(4), the Sec18 retary shall use the star rating that ap19 plied to the converted reasonable cost reim20 bursement contract for the year preceding 

21 the first plan year for such plan under this 

22 part.’’. 


smartinez on DSK6TPTVN1PROD with BILLS
205 

•S 1871 PCS

1 SEC. 208. QUALITY MEASURE ENDORSEMENT AND SELEC2 TION. 

3 (a) CONTRACT WITH AN ENTITY REGARDING INPUT

4 ON THE SELECTION OF MEASURES.— 

5 (1) IN GENERAL.—Title XVIII of the Social Se6 curity Act (42 U.S.C. 1395 et seq.) is amended— 

7 (A) by redesignating section 1890A as sec8 tion 1890B; and 

9 (B) by inserting after section 1890 the fol10 lowing new section: 

11 ‘‘CONTRACT WITH AN ENTITY REGARDING INPUT ON THE

12 SELECTION OF MEASURES

13 ‘‘SEC. 1890A (a) CONTRACT.— 

14 ‘‘(1) IN GENERAL.—For purposes of activities 

15 conducted under this Act, the Secretary shall iden16 tify and have in effect a contract with an entity that 

17 meets the requirements described in subsection (c). 

18 Such contract shall provide that the entity will per19 form the duties described in subsection (b). 

20 ‘‘(2) TIMING FOR FIRST CONTRACT.—The first 

21 contract under paragraph (1) shall begin on October 

22 1, 2014. 

23 ‘‘(3) PERIOD OF CONTRACT.—A contract under 

24 paragraph (1) shall be for a period of 3 years (ex25 cept as may be renewed after a subsequent bidding 

26 process). 


smartinez on DSK6TPTVN1PROD with BILLS
206 

•S 1871 PCS

1 ‘‘(4) COMPETITIVE PROCEDURES.—Competitive 

2 procedures (as defined in section 4(5) of the Office 

3 of Federal Procurement Policy Act (41 U.S.C. 

4 403(5))) shall be used to enter into a contract under 

5 paragraph (1). 

6 ‘‘(b) DUTIES.—The duties described in this sub7 section are the following: 

8 ‘‘(c) REQUIREMENTS DESCRIBED.—The require9 ments described in this subsection are the following: 

10 ‘‘(1) PRIVATE NONPROFIT, BOARD MEMBER11 SHIP, MEMBERSHIP FEES, AND NOT A MEASURE DE12 VELOPER.—The requirements described in para13 graphs (1), (2), (7), and (8) of section 1890(c). 

14 ‘‘(2) EXPERIENCE.—The entity has at least 4 

15 years of experience working with quality and effi16 ciency measures.’’. 

17 (2) DUTIES OF ENTITY.— 

18 (A) TRANSFER OF PRIORITY SETTING

19 PROCESS.—Paragraph (1) of section 1890(b) of 

20 the Social Security Act (42 U.S.C. 1395aaa(b)) 

21 is redesignated as paragraph (1) of section 

22 1890A(b) of such Act, as added by paragraph 

23 (1). 

24 (B) TRANSFER OF MULTI-STAKEHOLDER

25 PROCESS.—Paragraphs (7) and (8) of such secVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00206 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
207 

•S 1871 PCS

1 tion 1890(b) are redesignated as paragraphs 

2 (2) and (3), respectively, of section 1890A(b) of 

3 such Act, as added by paragraph (1) and 

4 amended by subparagraph (A). 

5 (C) ADDITIONAL DUTIES.—Section 

6 1890A(b) of such Act, as added by paragraph 

7 (1) and amended by subparagraphs (A) and 

8 (B), is amended by adding at the end the fol9 lowing new paragraphs: 

10 ‘‘(4) FACILITATION TO BETTER COORDINATE

11 AND ALIGN PUBLIC AND PRIVATE SECTOR USE OF

12 QUALITY MEASURES.— 

13 ‘‘(A) IN GENERAL.—The entity shall facili14 tate increased coordination and alignment be15 tween the public and private sector with respect 

16 to quality and efficiency measures. 

17 ‘‘(B) REPORTS.—The entity shall prepare 

18 and make available to the public annual reports 

19 on its findings under this paragraph. Such pub20 lic availability shall include posting each report 

21 on the Internet website of the entity. 

22 ‘‘(5) GAP ANALYSIS.—The entity shall conduct 

23 an ongoing analysis of— 

24 ‘‘(A) gaps in endorsed quality and effi25 ciency measures, which shall include measures 


smartinez on DSK6TPTVN1PROD with BILLS
208 

•S 1871 PCS

1 that are within priority areas identified by the 

2 Secretary under the national strategy estab3 lished under section 399HH of the Public 

4 Health Service Act; and 

5 ‘‘(B) areas where quality measures are un6 available or inadequate to identify or address 

7 such gaps. 

8 ‘‘(6) ANNUAL REPORT TO CONGRESS AND THE

9 SECRETARY; SECRETARIAL PUBLICATION AND COM10 MENT.— 

11 ‘‘(A) ANNUAL REPORT.—By not later than 

12 March 1 of each year, the entity shall submit 

13 to Congress and the Secretary a report con14 taining— 

15 ‘‘(i) a description of— 

16 ‘‘(I) the recommendations made 

17 under paragraph (1); 

18 ‘‘(II) the matters described in 

19 clauses (i) and (ii) of paragraph 

20 (2)(A); 

21 ‘‘(III) the results of the analysis 

22 under paragraph (5); and 

23 ‘‘(IV) the performance by the en24 tity of the duties required under the 


smartinez on DSK6TPTVN1PROD with BILLS
209 

•S 1871 PCS

1 contract entered into with the Sec2 retary under subsection (a); and 

3 ‘‘(ii) any other items determined ap4 propriate by the Secretary. 

5 ‘‘(B) SECRETARIAL REVIEW AND PUBLICA6 TION OF ANNUAL REPORT.—Not later than 6 

7 months after receiving a report under subpara8 graph (A) for a year, the Secretary shall— 

9 ‘‘(i) review such report; and 

10 ‘‘(ii) publish such report in the Fed11 eral Register, together with any comments 

12 of the Secretary on such report.’’. 

13 (D) ADDITIONAL AMENDMENTS.—Section 

14 1890A(b) of such Act, as so added and amend15 ed, is amended— 

16 (i) in paragraph (2)— 

17 (I) in the heading of subpara18 graph (B) by inserting ‘‘AND EFFI19 CIENCY’’ after ‘‘QUALITY’’; 

20 (II) in subparagraph (B)(i)(III), 

21 by striking ‘‘this Act’’ and inserting 

22 ‘‘this title’’; and 

23 (III) by adding at the end the 

24 following new subparagraphs: 


smartinez on DSK6TPTVN1PROD with BILLS
210 

•S 1871 PCS

1 ‘‘(E) INPUT.—In providing the input de2 scribed in subparagraph (A), the multi-stake3 holder groups— 

4 ‘‘(i) shall include a detailed descrip5 tion of the rationale for each recommenda6 tion made by the multi-stakeholder group, 

7 including in areas relating to— 

8 ‘‘(I) the expected impact that im9 plementing the measure will have on 

10 individuals; 

11 ‘‘(II) the burden on providers of 

12 services and suppliers; 

13 ‘‘(III) the expected influence over 

14 the behavior of providers of services 

15 and suppliers; 

16 ‘‘(IV) the applicability of a meas17 ure for more than one setting or pro18 gram; and 

19 ‘‘(V) other areas determined in 

20 consultation with the Secretary; and 

21 ‘‘(ii) may consider whether it is appro22 priate to provide separate recommenda23 tions with respect to measures for internal 

24 use, public reporting, and payment provi25 sions. 


smartinez on DSK6TPTVN1PROD with BILLS
211 

•S 1871 PCS

1 ‘‘(F) EQUAL REPRESENTATION.—In con2 vening multi-stakeholder groups pursuant to 

3 this paragraph, the entity shall, to the extent 

4 feasible, make every effort to ensure such 

5 groups are balanced across stakeholders.’’; and 

6 (ii) in paragraph (3), by striking ‘‘Not 

7 later’’ and all that follows through the pe8 riod at the end and inserting the following: 

9 ‘‘Not later than the applicable dates de10 scribed in section 1890B(a)(3) of each 

11 year (or, as applicable, the timeframe de12 scribed in section 1890A(a)(4)), the entity 

13 shall transmit to the Secretary the input of 

14 the multi-stakeholder group under para15 graph (2).’’. 

16 (b) REVISIONS TO CONTRACT WITH CONSENSUS17 BASED ENTITY.— 

18 (1) CONTRACT.—Section 1890(a) of the Social 

19 Security Act (42 U.S.C. 1395aaa(a)) is amended— 

20 (A) in paragraph (1), by striking ‘‘, such 

21 as the National Quality Forum,’’; and 

22 (B) in paragraph (3), by striking ‘‘4 

23 years’’ and inserting ‘‘3 years’’. 


smartinez on DSK6TPTVN1PROD with BILLS
212 

•S 1871 PCS

1 (2) DUTIES.—Section 1890(b) of the Social Se2 curity Act (42 U.S.C. 1395aaa(b)), as amended by 

3 subsection (a)(2), is amended— 

4 (A) by redesignating paragraphs (2) and 

5 (3) as paragraphs (1) and (2), respectively; 

6 (B) in paragraph (2), as redesignated by 

7 subparagraph (A), by striking ‘‘paragraph (2)’’ 

8 and inserting ‘‘paragraph (1)’’; 

9 (C) by striking paragraphs (5) and (6); 

10 and 

11 (D) by adding at the end the following new 

12 paragraphs: 

13 ‘‘(3) FACILITATION TO BETTER COORDINATE

14 AND ALIGN PUBLIC AND PRIVATE SECTOR USE OF

15 QUALITY MEASURES.— 

16 ‘‘(A) IN GENERAL.—The entity shall facili17 tate increased coordination and alignment be18 tween the public and private sector with respect 

19 to quality and efficiency measures. 

20 ‘‘(B) REPORTS.—The entity shall prepare 

21 and make available to the public annual reports 

22 on its findings under this paragraph. Such pub23 lic availability shall include posting each report 

24 on the Internet website of the entity. 


smartinez on DSK6TPTVN1PROD with BILLS
213 

•S 1871 PCS

1 ‘‘(4) ANNUAL REPORT TO CONGRESS AND THE

2 SECRETARY; SECRETARIAL PUBLICATION AND COM3 MENT.— 

4 ‘‘(A) ANNUAL REPORT.—By not later than 

5 March 1 of each year, the entity shall submit 

6 to Congress and the Secretary a report con7 taining— 

8 ‘‘(i) a description of— 

9 ‘‘(I) the coordination of quality 

10 initiatives under this Act with quality 

11 initiatives implemented by other pay12 ers; 

13 ‘‘(II) areas in which evidence is 

14 insufficient to support endorsement of 

15 quality measures in priority areas 

16 identified by the Secretary under the 

17 national strategy established under 

18 section 399HH of the Public Health 

19 Service Act and where targeted re20 search may address such gaps; and 

21 ‘‘(III) the performance by the en22 tity of the duties required under the 

23 contract entered into with the Sec24 retary under subsection (a); and 


smartinez on DSK6TPTVN1PROD with BILLS
214 

•S 1871 PCS

1 ‘‘(ii) any other items determined ap2 propriate by the Secretary. 

3 ‘‘(B) SECRETARIAL REVIEW AND PUBLICA4 TION OF ANNUAL REPORT.—Not later than 6 

5 months after receiving a report under subpara6 graph (A) for a year, the Secretary shall— 

7 ‘‘(i) review such report; and 

8 ‘‘(ii) publish such report in the Fed9 eral Register, together with any comments 

10 of the Secretary on such report.’’. 

11 (3) REQUIREMENTS.—Section 1890(c) of the 

12 Social Security Act (42 U.S.C. 1395aaa(c)) is 

13 amended by adding at the end the following new 

14 paragraph: 

15 ‘‘(8) NOT A MEASURE DEVELOPER.—The entity 

16 is not a measure developer.’’. 

17 (c) REVISIONS TO DUTIES OF THE SECRETARY RE18 GARDING USE OF MEASURES.— 

19 (1) IN GENERAL.—Section 1890B(a) of the So20 cial Security Act (42 U.S.C. 1395aaa–1(a)), as re21 designated by subsection (a)(1)(A), is amended— 

22 (A) by striking ‘‘section 1890(b)(7)(B)’’ 

23 each place it appears and inserting ‘‘section 

24 1890A(b)(2)(B)’’; 

25 (B) in paragraph (1)— 


smartinez on DSK6TPTVN1PROD with BILLS
215 

•S 1871 PCS

1 (i) by striking ‘‘section 1890(b)(7)’’ 

2 and inserting ‘‘section 1890A(b)(2)’’; and 

3 (ii) by striking ‘‘section 1890’’ and in4 serting ‘‘section 1890A’’; 

5 (C) by striking paragraphs (2) and (3) and 

6 inserting the following: 

7 ‘‘(2) PUBLIC AVAILABILITY OF MEASURES CON8 SIDERED FOR SELECTION.—Subject to paragraph 

9 (4), not later than October 1 or December 31 of 

10 each year, the Secretary shall make available to the 

11 public a list of quality and efficiency measures de12 scribed in section 1890A(b)(2)(B) that the Secretary 

13 is considering under this title. The Secretary shall 

14 provide for an appropriate balance of the number of 

15 measures to be made available by each such date in 

16 a year. 

17 ‘‘(3) TRANSMISSION OF MULTI-STAKEHOLDER

18 INPUT.— 

19 ‘‘(A) IN GENERAL.—Subject to paragraph 

20 (4), not later than the applicable date described 

21 in subparagraph (B) of each year, the entity 

22 with a contract under section 1890A shall, pur23 suant to subsection (b)(3) of such section, 

24 transmit to the Secretary the input of multi25 stakeholder groups described in paragraph (1). 


smartinez on DSK6TPTVN1PROD with BILLS
216 

•S 1871 PCS

1 ‘‘(B) APPLICABLE DATE DESCRIBED.—The 

2 applicable date described in this subparagraph 

3 for a year is— 

4 ‘‘(i) February 1 with respect to qual5 ity and efficiency measures made available 

6 under paragraph (2) by October 1 of the 

7 preceding year; and 

8 ‘‘(ii) April 1 with respect to quality 

9 and efficiency measures made available 

10 under paragraph (2) by December 31 of 

11 the preceding year.’’; 

12 (D) by redesignating— 

13 (i) paragraph (6) as paragraph (8); 

14 and 

15 (ii) paragraphs (4) and (5) as para16 graphs (5) and (6), respectively; 

17 (E) by inserting after paragraph (3) the 

18 following new paragraph: 

19 ‘‘(4) LIMITED PROCESS FOR ADDITIONAL

20 MULTI-STAKEHOLDER INPUT.—In addition to the 

21 Secretary making measures publically available pur22 suant to the dates described in paragraph (2) and 

23 multi-stakeholder groups transmitting the input pur24 suant to the applicable dates described in paragraph 

25 (3)— 


smartinez on DSK6TPTVN1PROD with BILLS
217 

•S 1871 PCS

1 ‘‘(A) the Secretary may, at times that do 

2 not meet the time requirements described in 

3 paragraph (2), make available to the public a 

4 limited number of quality and efficiency meas5 ures described in section 1890A(b)(2) that the 

6 Secretary is considering under this title; and 

7 ‘‘(B) if the Secretary uses the authority 

8 under subparagraph (A), the entity with a con9 tract under section 1890A shall, pursuant to 

10 section 1890A(b)(3), transmit to the Secretary 

11 on a timely basis the input from a multi-stake12 holder group described in paragraph (1) with 

13 respect to such measures.’’; 

14 (F) in paragraph (6), as redesignated by 

15 subparagraph (D)(ii), by inserting ‘‘or that has 

16 not been recommended by the multi-stakeholder 

17 group under section 1890A(b)(2)’’ before the 

18 period at the end; and 

19 (G) by inserting after paragraph (6) the 

20 following new paragraph: 

21 ‘‘(7) CONCORDANCE RATES.—For each year 

22 (beginning with 2015), the Secretary shall include a 

23 list of concordance rates for each type of provider of 

24 services and supplier in the annual final rule appli25 cable to such type of provider or supplier.’’. 


smartinez on DSK6TPTVN1PROD with BILLS
218 

•S 1871 PCS

1 (2) REVIEW.—Section 1890B(c) of the Social 

2 Security Act (42 U.S.C. 1395aaa–1(c)), as redesig3 nated by subsection (a)(1)(A), is amended— 

4 (A) in paragraph (1)(A), by striking ‘‘sec5 tion 1890(b)(7)(B)’’ and inserting ‘‘section 

6 1890A(b)(2)(B)’’; and 

7 (B) in paragraph (2)— 

8 (i) in subparagraph (A), by striking 

9 ‘‘and’’ at the end; 

10 (ii) in subparagraph (B), by striking 

11 the period at the end and inserting ‘‘; 

12 and’’; and 

13 (iii) by adding at the end the fol14 lowing new subparagraph: 

15 ‘‘(C) take into consideration the benefits of 

16 the alignment of measures between the public 

17 and private sector.’’. 

18 (d) FUNDING FOR QUALITY MEASURE ENDORSE19 MENT AND SELECTION.— 

20 (1) FISCAL YEAR 2014.—In addition to amounts 

21 transferred under section 3014(c) of the Patient 

22 Protection and Affordable Care Act (Public Law 

23 111–148), for purposes of carrying out section 1890 

24 and section 1890A (other than subsections (e) and 

25 (f)), the Secretary shall provide for the transfer, 


smartinez on DSK6TPTVN1PROD with BILLS
219 

•S 1871 PCS

1 from the Federal Hospital Insurance Trust Fund 

2 under section 1817 and the Federal Supplementary 

3 Medical Insurance Trust Fund under section 1841, 

4 in such proportion as the Secretary determines ap5 propriate, to the Centers for Medicare & Medicaid 

6 Services Program Management Account of 

7 $7,000,000 for fiscal year 2014. Amounts trans8 ferred under the preceding sentence shall remain 

9 available until expended. 

10 (2) FISCAL YEARS 2015 THROUGH 2017.—Sec11 tion 1890B of the Social Security Act (42 U.S.C. 

12 1395aaa–1), as redesignated by subsection 

13 (a)(1)(A), is amended by adding at the end the fol14 lowing new subsection: 

15 ‘‘(g) FUNDING.— 

16 ‘‘(1) IN GENERAL.—For purposes of carrying 

17 out this section (other than subsections (e) and (f)) 

18 and sections 1890 and 1890A, the Secretary shall 

19 provide for the transfer, from the Federal Hospital 

20 Insurance Trust Fund under section 1817 and the 

21 Federal Supplementary Medical Insurance Trust 

22 Fund under section 1841, in such proportion as the 

23 Secretary determines appropriate, to the Centers for 

24 Medicare & Medicaid Services Program Management 


smartinez on DSK6TPTVN1PROD with BILLS
220 

•S 1871 PCS

1 Account of $25,000,000 for each of fiscal years 

2 2015 through 2017. 

3 ‘‘(2) AVAILABILITY.—Amounts transferred 

4 under paragraph (1) shall remain available until ex5 pended.’’. 

6 (3) CONFORMING AMENDMENT.—Subsection (d) 

7 of section 1890 of the Social Security Act (42 

8 U.S.C. 1395aaa) is repealed. 

9 (e) CONFORMING AMENDMENTS.—(1) Section 

10 1848(m)(3)(E)(iii) of the Social Security Act (42 U.S.C. 

11 1395w–4(m)(3)(E)(iii)) is amended by striking ‘‘section 

12 1890(b)(7) and 1890A(a)’’ and inserting ‘‘section 

13 1890A(b)(2) and 1890B(a)’’. 

14 (2) Section 1866D(b)(2)(C) of the Social Security 

15 Act (42 U.S.C. 1395cc–4(b)(2)(C)) is amended by striking 

16 ‘‘section 1890 and 1890A’’ and inserting ‘‘sections 1890, 

17 1890A, and 1890B’’. 

18 (3) Section 1899A(n)(2)(A) of the Social Security 

19 Act (42 U.S.C. 1395cc–4(n)(2)(A)) is amended by strik20 ing ‘‘section 1890(b)(7)(B)’’ and inserting ‘‘section 

21 1890A(b)(2)(B)’’. 

22 (f) EFFECTIVE DATE.— 

23 (1) IN GENERAL.—The amendments made by 

24 this section shall take effect on October 1, 2014, 

25 and shall apply with respect to contract periods 


smartinez on DSK6TPTVN1PROD with BILLS
221 

•S 1871 PCS

1 under sections 1890 and 1890A of the Social Secu2 rity Act that begin on or after such date. 

3 (2) NEW CONTRACTS BEGINNING WITH FISCAL

4 YEAR 2015.—The Secretary of Health and Human 

5 Services shall enter into a new contract under both 

6 sections 1890 and 1890A of the Social Security Act, 

7 as amended by this Act, for a contract period begin8 ning on October 1, 2014. 

9 SEC. 209. PERMANENT EXTENSION OF FUNDING OUTREACH 

10 AND ASSISTANCE FOR LOW-INCOME PRO11 GRAMS. 

12 (a) ADDITIONAL FUNDING FOR STATE HEALTH IN13 SURANCE PROGRAMS.—Subsection (a)(1)(B)(iii) of sec14 tion 119 of the Medicare Improvements for Patients and 

15 Providers Act of 2008 (42 U.S.C. 1395b–3 note), as 

16 amended by section 3306 of the Patient Protection and 

17 Affordable Care Act (Public Law 111–148) and section 

18 610 of the American Taxpayer Relief Act of 2012 (Public 

19 Law 112–240), is amended by inserting ‘‘and for each 

20 subsequent fiscal year’’ after ‘‘fiscal year 2013’’. 

21 (b) ADDITIONAL FUNDING FOR AREA AGENCIES ON

22 AGING.—Subsection (b)(1)(B) of such section 119, as so 

23 amended, is amended by inserting ‘‘and for each subse24 quent fiscal year’’ after ‘‘fiscal year 2013’’. 


smartinez on DSK6TPTVN1PROD with BILLS
222 

•S 1871 PCS

1 (c) ADDITIONAL FUNDING FOR AGING AND DIS2 ABILITY RESOURCE CENTERS.—Subsection (c)(1)(B) of 

3 such section 119, as so amended, is amended by inserting 

4 ‘‘and for each subsequent fiscal year’’ after ‘‘fiscal year 

5 2013’’. 

6 (d) ADDITIONAL FUNDING FOR CONTRACT WITH

7 THE NATIONAL CENTER FOR BENEFITS AND OUTREACH

8 ENROLLMENT.—Subsection (d)(2) of such section 119, as 

9 so amended, is amended by inserting ‘‘and for each subse10 quent fiscal year’’ after ‘‘fiscal year 2013’’. 

11 Subtitle B—Medicaid and Other 

12 Extensions 

13 SEC. 211. QUALIFYING INDIVIDUAL PROGRAM. 

14 (a) EXTENSION.—Section 1902(a)(10)(E)(iv) of the 

15 Social Security Act (42 U.S.C. 1396a(a)(10)(E)(iv)) is 

16 amended by striking ‘‘December 2013’’ and inserting ‘‘De17 cember 2018’’. 

18 (b) ELIMINATING LIMITATIONS ON ELIGIBILITY.— 

19 Section 1933 of the Social Security Act (42 U.S.C. 

20 1396u–3) is amended by striking subsections (b) and (e). 

21 (c) ELIMINATING ALLOCATIONS.—Section 1933 of 

22 the Social Security Act (42 U.S.C. 1396u–3) is amended 

23 by striking subsections (c) and (g). 

24 (d) CONFORMING AMENDMENTS.— 


smartinez on DSK6TPTVN1PROD with BILLS
223 

•S 1871 PCS

1 (1) IN GENERAL.—Section 1933 of the Social 

2 Security Act (42 U.S.C. 1396u–3), as amended by 

3 subsections (b) and (c), is further amended— 

4 (A) by striking subsection (a) and insert5 ing the following new subsection: 

6 ‘‘(a) APPLICABLE FMAP.—With respect to assist7 ance described in section 1902(a)(10)(E)(iv) furnished in 

8 a State, the Federal medical assistance percentage shall 

9 be equal to 100 percent.’’; 

10 (B) by striking subsection (d); and 

11 (C) by redesignating subsection (f) as sub12 section (b). 

13 (2) DEFINITION OF FMAP.—Section 1905(b) of 

14 the Social Security Act (42 U.S.C. 1396d(b)) is 

15 amended by striking ‘‘section 1933(d)’’ and insert16 ing ‘‘section 1933(a)’’. 

17 (e) EFFECTIVE DATE.—The amendments made by 

18 this section shall take effect on January 1, 2014, and shall 

19 apply with respect to calendar quarters beginning on or 

20 after such date. 

21 SEC. 212. TRANSITIONAL MEDICAL ASSISTANCE. 

22 (a) EXTENSION.—Sections 1902(e)(1)(B) and 

23 1925(f) of the Social Security Act (42 U.S.C. 

24 1396a(e)(1)(B), 1396r–6(f)) are each amended by strikVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00223 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
224 

•S 1871 PCS

1 ing ‘‘December 31, 2013’’ and inserting ‘‘December 31, 

2 2018’’. 

3 (b) OPT-OUT OPTION FOR STATES THAT EXPAND

4 ADULT COVERAGE AND PROVIDE 12-MONTH CONTINUOUS

5 ELIGIBILITY UNDER MEDICAID AND CHIP.— 

6 (1) IN GENERAL.—Section 1925 of the Social 

7 Security Act (42 U.S.C. 1396r–6), as amended by 

8 subsection (a), is further amended— 

9 (A) in subsection (a)— 

10 (i) in paragraph (1)(A), by striking 

11 ‘‘paragraph (5)’’ and inserting ‘‘para12 graphs (5) and (6)’’; and 

13 (ii) by adding at the end the fol14 lowing: 

15 ‘‘(6) OPT-OUT OPTION FOR STATES THAT EX16 PAND ADULT COVERAGE AND PROVIDE 12-MONTH

17 CONTINUOUS ELIGIBILITY UNDER MEDICAID AND

18 CHIP.— 

19 ‘‘(A) IN GENERAL.—In the case of a State 

20 described in subparagraph (B), the State may 

21 elect through a State plan amendment to have 

22 this section and sections 408(a)(11)(A), 

23 1902(a)(52), 1902(e)(1), and 1931(c)(2) not 

24 apply to the State. 


smartinez on DSK6TPTVN1PROD with BILLS
225 

•S 1871 PCS

1 ‘‘(B) STATE DESCRIBED.—A State is de2 scribed in this subparagraph if the State is one 

3 of the 50 States or the District of Columbia 

4 and— 

5 ‘‘(i) has elected to provide medical as6 sistance to individuals under subclause 

7 (VIII) of section 1902(a)(10)(A)(i); 

8 ‘‘(ii) has elected under section 

9 1902(e)(12)(A) the option to provide con10 tinuous eligibility for a 12-month period 

11 for individuals under 19 years of age; 

12 ‘‘(iii) has elected under section 

13 1902(e)(12)(B) the option to provide con14 tinuous eligibility for a 12-month period 

15 for all categories of individuals described in 

16 that section; and 

17 ‘‘(iv) has elected to apply section 

18 1902(e)(12)(A) to the State child health 

19 plan under title XXI.’’; and 

20 (B) in subsection (b)(1), by striking ‘‘sub21 section (a)(5)’’ and inserting ‘‘paragraphs (5) 

22 and (6) of subsection (a)’’. 

23 (2) CONFORMING AMENDMENT TO 4-MONTH RE24 QUIREMENT.—Section 1902(e)(1) of the Social SeVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00225 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
226 

•S 1871 PCS

1 curity Act (42 U.S.C. 1396a(e)(1)), as amended by 

2 subsection (a), is further amended— 

3 (A) in subparagraph (B), by striking 

4 ‘‘Subparagraph (A)’’ and inserting ‘‘Subject to 

5 subparagraph (C), subparagraph (A)’’; and 

6 (B) by adding at the end the following: 

7 ‘‘(C) If a State has made an election under section 

8 1925(a)(6), subparagraph (A) and section 1925 shall not 

9 apply to the State.’’. 

10 (c) EXTENSION OF 12-MONTH CONTINUOUS ELIGI11 BILITY OPTION TO CERTAIN ADULT ENROLLEES UNDER

12 MEDICAID; CLARIFICATION OF APPLICATION TO CHIP.— 

13 (1) IN GENERAL.—Section 1902(e)(12) of the 

14 Social Security Act (42 U.S.C. 1396a(e)(12)) is 

15 amended— 

16 (A) by redesignating subparagraphs (A) 

17 and (B) as clauses (i) and (ii), respectively; 

18 (B) by inserting ‘‘(A)’’ after ‘‘(12)’’; and 

19 (C) by adding at the end the following: 

20 ‘‘(B) At the option of the State, the plan may provide 

21 that an individual who is determined to be eligible for ben22 efits under a State plan approved under this title under 

23 any of the following eligibility categories, or who is rede24 termined to be eligible for such benefits under any of such 

25 categories, shall be considered to meet the eligibility reVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00226 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
227 

•S 1871 PCS

1 quirements met on the date of application and shall re2 main eligible for those benefits until the end of the 12– 

3 month period following the date of the determination or 

4 redetermination of eligibility: 

5 ‘‘(i) Section 1902(a)(10)(A)(i)(VIII). 

6 ‘‘(ii) Section 1931.’’. 

7 (2) APPLICATION TO CHIP.—Section 2107(e)(1) 

8 of the Social Security Act (42 U.S.C. 1397gg(e)(1)) 

9 is amended— 

10 (A) by redesignating subparagraphs (E) 

11 through (O) as subparagraphs (F) through (P), 

12 respectively; and 

13 (B) by inserting after subparagraph (D), 

14 the following: 

15 ‘‘(E) Section 1902(e)(12)(A) (relating to 

16 the State option for 12-month continuous eligi17 bility and enrollment).’’. 

18 (d) CONFORMING AND TECHNICAL AMENDMENTS

19 RELATING TO SECTION 1931 TRANSITIONAL COVERAGE

20 REQUIREMENTS.— 

21 (1) IN GENERAL.—Section 1931(c) of the So22 cial Security Act (42 U.S.C. 1396u–1(c)) is amend23 ed— 

24 (A) in paragraph (1)— 


smartinez on DSK6TPTVN1PROD with BILLS
228 

•S 1871 PCS

1 (i) in the paragraph heading, by strik2 ing ‘‘CHILD’’ and inserting ‘‘SPOUSAL’’; 

3 (ii) by striking ‘‘The provisions’’ and 

4 inserting ‘‘Subject to paragraph (3), the 

5 provisions’’; and 

6 (iii) by striking ‘‘child or’’; 

7 (B) in paragraph (2), by striking ‘‘For 

8 continued’’ and inserting ‘‘Subject to paragraph 

9 (3), for continued’’; and 

10 (C) by adding at the end the following: 

11 ‘‘(3) OPT-OUT OPTION FOR STATES THAT EX12 PAND ADULT COVERAGE AND PROVIDE 12-MONTH

13 CONTINUOUS ELIGIBILITY UNDER MEDICAID AND

14 CHIP.— 

15 ‘‘(A) IN GENERAL.—In the case of a State 

16 described in subparagraph (B), the State may 

17 elect through a State plan amendment to have 

18 paragraphs (1) and (2) of this subsection and 

19 sections 408(a)(11), 1902(a)(52), 1902(e)(1), 

20 and 1925 not apply to the State. 

21 ‘‘(B) STATE DESCRIBED.—A State is de22 scribed in this subparagraph if the State is one 

23 of the 50 States or the District of Columbia 

24 and— 


smartinez on DSK6TPTVN1PROD with BILLS
229 

•S 1871 PCS

1 ‘‘(i) has elected to provide medical as2 sistance to individuals under subclause 

3 (VIII) of section 1902(a)(10)(A)(i); 

4 ‘‘(ii) has elected under section 

5 1902(e)(12)(A) the option to provide con6 tinuous eligibility for a 12-month period 

7 for individuals under 19 years of age; 

8 ‘‘(iii) has elected under section 

9 1902(e)(12)(B) the option to provide con10 tinuous eligibility for a 12-month period 

11 for all categories of individuals described in 

12 that section; and 

13 ‘‘(iv) has elected to apply section 

14 1902(e)(12)(A) to the State child health 

15 plan under title XXI.’’. 

16 (2) CONFORMING AMENDMENT TO SECTION

17 408.—Section 408(a)(11) of the Social Security Act 

18 (42 U.S.C. 608(a)(11) is amended— 

19 (A) in the paragraph heading, by striking 

20 ‘‘CHILD’’ and inserting ‘‘SPOUSAL’’; and 

21 (B) in subparagraph (B)— 

22 (i) in the subparagraph heading, by 

23 striking ‘‘CHILD’’ and inserting ‘‘SPOUS24 AL’’; and 

25 (ii) by striking ‘‘child or’’. 


smartinez on DSK6TPTVN1PROD with BILLS
230 

•S 1871 PCS

1 (e) CONFORMING AMENDMENT RELATING TO MAIN2 TENANCE OF EFFORT FOR CHILDREN.—Section 

3 1902(gg)(4) of the Social Security Act (42 U.S.C. 

4 1396a(gg)(4)) is amended by adding at the end the fol5 lowing: 

6 ‘‘(C) STATES THAT EXPAND ADULT COV7 ERAGE AND ELECT TO OPT-OUT OF TRANSI8 TIONAL COVERAGE.— 

9 ‘‘(i) IN GENERAL.—For purposes of 

10 determining compliance with the require11 ments of paragraph (2), a State which ex12 ercises the option under sections 

13 1925(a)(6) and 1931(c)(3) to provide no 

14 transitional medical assistance or other ex15 tended eligibility (as applicable) shall not, 

16 as a result of exercising such option, be 

17 considered to have in effect eligibility 

18 standards, methodologies, or procedures 

19 described in clause (ii) that are more re20 strictive than the standards, methodolo21 gies, or procedures in effect under the 

22 State plan or under a waiver of the plan 

23 on the date of enactment of the Patient 

24 Protection and Affordable Care Act. 


smartinez on DSK6TPTVN1PROD with BILLS
231 

•S 1871 PCS

1 ‘‘(ii) STANDARDS, METHODOLOGIES, 

2 OR PROCEDURES DESCRIBED.—The eligi3 bility standards, methodologies, or proce4 dures described in this clause are those 

5 standards, methodologies, or procedures 

6 applicable to determining the eligibility for 

7 medical assistance of any child under 19 

8 years of age (or such higher age as the 

9 State may have elected).’’. 

10 (f) EFFECTIVE DATE.—The amendments made by 

11 this section shall take effect on January 1, 2014. 

12 SEC. 213. EXPRESS LANE ELIGIBILITY. 

13 Section 1902(e)(13)(I) of the Social Security Act (42 

14 U.S.C. 1396a(e)(13)(I)) is amended by striking ‘‘Sep15 tember 30, 2014’’ and inserting ‘‘September 30, 2015’’. 

16 SEC. 214. PEDIATRIC QUALITY MEASURES. 

17 (a) CONTINUATION OF FUNDING FOR PEDIATRIC

18 QUALITY MEASURES FOR IMPROVING THE QUALITY OF

19 CHILDREN’S HEALTH CARE.—Section 1139B(e) of the 

20 Social Security Act (42 U.S.C. 1320b–9b(e)) is amended 

21 by adding at the end the following: ‘‘Of the funds appro22 priated under this subsection, not less than $15,000,000 

23 shall be used to carry out section 1139A(b).’’. 

24 (b) ELIMINATION OF RESTRICTION ON MEDICAID

25 QUALITY MEASUREMENT PROGRAM.—Section 


smartinez on DSK6TPTVN1PROD with BILLS
232 

•S 1871 PCS

1 1139B(b)(5)(A) of the Social Security Act (42 U.S.C. 

2 1320b–9b(b)(5)(A)) is amended by striking ‘‘The aggre3 gate amount awarded by the Secretary for grants and con4 tracts for the development, testing, and validation of 

5 emerging and innovative evidence-based measures under 

6 such program shall equal the aggregate amount awarded 

7 by the Secretary for grants under section 

8 1139A(b)(4)(A)’’. 

9 SEC. 215. SPECIAL DIABETES PROGRAMS. 

10 (a) SPECIAL DIABETES PROGRAMS FOR TYPE I DIA11 BETES.—Section 330B(b)(2)(C) of the Public Health 

12 Service Act (42 U.S.C. 254c–2(b)(2)(C)) is amended by 

13 striking ‘‘2014’’ and inserting ‘‘2019’’. 

14 (b) SPECIAL DIABETES PROGRAMS FOR INDIANS.— 

15 Section 330C(c)(2)(C) of the Public Health Service Act 

16 (42 U.S.C. 254c–3(c)(2)(C)) is amended by striking 

17 ‘‘2014’’ and inserting ‘‘2019’’. 

18 Subtitle C—Human Services 

19 Extensions 

20 SEC. 221. ABSTINENCE EDUCATION GRANTS. 

21 (a) IN GENERAL.—Section 510 of the Social Security 

22 Act (42 U.S.C. 710) is amended— 

23 (1) in subsection (a), in the matter preceding 

24 paragraph (1), by striking ‘‘2010 through 2014’’ 

25 and inserting ‘‘2015 through 2019’’; and 


smartinez on DSK6TPTVN1PROD with BILLS
233 

•S 1871 PCS

1 (2) in subsection (d)— 

2 (A) by striking ‘‘2010 through 2014’’ and 

3 inserting ‘‘2015 through 2019’’; and 

4 (B) by striking the second sentence. 

5 (b) EFFECTIVE DATE.—The amendments made by 

6 this section shall take effect on October 1, 2014. 

7 SEC. 222. PERSONAL RESPONSIBILITY EDUCATION PRO8 GRAM. 

9 (a) IN GENERAL.—Section 513 of the Social Security 

10 Act (42 U.S.C. 713) is amended— 

11 (1) in subsection (a)— 

12 (A) in paragraph (1)(A), by striking ‘‘2010 

13 through 2014’’ and inserting ‘‘2015 through 

14 2019’’; 

15 (B) in paragraph (4)— 

16 (i) in subparagraph (A)— 

17 (I) by striking ‘‘2010 or 2011’’ 

18 and inserting ‘‘2015 or 2016’’; 

19 (II) by striking ‘‘2010 through 

20 2014’’ and inserting ‘‘2015 through 

21 2019’’; and 

22 (III) by striking ‘‘2012 through 

23 2014’’ and inserting ‘‘2017 through 

24 2019’’; and 

25 (ii) in subparagraph (B)(i)— 


smartinez on DSK6TPTVN1PROD with BILLS
234 

•S 1871 PCS

1 (I) by striking ‘‘2012, 2013, and 

2 2014’’ and inserting ‘‘2017, 2018, 

3 and 2019’’; and 

4 (II) by striking ‘‘2010 or 2011’’ 

5 and inserting ‘‘2015 or 2016’’; and 

6 (C) in paragraph (5), by striking ‘‘2009’’ 

7 and inserting ‘‘2014’’; 

8 (2) in subsection (b)(2)(A), in the matter pre9 ceding clause (i), by inserting ‘‘and youth at risk of 

10 becoming victims of sex trafficking (as defined in 

11 section 103(10) of the Trafficking Victims Protec12 tion Act of 2000 (22 U.S.C. 7102(10))) or victims 

13 of a severe form of trafficking in persons described 

14 in paragraph (9)(A) of that Act (22 U.S.C. 

15 7102(9)(A)’’ after ‘‘adolescents’’; 

16 (3) in subsection(c)(1), by inserting ‘‘youth at 

17 risk of becoming victims of sex trafficking (as de18 fined in section 103(10) of the Trafficking Victims 

19 Protection Act of 2000 (22 U.S.C. 7102(10))) or 

20 victims of a severe form of trafficking in persons de21 scribed in paragraph (9)(A) of that Act (22 U.S.C. 

22 7102(9)(A),’’ after ‘‘youth in foster care,’’; and 

23 (4) in subsection (f), by striking ‘‘2010 through 

24 2014’’ and inserting ‘‘2015 through 2019’’. 


smartinez on DSK6TPTVN1PROD with BILLS
235 

•S 1871 PCS

1 (b) EFFECTIVE DATE.—The amendments made by 

2 this section shall take effect on October 1, 2014. 

3 SEC. 223. FAMILY-TO-FAMILY HEALTH INFORMATION CEN4 TERS. 

5 (a) IN GENERAL.—Section 501(c) of the Social Secu6 rity Act (42 U.S.C. 701(c)) is amended— 

7 (1) in paragraph (1)(A)— 

8 (A) in clause (ii), by striking ‘‘and’’ after 

9 the semicolon; 

10 (B) in clause (iii), by striking the period 

11 and inserting ‘‘; and’’; and 

12 (C) by adding at the end the following: 

13 ‘‘(iv) $6,000,000 for each of fiscal 

14 years 2014 through 2018.’’; and 

15 (2) by striking paragraph (5). 

16 (b) EFFECTIVE DATE.—The amendments made by 

17 this section shall take effect as if enacted on October 1, 

18 2013. 

19 SEC. 224. HEALTH WORKFORCE DEMONSTRATION PROJECT 

20 FOR LOW-INCOME INDIVIDUALS. 

21 Section 2008(c)(1) of the Social Security Act (42 

22 U.S.C. 1397g(c)(1)) is amended by striking ‘‘ through 

23 2014’’ and inserting ‘‘2012, and only to carry out sub24 section (a), $85,000,000 for each of fiscal years 2013 

25 through 2016’’. 


smartinez on DSK6TPTVN1PROD with BILLS
236 

•S 1871 PCS

1 Subtitle D—Program Integrity 

2 SEC. 231. REDUCING IMPROPER MEDICARE PAYMENTS. 

3 (a) MEDICARE ADMINISTRATIVE CONTRACTOR IM4 PROPER PAYMENT OUTREACH AND EDUCATION PRO5 GRAM.— 

6 (1) IN GENERAL.—Section 1874A of the Social 

7 Security Act (42 U.S.C. 1395kk–1) is amended— 

8 (A) in subsection (a)(4)— 

9 (i) by redesignating subparagraph (G) 

10 as subparagraph (H); and 

11 (ii) by inserting after subparagraph 

12 (F) the following new subparagraph: 

13 ‘‘(G) IMPROPER PAYMENT OUTREACH AND

14 EDUCATION PROGRAM.—Having in place an im15 proper payment outreach and education pro16 gram described in subsection (h).’’; and 

17 (B) by adding at the end the following new 

18 subsection: 

19 ‘‘(h) IMPROPER PAYMENT OUTREACH AND EDU20 CATION PROGRAM.— 

21 ‘‘(1) IN GENERAL.—In order to reduce im22 proper payments under this title, each medicare ad23 ministrative contractor shall establish and have in 

24 place an improper payment outreach and education 

25 program under which the contractor, through outVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00236 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
237 

•S 1871 PCS

1 reach, education, training, and technical assistance 

2 activities, shall provide providers of services and sup3 pliers located in the region covered by the contract 

4 under this section with the information described in 

5 paragraph (3). The activities described in the pre6 ceding sentence shall be conducted on a regular 

7 basis. 

8 ‘‘(2) FORMS OF OUTREACH, EDUCATION, TRAIN9 ING, AND TECHNICAL ASSISTANCE ACTIVITIES.—The 

10 outreach, education, training, and technical assist11 ance activities under a payment outreach and edu12 cation program shall be carried out through any of 

13 the following: 

14 ‘‘(A) Emails and other electronic commu15 nications. 

16 ‘‘(B) Webinars. 

17 ‘‘(C) Telephone calls. 

18 ‘‘(D) In-person training. 

19 ‘‘(E) Other forms of communications de20 termined appropriate by the Secretary. 

21 ‘‘(3) INFORMATION TO BE PROVIDED THROUGH

22 ACTIVITIES.—The information to be provided to pro23 viders of services and suppliers under a payment 

24 outreach and education program shall include all of 

25 the following information: 


smartinez on DSK6TPTVN1PROD with BILLS
238 

•S 1871 PCS

1 ‘‘(A) A list of the provider’s or supplier’s 

2 most frequent and expensive payment errors 

3 over the last quarter. 

4 ‘‘(B) Specific instructions regarding how to 

5 correct or avoid such errors in the future. 

6 ‘‘(C) A notice of all new topics that have 

7 been approved by the Secretary for audits con8 ducted by recovery audit contractors under sec9 tion 1893(h). 

10 ‘‘(D) Specific instructions to prevent fu11 ture issues related to such new audits. 

12 ‘‘(E) Other information determined appro13 priate by the Secretary. 

14 ‘‘(4) ERROR RATE REDUCTION TRAINING.— 

15 ‘‘(A) IN GENERAL.—The activities under a 

16 payment outreach and education program shall 

17 include error rate reduction training. 

18 ‘‘(B) REQUIREMENTS.— 

19 ‘‘(i) IN GENERAL.—The training de20 scribed in subparagraph (A) shall— 

21 ‘‘(I) be provided at least annu22 ally; and 

23 ‘‘(II) focus on reducing the im24 proper payments described in para25 graph (5). 


smartinez on DSK6TPTVN1PROD with BILLS
239 

•S 1871 PCS

1 ‘‘(C) INVITATION.—A medicare adminis2 trative contractor shall ensure that all providers 

3 of services and suppliers located in the region 

4 covered by the contract under this section are 

5 invited to attend the training described in sub6 paragraph (A) either in person or online. 

7 ‘‘(5) PRIORITY.—A medicare administrative 

8 contractor shall give priority to activities under the 

9 improper payment outreach and education program 

10 that will reduce improper payments for items and 

11 services that— 

12 ‘‘(A) have the highest rate of improper 

13 payment; 

14 ‘‘(B) have the greatest total dollar amount 

15 of improper payments; 

16 ‘‘(C) are due to clear misapplication or 

17 misinterpretation of Medicare policies; 

18 ‘‘(D) are clearly due to common and inad19 vertent clerical or administrative errors; or 

20 ‘‘(E) are due to other types of errors that 

21 the Secretary determines could be prevented 

22 through activities under the program. 

23 ‘‘(6) INFORMATION ON IMPROPER PAYMENTS

24 FROM RECOVERY AUDIT CONTRACTORS.— 


smartinez on DSK6TPTVN1PROD with BILLS
240 

•S 1871 PCS

1 ‘‘(A) IN GENERAL.—In order to assist 

2 medicare administrative contractors in carrying 

3 out improper payment outreach and education 

4 programs, the Secretary shall provide each con5 tractor with a complete list of improper pay6 ments identified by recovery audit contractors 

7 under section 1893(h) with respect to providers 

8 of services and suppliers located in the region 

9 covered by the contract under this section. Such 

10 information shall be provided on a quarterly 

11 basis. 

12 ‘‘(B) INFORMATION.—The information de13 scribed in subparagraph (A) shall include the 

14 following information: 

15 ‘‘(i) The providers of services and 

16 suppliers that have the highest rate of im17 proper payments. 

18 ‘‘(ii) The providers of services and 

19 suppliers that have the greatest total dollar 

20 amounts of improper payments. 

21 ‘‘(iii) The items and services furnished 

22 in the region that have the highest rates of 

23 improper payments. 

24 ‘‘(iv) The items and services furnished 

25 in the region that are responsible for the 


smartinez on DSK6TPTVN1PROD with BILLS
241 

•S 1871 PCS

1 greatest total dollar amount of improper 

2 payments. 

3 ‘‘(v) Other information the Secretary 

4 determines would assist the contractor in 

5 carrying out the improper payment out6 reach and education program. 

7 ‘‘(C) FORMAT OF INFORMATION.—The in8 formation furnished to medicare administrative 

9 contractors by the Secretary under this para10 graph shall be transmitted in a manner that 

11 permits the contractor to easily identify the 

12 areas of the Medicare program in which tar13 geted outreach, education, training, and tech14 nical assistance would be most effective. In car15 rying out the preceding sentence, the Secretary 

16 shall ensure that— 

17 ‘‘(i) the information with respect to 

18 improper payments made to a provider of 

19 services or supplier clearly displays the 

20 name and address of the provider or sup21 plier, the amount of the improper payment, 

22 and any other information the Secretary 

23 determines appropriate; and 

24 ‘‘(ii) the information is in an elec25 tronic, easily searchable database. 


smartinez on DSK6TPTVN1PROD with BILLS
242 

•S 1871 PCS

1 ‘‘(7) COMMUNICATIONS.—All communications 

2 with providers of services and suppliers under a pay3 ment outreach and education program are subject to 

4 the standards and requirements of subsection (g). 

5 ‘‘(8) FUNDING.—After application of paragraph 

6 (1)(C) of section 1893(h), the Secretary shall retain 

7 a portion of the amounts recovered by recovery audit 

8 contractors under such section which shall be avail9 able to the program management account of the 

10 Centers for Medicare & Medicaid Services for pur11 poses of carrying out this subsection and to imple12 ment corrective actions to help reduce the error rate 

13 of payments under this title. The amount retained 

14 under the preceding sentence shall not exceed an 

15 amount equal to 25 percent of the amounts recov16 ered under section 1893(h).’’. 

17 (2) FUNDING CONFORMING AMENDMENT.—Sec18 tion 1893(h)(2) of the Social Security Act (42 

19 U.S.C. 1395ddd(h)(2)) is amended by inserting ‘‘or 

20 section 1874(h)(8)’’ after ‘‘paragraph (1)(C)’’. 

21 (3) EFFECTIVE DATE.—The amendments made 

22 by this subsection take effect on January 1, 2015. 

23 (b) TRANSPARENCY.—Section 1893(h)(8) of the So24 cial Security Act (42 U.S.C. 1395ddd(h)(8)) is amended— 


smartinez on DSK6TPTVN1PROD with BILLS
243 

•S 1871 PCS

1 (1) by striking ‘‘REPORT.—The Secretary’’ and 

2 inserting ‘‘REPORT.— 

3 ‘‘(A) IN GENERAL.—The Secretary’’; and 

4 (2) by adding at the end the following new sub5 paragraph: 

6 ‘‘(B) INCLUSION OF CERTAIN INFORMA7 TION.— 

8 ‘‘(i) IN GENERAL.—For reports sub9 mitted under this paragraph for 2015 or a 

10 subsequent year, each such report shall in11 clude the information described in clause 

12 (ii) with respect to each of the following 

13 categories of audits carried out by recovery 

14 audit contractors under this subsection: 

15 ‘‘(I) Automated. 

16 ‘‘(II) Complex. 

17 ‘‘(III) Medical necessity review. 

18 ‘‘(IV) Part A. 

19 ‘‘(V) Part B. 

20 ‘‘(VI) Durable medical equip21 ment. 

22 ‘‘(ii) INFORMATION DESCRIBED.—For 

23 purposes of clause (i), the information de24 scribed in this clause, with respect to a 

25 category of audit described in clause (i), is 


smartinez on DSK6TPTVN1PROD with BILLS
244 

•S 1871 PCS

1 the result of all appeals for each individual 

2 level of appeals in such category.’’. 

3 (c) RECOVERY AUDIT CONTRACTOR DEMONSTRA4 TION PROJECT.— 

5 (1) IN GENERAL.—The Secretary shall conduct 

6 a demonstration project under title XVIII of the So7 cial Security Act that— 

8 (A) targets audits by recovery audit con9 tractors under section 1893(h) of the Social Se10 curity Act (42 U.S.C. 1395ddd(h)) with respect 

11 to high error providers of services and suppliers 

12 identified under paragraph (3); and 

13 (B) rewards low error providers of services 

14 and suppliers identified under such paragraph. 

15 (2) SCOPE.— 

16 (A) DURATION.—The demonstration 

17 project shall be implemented not later than 

18 January 1, 2015, and shall be conducted for a 

19 period of three years. 

20 (B) DEMONSTRATION AREA.—In deter21 mining the geographic area of the demonstra22 tion project, the Secretary shall consider the 

23 following: 

24 (i) The total number of providers of 

25 services and suppliers in the region. 


smartinez on DSK6TPTVN1PROD with BILLS
245 

•S 1871 PCS

1 (ii) The diversity of types of providers 

2 of services and suppliers in the region. 

3 (iii) The level and variation of im4 proper payment rates of and among indi5 vidual providers of services and suppliers 

6 in the region. 

7 (iv) The inclusion of a mix of both 

8 urban and rural areas. 

9 (3) IDENTIFICATION OF LOW ERROR AND HIGH

10 ERROR PROVIDERS OF SERVICES AND SUPPLIERS.— 

11 (A) IN GENERAL.—In conducting the dem12 onstration project, the Secretary shall identify 

13 the following two groups of providers in accord14 ance with this paragraph: 

15 (i) Low error providers of services and 

16 suppliers. 

17 (ii) High error providers of services 

18 and suppliers. 

19 (B) ANALYSIS.—For purposes of identi20 fying the groups under subparagraph (A), the 

21 Secretary shall analyze the following as they re22 late to the total number and amount of claims 

23 submitted in the area and by each provider: 

24 (i) The improper payment rates of in25 dividual providers of services and suppliers. 


smartinez on DSK6TPTVN1PROD with BILLS
246 

•S 1871 PCS

1 (ii) The amount of improper payments 

2 made to individual providers of services 

3 and suppliers. 

4 (iii) The frequency of errors made by 

5 the provider of services or supplier over 

6 time. 

7 (iv) Other information determined ap8 propriate by the Secretary. 

9 (C) ASSIGNMENT BASED ON COMPOSITE

10 SCORE.—The Secretary shall assign selected 

11 providers of services and suppliers under the 

12 demonstration program based on a composite 

13 score determined using the analysis under sub14 paragraph (B) as follows: 

15 (i) Providers of services and suppliers 

16 with high, expensive, and frequent errors 

17 shall receive a high score and be identified 

18 as high error providers of services and sup19 pliers under subparagraph (A). 

20 (ii) Providers of services and suppliers 

21 with few, inexpensive, and infrequent er22 rors shall receive a low score and be identi23 fied as low error providers of services and 

24 suppliers under such subparagraph. 


smartinez on DSK6TPTVN1PROD with BILLS
247 

•S 1871 PCS

1 (iii) Only a small proportion of the 

2 total providers of services and suppliers 

3 and individual types of providers of serv4 ices and suppliers in the geographic area 

5 of the demonstration project shall be as6 signed to either group identified under 

7 such subparagraph. 

8 (D) TIMEFRAME OF IDENTIFICATION.— 

9 (i) IN GENERAL.—Any identification 

10 of a provider of services or a supplier 

11 under subparagraph (A) shall be for a pe12 riod of 12 months. 

13 (ii) REEVALUATION.—The Secretary 

14 shall reevaluate each such identification at 

15 the end of such period. 

16 (iii) USE OF MOST CURRENT INFOR17 MATION.—In carrying out the reevaluation 

18 under clause (ii) with respect to a provider 

19 of services or supplier, the Secretary 

20 shall— 

21 (I) consider the most current in22 formation available with respect to the 

23 provider of services or supplier under 

24 the analysis under subparagraph (B); 

25 and 


smartinez on DSK6TPTVN1PROD with BILLS
248 

•S 1871 PCS

1 (II) take into account improve2 ment or regression of the provider of 

3 services or supplier. 

4 (4) ADJUSTMENT OF RECORD REQUEST MAX5 IMUM.—Under the demonstration project, the Sec6 retary shall establish procedures to— 

7 (A) increase the maximum record request 

8 made by recovery audit contractors to providers 

9 of services and suppliers identified as high error 

10 providers of services and suppliers under para11 graph (3); and 

12 (B) decrease the maximum record request 

13 made by recovery audit contractors to providers 

14 of services and suppliers identified as low error 

15 providers of services and supplier under such 

16 paragraph. 

17 (5) ADDITIONAL ADJUSTMENTS.— 

18 (A) IN GENERAL.—Under the demonstra19 tion project, the Secretary may make additional 

20 adjustments to requirements for recovery audit 

21 contractors under section 1893(h) of the Social 

22 Security Act (42 U.S.C. 1395ddd(h)) and the 

23 conduct of audits with respect to low error pro24 viders of services and suppliers identified under 

25 paragraph (3) and high error providers of servVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00248 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
249 

•S 1871 PCS

1 ices and suppliers identified under such para2 graph as the Secretary determines necessary in 

3 order to incentivize reductions in improper pay4 ment rates under title XVIII of such Act (42 

5 U.S.C. 1395 et seq.). 

6 (B) LIMITATION.—The Secretary shall not 

7 exempt any group of providers of services or 

8 suppliers in the demonstration project from 

9 being subject to audit by a recovery audit con10 tractor under such section 1893(h). 

11 (6) EVALUATION AND REPORT.— 

12 (A) EVALUATION.—The Inspector General 

13 of the Department of Health and Human Serv14 ices shall conduct an evaluation of the dem15 onstration project under this subsection. The 

16 evaluation shall include an analysis of— 

17 (i) the error rates of providers of serv18 ices and suppliers— 

19 (I) identified under paragraph 

20 (3) as low error providers of services 

21 and suppliers; 

22 (II) identified under such para23 graph as high error providers of serv24 ices and suppliers; and 


smartinez on DSK6TPTVN1PROD with BILLS
250 

•S 1871 PCS

1 (III) that are located in the geo2 graphic area of the demonstration 

3 project and are not identified as either 

4 a low error or high error provider of 

5 services or supplier under such para6 graph; and 

7 (ii) any improvements in the error 

8 rates of those high error providers of serv9 ices and suppliers identified under such 

10 paragraph. 

11 (B) REPORT.—Not later than 12 months 

12 after completion of the demonstration project, 

13 the Inspector General shall submit to Congress 

14 a report containing the results of the evaluation 

15 conducted under subparagraph (A), together 

16 with recommendations on whether the dem17 onstration project should be continued or ex18 panded, including on a permanent or nation19 wide basis. 

20 (7) FUNDING.— 

21 (A) FUNDING FOR IMPLEMENTATION.— 

22 For purposes of carrying out the demonstration 

23 project under this subsection (other than the 

24 evaluation and report under paragraph (6)), the 

25 Secretary shall provide for the transfer, from 


smartinez on DSK6TPTVN1PROD with BILLS
251 

•S 1871 PCS

1 the Federal Hospital Insurance Trust Fund 

2 under section 1817 (42 U.S.C. 1395i) and the 

3 Federal Supplementary Medical Insurance 

4 Trust Fund under section 1841 (42 U.S.C. 

5 1395t), in such proportion as the Secretary de6 termines appropriate, of $10,000,000 to the 

7 Centers for Medicare & Medicaid Services Pro8 gram Management Account. 

9 (B) FUNDING FOR INSPECTOR GENERAL

10 EVALUATION AND REPORT.—For purposes of 

11 carrying out the evaluation and report under 

12 paragraph (6), the Secretary shall provide for 

13 the transfer, from the Federal Hospital Insur14 ance Trust Fund under such section 1817 and 

15 the Federal Supplementary Medical Insurance 

16 Trust Fund under such section 1841, in such 

17 proportion as the Secretary determines appro18 priate, of $245,000 to the Inspector General of 

19 the Department of Health and Human Services. 

20 (C) AVAILABILITY.—Amounts transferred 

21 under subparagraph (A) or (B) shall remain 

22 available until expended. 

23 (8) DEFINITIONS.—In this section: 


smartinez on DSK6TPTVN1PROD with BILLS
252 

•S 1871 PCS

1 (A) DEMONSTRATION PROJECT.—The term 

2 ‘‘demonstration project’’ means the demonstra3 tion project under this subsection. 

4 (B) PROVIDER OF SERVICES.—The term 

5 ‘‘provider of services’’ has the meaning given 

6 that term in section 1861(u). 

7 (C) RECOVERY AUDIT CONTRACTOR.—The 

8 term ‘‘recovery audit contractor’’ means an en9 tity with a contract under section 1893(h) of 

10 the Social Security Act (42 U.S.C. 

11 1395ddd(h)). 

12 (D) SECRETARY.—The term ‘‘Secretary’’ 

13 means the Secretary of Health and Human 

14 Services. 

15 (E) SUPPLIER.—The term ‘‘supplier’’ has 

16 the meaning given that term in section 1861(d). 

17 SEC. 232. AUTHORITY FOR MEDICAID FRAUD CONTROL 

18 UNITS TO INVESTIGATE AND PROSECUTE 

19 COMPLAINTS OF ABUSE AND NEGLECT OF 

20 MEDICAID PATIENTS IN HOME AND COMMU21 NITY-BASED SETTINGS. 

22 (a) IN GENERAL.—Section 1903(q)(4)(A) of the So23 cial Security Act (42 U.S.C. 1396b(q)(4)(A)) is amended 

24 to read as follows: 


smartinez on DSK6TPTVN1PROD with BILLS
253 

•S 1871 PCS

1 ‘‘(4)(A) The entity’s function includes a state2 wide program for the— 

3 ‘‘(i) investigation and prosecution, or refer4 ral for prosecution or other action, of com5 plaints of abuse or neglect of patients in health 

6 care facilities which receive payments under the 

7 State plan under this title or under a waiver of 

8 such plan; 

9 ‘‘(ii) at the option of the entity, investiga10 tion and prosecution, or referral for prosecution 

11 or other action, of complaints of abuse or ne12 glect of individuals in connection with any as13 pect of the provision of medical assistance and 

14 the activities of providers of such assistance in 

15 a home or community based setting that is paid 

16 for under the State plan under this title or 

17 under a waiver of such plan; and 

18 ‘‘(iii) at the option of the entity, investiga19 tion and prosecution, or referral for prosecution 

20 or other action, of complaints of abuse or ne21 glect of patients residing in board and care fa22 cilities.’’. 

23 (b) EFFECTIVE DATE.—The amendment made by 

24 subsection (a) shall take effect on January 1, 2015. 


smartinez on DSK6TPTVN1PROD with BILLS
254 

•S 1871 PCS

1 SEC. 233. IMPROVED USE OF FUNDS RECEIVED BY THE HHS 

2 INSPECTOR GENERAL FROM OVERSIGHT AND 

3 INVESTIGATIVE ACTIVITIES. 

4 (a) IN GENERAL.—Section 1128C(b) of the Social 

5 Security Act (42 U.S.C. 1320a–7c(b)) is amended to read 

6 as follows: 

7 ‘‘(b) ADDITIONAL USE OF FUNDS BY INSPECTOR

8 GENERAL.— 

9 ‘‘(1) COLLECTIONS FROM MEDICARE AND MED10 ICAID RECOVERY ACTIONS.—Notwithstanding section 

11 3302 of title 31, United States Code, or any other 

12 provision of law affecting the crediting of collections, 

13 the Inspector General of the Department of Health 

14 and Human Services may receive and retain three 

15 percent of all amounts collected pursuant to civil 

16 debt collection actions related to false claims or 

17 frauds involving the Medicare program under title 

18 XVIII or the Medicaid program under title XIX. 

19 ‘‘(2) CREDITING.—Funds received by the In20 spector General under paragraph (1) shall be depos21 ited to the credit of any appropriation available for 

22 oversight and enforcement activities of the Inspector 

23 General permitted under subsection (a), and shall 

24 remain available until expended.’’. 

25 (b) EFFECTIVE DATE.—The amendment made by 

26 subsection (a) shall apply to funds received from settleVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00254 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
255 

•S 1871 PCS

1 ments finalized, or judgements entered, on or after the 

2 date of the enactment of this Act. 

3 SEC. 234. PREVENTING AND REDUCING IMPROPER MEDI4 CARE AND MEDICAID EXPENDITURES. 

5 (a) REQUIRING VALID PRESCRIBER NATIONAL PRO6 VIDER IDENTIFIERS ON PHARMACY CLAIMS.—Section 

7 1860D–4(c) of the Social Security Act (42 U.S.C. 1395w– 

8 104(c)) is amended by adding at the end the following new 

9 paragraph: 

10 ‘‘(4) REQUIRING VALID PRESCRIBER NATIONAL

11 PROVIDER IDENTIFIERS ON PHARMACY CLAIMS.— 

12 ‘‘(A) IN GENERAL.—For plan year 2015 

13 and subsequent plan years, subject to subpara14 graph (B), the Secretary shall prohibit PDP 

15 sponsors of prescription drug plans from paying 

16 claims for prescription drugs under this part 

17 that do not include a valid prescriber National 

18 Provider Identifier. 

19 ‘‘(B) PROCEDURES.—The Secretary shall 

20 establish procedures for determining the validity 

21 of prescriber National Provider Identifiers 

22 under subparagraph (A). 

23 ‘‘(C) REPORT.—Not later than January 1, 

24 2017, the Inspector General of the Department 

25 of Health and Human Services shall submit to 


smartinez on DSK6TPTVN1PROD with BILLS
256 

•S 1871 PCS

1 Congress a report on the effectiveness of the 

2 procedures established under subparagraph 

3 (B).’’. 

4 (b) REFORMING HOW CMS TRACKS AND CORRECTS

5 THE VULNERABILITIES IDENTIFIED BY RECOVERY AUDIT

6 CONTRACTORS.—Section 1893(h) of the Social Security 

7 Act (42 U.S.C. 1395ddd(h)) is amended— 

8 (1) in paragraph (8), as amended by section 

9 231, by adding at the end the following new sub10 paragraphs: 

11 ‘‘(C) INCLUSION OF IMPROPER PAYMENT

12 VULNERABILITIES IDENTIFIED.—For reports 

13 submitted under this paragraph for 2015 or a 

14 subsequent year, each such report shall in15 clude— 

16 ‘‘(i) a description of— 

17 ‘‘(I) the types and financial cost 

18 to the program under this title of im19 proper payment vulnerabilities identi20 fied by recovery audit contractors 

21 under this subsection; and 

22 ‘‘(II) how the Secretary is ad23 dressing such improper payment 

24 vulnerabilities; and 


smartinez on DSK6TPTVN1PROD with BILLS
257 

•S 1871 PCS

1 ‘‘(ii) an assessment of the effective2 ness of changes made to payment policies 

3 and procedures under this title in order to 

4 address the vulnerabilities so identified. 

5 ‘‘(D) LIMITATION.—The Secretary shall 

6 ensure that each report submitted under sub7 paragraph (A) does not include information 

8 that the Secretary determines would be sen9 sitive or would otherwise negatively impact pro10 gram integrity.’’; and 

11 (2) by adding at the end the following new 

12 paragraph: 

13 ‘‘(10) ADDRESSING IMPROPER PAYMENT

14 VULNERABILITIES.—The Secretary shall address im15 proper payment vulnerabilities identified by recovery 

16 audit contractors under this subsection in a timely 

17 manner, prioritized based on the risk to the program 

18 under this title.’’. 

19 (c) STRENGTHENING MEDICAID PROGRAM INTEG20 RITY THROUGH FLEXIBILITY.—Section 1936 of the Social 

21 Security Act (42 U.S.C. 1396u–6) is amended— 

22 (1) in subsection (a), by inserting ‘‘, or other23 wise,’’ after ‘‘entities’’; and 

24 (2) in subsection (e)— 


smartinez on DSK6TPTVN1PROD with BILLS
258 

•S 1871 PCS

1 (A) in paragraph (1), in the matter pre2 ceding subparagraph (A), by inserting ‘‘(includ3 ing the costs of equipment, salaries and bene4 fits, and travel and training)’’ after ‘‘Program 

5 under this section’’; and 

6 (B) in paragraph (3), by striking ‘‘by 100’’ 

7 and inserting ‘‘by 100, or such number as de8 termined necessary by the Secretary to carry 

9 out the Program under this section,’’. 

10 (d) ACCESS TO THE NATIONAL DIRECTORY OF NEW

11 HIRES.—Section 453(j) of the Social Security Act (42 

12 U.S.C. 653(j)) is amended by adding at the end the fol13 lowing new paragraph: 

14 ‘‘(12) INFORMATION COMPARISONS AND DIS15 CLOSURES TO ASSIST IN ADMINISTRATION OF THE

16 MEDICARE PROGRAM AND STATE HEALTH SUBSIDY

17 PROGRAMS.— 

18 ‘‘(A) DISCLOSURE TO THE ADMINIS19 TRATOR OF THE CENTERS FOR MEDICARE &

20 MEDICAID SERVICES.—The Administrator of 

21 the Centers for Medicare & Medicaid shall have 

22 access to the information in the National Direc23 tory of New Hires for purposes of determining 

24 the eligibility of an applicant for, or enrollee in, 

25 the Medicare program under title XVIII or an 


smartinez on DSK6TPTVN1PROD with BILLS
259 

•S 1871 PCS

1 applicable State health subsidy program (as de2 fined in section 1413(e) of the Patient Protec3 tion and Affordable Care Act (42 U.S.C. 

4 18083(e)). 

5 ‘‘(B) DISCLOSURE TO THE INSPECTOR

6 GENERAL OF THE DEPARTMENT OF HEALTH

7 AND HUMAN SERVICES.— 

8 ‘‘(i) IN GENERAL.—If the Inspector 

9 General of the Department of Health and 

10 Human Services transmits to the Secretary 

11 the names and social security account 

12 numbers of individuals, the Secretary shall 

13 disclose to the Inspector General informa14 tion on such individuals and their employ15 ers maintained in the National Directory 

16 of New Hires. 

17 ‘‘(ii) USE OF INFORMATION.—The In18 spector General of the Department of 

19 Health and Human Services may use in20 formation provided under clause (i) only 

21 for purposes of — 

22 ‘‘(I) determining the eligibility of 

23 an applicant for, or enrollee in, the 

24 Medicare program under title XVIII 

25 or an applicable State health subsidy 


smartinez on DSK6TPTVN1PROD with BILLS
260 

•S 1871 PCS

1 program (as defined in section 

2 1413(e) of the Patient Protection and 

3 Affordable Care Act (42 U.S.C. 

4 18083(e)); or 

5 ‘‘(II) evaluating the integrity of 

6 the Medicare program or an applica7 ble State health subsidy program (as 

8 so defined). 

9 ‘‘(C) DISCLOSURE TO STATE AGENCIES.— 

10 ‘‘(i) IN GENERAL.—If, for purposes of 

11 determining the eligibility of an applicant 

12 for, or an enrollee in, an applicable State 

13 health subsidy program (as defined in sec14 tion 1413(e) of the Patient Protection and 

15 Affordable Care Act (42 U.S.C. 18083(e)), 

16 a State agency responsible for admin17 istering such program transmits to the 

18 Secretary the names, dates of birth, and 

19 social security account numbers of individ20 uals, the Secretary shall disclose to such 

21 State agency information on such individ22 uals and their employers maintained in the 

23 National Directory of New Hires, subject 

24 to this subparagraph. 


smartinez on DSK6TPTVN1PROD with BILLS
261 

•S 1871 PCS

1 ‘‘(ii) CONDITION ON DISCLOSURE BY

2 THE SECRETARY.—The Secretary shall 

3 make a disclosure under clause (i) only to 

4 the extent that the Secretary determines 

5 that the disclosure would not interfere with 

6 the effective operation of the program 

7 under this part. 

8 ‘‘(iii) USE AND DISCLOSURE OF IN9 FORMATION BY STATE AGENCIES.— 

10 ‘‘(I) IN GENERAL.—A State 

11 agency may not use or disclose infor12 mation provided under clause (i) ex13 cept for purposes of determining the 

14 eligibility of an applicant for, or an 

15 enrollee in, a program referred to in 

16 clause (i). 

17 ‘‘(II) INFORMATION SECURITY.— 

18 The State agency shall have in effect 

19 data security and control policies that 

20 the Secretary finds adequate to ensure 

21 the security of information obtained 

22 under clause (i) and to ensure that 

23 access to such information is re24 stricted to authorized persons for purVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00261 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
262 

•S 1871 PCS

1 poses of authorized uses and disclo2 sures. 

3 ‘‘(III) PENALTY FOR MISUSE OF

4 INFORMATION.—An officer or em5 ployee of the State agency who fails to 

6 comply with this clause shall be sub7 ject to the sanctions under subsection 

8 (l)(2) to the same extent as if such of9 ficer or employee were an officer or 

10 employee of the United States. 

11 ‘‘(iv) PROCEDURAL REQUIREMENTS.— 

12 State agencies requesting information 

13 under clause (i) shall adhere to uniform 

14 procedures established by the Secretary 

15 governing information requests and data 

16 matching under this paragraph. 

17 ‘‘(v) REIMBURSEMENT OF COSTS.— 

18 The State agency shall reimburse the Sec19 retary, in accordance with subsection 

20 (k)(3), for the costs incurred by the Sec21 retary in furnishing the information re22 quested under this subparagraph.’’. 

23 (e) IMPROVING THE SHARING OF DATA BETWEEN

24 THE FEDERAL GOVERNMENT AND STATE MEDICAID PRO25 GRAMS.— 


smartinez on DSK6TPTVN1PROD with BILLS
263 

•S 1871 PCS

1 (1) IN GENERAL.—The Secretary of Health and 

2 Human Services (in this subsection referred to as 

3 the ‘‘Secretary’’) shall establish a plan to encourage 

4 and facilitate the participation of States in the Medi5 care-Medicaid Data Match Program (commonly re6 ferred to as the ‘‘Medi-Medi Program’’) under sec7 tion 1893(g) of the Social Security Act (42 U.S.C. 

8 1395ddd(g)). 

9 (2) PROGRAM REVISIONS TO IMPROVE MEDI10 MEDI DATA MATCH PROGRAM PARTICIPATION BY

11 STATES.—Section 1893(g)(1)(A) of the Social Secu12 rity Act (42 U.S.C. 1395ddd(g)(1)(A)) is amend13 ed— 

14 (A) in the matter preceding clause (i), by 

15 inserting ‘‘or otherwise’’ after ‘‘eligible enti16 ties’’; 

17 (B) in clause (i)— 

18 (i) by inserting ‘‘to review claims 

19 data’’ after ‘‘algorithms’’; and 

20 (ii) by striking ‘‘service, time, or pa21 tient’’ and inserting ‘‘provider, service, 

22 time, or patient’’; 

23 (C) in clause (ii)— 


smartinez on DSK6TPTVN1PROD with BILLS
264 

•S 1871 PCS

1 (i) by inserting ‘‘to investigate and re2 cover amounts with respect to suspect 

3 claims’’ after ‘‘appropriate actions’’; and 

4 (ii) by striking ‘‘; and’’ and inserting 

5 a semicolon; 

6 (D) in clause (iii), by striking the period 

7 and inserting ‘‘; and’’; and 

8 (E) by adding at end the following new 

9 clause: 

10 ‘‘(iv) furthering the Secretary’s de11 sign, development, installation, or enhance12 ment of an automated data system archi13 tecture— 

14 ‘‘(I) to collect, integrate, and as15 sess data for purposes of program in16 tegrity, program oversight, and ad17 ministration, including the Medi-Medi 

18 Program; and 

19 ‘‘(II) that improves the coordina20 tion of requests for data from 

21 States.’’. 

22 (3) PROVIDING STATES WITH DATA ON IM23 PROPER PAYMENTS MADE FOR ITEMS OR SERVICES

24 PROVIDED TO DUAL ELIGIBLE INDIVIDUALS.— 


smartinez on DSK6TPTVN1PROD with BILLS
265 

•S 1871 PCS

1 (A) IN GENERAL.—The Secretary shall de2 velop and implement a plan that allows each 

3 State agency responsible for administering a 

4 State plan for medical assistance under title 

5 XIX of the Social Security Act access to rel6 evant data on improper or fraudulent payments 

7 made under the Medicare program under title 

8 XVIII of the Social Security Act (42 U.S.C. 

9 1395 et seq.) for health care items or services 

10 provided to dual eligible individuals. 

11 (B) DUAL ELIGIBLE INDIVIDUAL DE12 FINED.—In this paragraph, the term ‘‘dual eli13 gible individual’’ means an individual who is en14 titled to, or enrolled for, benefits under part A 

15 of title XVIII of the Social Security Act (42 

16 U.S.C. 1395c et seq.), or enrolled for benefits 

17 under part B of title XVIII of such Act (42 

18 U.S.C. 1395j et seq.), and is eligible for medical 

19 assistance under a State plan under title XIX 

20 of such Act (42 U.S.C. 1396 et seq.) or under 

21 a waiver of such plan. 

22 Subtitle E—Other Provisions 

23 SEC. 241. COMMISSION ON IMPROVING PATIENT DIRECTED 

24 HEALTH CARE. 

25 (a) FINDINGS.—Congress finds the following: 


smartinez on DSK6TPTVN1PROD with BILLS
266 

•S 1871 PCS

1 (1) In order to elevate the role of patient 

2 choices in the health care system, the American pub3 lic must engage in an informed, national, public de4 bate on how the current health care system empow5 ers and informs health care decision-making, and 

6 what can be done to improve the likelihood patients 

7 receive the care they want and need. 

8 (2) Research suggests that patients often do 

9 not receive the care they want. As a result, the end 

10 of life is associated with a substantial burden of suf11 fering by the patient and negative health and finan12 cial consequences that extend to family members and 

13 society. 

14 (3) Patients face a complex and fragmented 

15 health care system that may decrease the likelihood 

16 that health care choices are known and carried out. 

17 The health care system should embed principles that 

18 take into account patient wishes. 

19 (4) Decisions concerning health care, including 

20 end-of-life issues, affect an increasing number of 

21 Americans. 

22 (5) Medical advances are prolonging life expect23 ancy in the United States both in acute life-threat24 ening situations and protracted battles with illness. 


smartinez on DSK6TPTVN1PROD with BILLS
267 

•S 1871 PCS

1 These advances raise new challenges surrounding 

2 health care decision-making. 

3 (6) The United States health care system 

4 should promote consideration of a person’s pref5 erence in health care decision-making and end-of-life 

6 choices. 

7 (b) COMMISSION.—The Social Security Act is amend8 ed by inserting after section 1150B (42 U.S.C. 1320b– 

9 24) the following new section: 

10 ‘‘SEC. 1150C. COMMISSION ON IMPROVING PATIENT DI11 RECTED HEALTH CARE. 

12 ‘‘(a) PURPOSES.—The purposes of this section are 

13 to— 

14 ‘‘(1) provide a forum for a nationwide public 

15 debate on improving patient self-determination in 

16 health care decision-making; 

17 ‘‘(2) identify strategies that ensure every Amer18 ican has the health care they want; and 

19 ‘‘(3) provide recommendations to Congress that 

20 result from the debate. 

21 ‘‘(b) ESTABLISHMENT.—The Secretary shall estab22 lish an entity to be known as the Commission on Improv23 ing Patient Directed Health Care (referred to in this sec24 tion as the ‘Commission’). 

25 ‘‘(c) MEMBERSHIP.— 


smartinez on DSK6TPTVN1PROD with BILLS
268 

•S 1871 PCS

1 ‘‘(1) NUMBER AND APPOINTMENT.—The Com2 mission shall be composed of 15 members. One 

3 member shall be the Secretary. The Comptroller 

4 General of the United States shall appoint 14 mem5 bers. 

6 ‘‘(2) QUALIFICATIONS.—The membership of the 

7 Commission shall include— 

8 ‘‘(A) health care consumers impacted by 

9 decision-making in advance of a health care cri10 sis, such as individuals of advanced age, indi11 viduals with chronic, terminal and mental ill12 nesses, family care givers, and individuals with 

13 disabilities; 

14 ‘‘(B) providers in settings where crucial 

15 health care decision-making occurs, such as 

16 those working in intensive care settings, emer17 gency room departments, primary care settings, 

18 nursing homes, hospice, or palliative care set19 tings; 

20 ‘‘(C) payors ensuring patients get the level 

21 of care they want; 

22 ‘‘(D) experts in advance care planning, 

23 hospice, palliative care, information technology, 

24 bioethics, aging policy, disability policy, pediVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00268 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
269 

•S 1871 PCS

1 atric ethics, cultural sensitivity, psychology, and 

2 health care financing; 

3 ‘‘(E) individuals who represent culturally 

4 diverse perspectives on patient self-determina5 tion and end-of-life issues; and 

6 ‘‘(F) members of the faith community. 

7 ‘‘(d) PERIOD OF APPOINTMENT.—Members of the 

8 Commission shall be appointed for the life of the Commis9 sion. Any vacancies shall not affect the power and duties 

10 of the Commission but shall be filled in the same manner 

11 as the original appointment. 

12 ‘‘(e) DESIGNATION OF THE CHAIRPERSON.—Not 

13 later than 15 days after the date on which all members 

14 of the Commission have been appointed, the Comptroller 

15 General shall designate the chairperson of the Commis16 sion. 

17 ‘‘(f) SUBCOMMITTEES.—The Commission may estab18 lish subcommittees if doing so increases the efficiency of 

19 the Commission in completing tasks. 

20 ‘‘(g) DUTIES.— 

21 ‘‘(1) HEARINGS.—Not later than 90 days after 

22 the date of designation of the chairperson under 

23 subsection (e), the Commission shall hold no fewer 

24 than 8 hearings to examine— 


smartinez on DSK6TPTVN1PROD with BILLS
270 

•S 1871 PCS

1 ‘‘(A) the current state of health care deci2 sion-making and advance care planning laws in 

3 the United States at the Federal level and 

4 across the States, as well as options for improv5 ing advance care planning tools, especially with 

6 regard to use, portability, and storage; 

7 ‘‘(B) consumer-focused approaches that 

8 educate the American public about patient 

9 choices, care planning, and other end-of-life 

10 issues; 

11 ‘‘(C) the use of comprehensive, patient-cen12 tered care plans by providers, the impact care 

13 plans have on health care delivery, and methods 

14 to expand the use of high quality care planning 

15 tools in both public and private health care sys16 tems; 

17 ‘‘(D) the role of electronic medical records 

18 and other technologies in improving patient-di19 rected health care; 

20 ‘‘(E) innovative tools for improving patient 

21 experience with advanced illness, such as pallia22 tive care, hospice, and other models; 

23 ‘‘(F) the role social determinants of health, 

24 such as socio-economic status, play in patient 

25 self-direction in health care; 


smartinez on DSK6TPTVN1PROD with BILLS
271 

•S 1871 PCS

1 ‘‘(G) the use of culturally-competent tools 

2 for health care decision-making; 

3 ‘‘(H) strategies for educating providers on 

4 care planning, palliative care, hospice care, and 

5 other issues surrounding honoring patient 

6 choices; 

7 ‘‘(I) the sociological and psychological fac8 tors that influence health care decision-making 

9 and end-of-life choices; and 

10 ‘‘(J) the role of spirituality and religion in 

11 patient self-determination in health care. 

12 ‘‘(2) ADDITIONAL HEARINGS.—The Commission 

13 may hold additional hearings on subjects other than 

14 those listed in paragraph (1) so long as such hear15 ings are determined necessary by the Commission in 

16 carrying out the purposes of this section. Such addi17 tional hearings do not have to be completed within 

18 the time period specified but shall not delay the 

19 other activities of the Commission under this sec20 tion. 

21 ‘‘(3) NUMBER AND LOCATION OF HEARINGS

22 AND ADDITIONAL HEARINGS.—The Commission shall 

23 hold no fewer than 8 hearings as indicated in para24 graph (1) and in sufficient number in order to re25 ceive information that reflects— 


smartinez on DSK6TPTVN1PROD with BILLS
272 

•S 1871 PCS

1 ‘‘(A) the geographic differences throughout 

2 the United States; 

3 ‘‘(B) diverse populations; and 

4 ‘‘(C) a balance among urban and rural 

5 populations. 

6 ‘‘(4) INTERACTIVE TECHNOLOGY.—The Com7 mission may encourage public participation in hear8 ings through interactive technology and other means 

9 as determined appropriate by the Commission. 

10 ‘‘(5) REPORT TO THE AMERICAN PEOPLE ON

11 PATIENT DIRECTED HEALTH CARE.—Not later than 

12 90 days after the hearings described in paragraphs 

13 (1) and (2) are completed, the Commission shall 

14 prepare and make available to health care consumers 

15 through the Internet and other appropriate public 

16 channels, a report to be entitled, ‘Report to the 

17 American People on Patient Directed Health Care’. 

18 Such a report shall be understandable to the general 

19 public and include— 

20 ‘‘(A) a summary of— 

21 ‘‘(i) the hearings described in such 

22 paragraphs; 

23 ‘‘(ii) how the current health care sys24 tem empowers and informs decision-mak25 ing in advance of a health care crisis; 


smartinez on DSK6TPTVN1PROD with BILLS
273 

•S 1871 PCS

1 ‘‘(iii) factors that contribute to the 

2 provision of health care that does not ad3 here to patient wishes; 

4 ‘‘(iv) the impact of care that does not 

5 follow patient choices, particularly at the 

6 end-of-life, on patients, families, providers, 

7 and the health care system; 

8 ‘‘(v) the laws surrounding advance 

9 care planning and health care decision10 making including issues of portability, use, 

11 and storage; 

12 ‘‘(vi) consumer-focused approaches to 

13 education of the American public about pa14 tient choices, care planning, and other end15 of-life issues; 

16 ‘‘(vii) the role of care plans in health 

17 care decision-making; 

18 ‘‘(viii) the role of providers in ensur19 ing patients receive the care they want; 

20 ‘‘(ix) the role of electronic medical 

21 records and other technologies in improv22 ing patient directed health care; 

23 ‘‘(x) the impact of social determinants 

24 on patient self-direction in health care 

25 services; 


smartinez on DSK6TPTVN1PROD with BILLS
274 

•S 1871 PCS

1 ‘‘(xi) the use of culturally competent 

2 methods for health care decision-making; 

3 ‘‘(xii) the sociological and psycho4 logical factors that influence patient self5 determination; and 

6 ‘‘(xiii) the role of spirituality and reli7 gion in health care decision-making and 

8 end-of-life care; 

9 ‘‘(B) best practices from communities, pro10 viders, and payors that document patient wish11 es and provide health care that adheres to those 

12 wishes; and 

13 ‘‘(C) information on educating providers 

14 about health care decision-making and end-of15 life issues. 

16 ‘‘(6) INTERIM REQUIREMENTS.—Not later than 

17 180 days after the date of completion of the hear18 ings, the Commission shall prepare and make avail19 able to the public through the Internet and other ap20 propriate public channels, an interim set of rec21 ommendations on patient self-determination in 

22 health care and ways to improve and strengthen the 

23 health care system based on the information and 

24 preferences expressed at the community meetings. 


smartinez on DSK6TPTVN1PROD with BILLS
275 

•S 1871 PCS

1 There shall be a 90-day public comment period on 

2 such recommendations. 

3 ‘‘(h) RECOMMENDATIONS.—Not later than 120 days 

4 after the expiration of the public comment period de5 scribed in subsection (g)(6), the Commission shall submit 

6 to Congress and the President a final set of recommenda7 tions. The recommendations must be comprehensive and 

8 detailed. The recommendations must contain rec9 ommendations or proposals for legislative or administra10 tive action as the Commission deems appropriate, includ11 ing proposed legislative language to carry out the rec12 ommendations or proposals. 

13 ‘‘(i) ADMINISTRATION.— 

14 ‘‘(1) EXECUTIVE DIRECTOR.—There shall be an 

15 Executive Director of the Commission who shall be 

16 appointed by the chairperson of the Commission in 

17 consultation with the members of the Commission. 

18 ‘‘(2) COMPENSATION.—While serving on the 

19 business of the Commission (including travel time), 

20 a member of the Commission shall be entitled to 

21 compensation at the per diem equivalent of the rate 

22 provided for level IV of the Executive Schedule 

23 under section 5315 of title 5, United States Code, 

24 and while so serving away from home and the mem25 ber’s regular place of business, a member may be alVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00275 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
276 

•S 1871 PCS

1 lowed travel expenses, as authorized by the chair2 person of the Commission. For purposes of pay and 

3 employment benefits, rights, and privileges, all per4 sonnel of the Commission shall be treated as if they 

5 were employees of the Senate. 

6 ‘‘(3) INFORMATION FROM FEDERAL AGEN7 CIES.—The Commission may secure directly from 

8 any Federal department or agency such information 

9 as the Commission considers necessary to carry out 

10 this section. Upon request of the Commission the 

11 head of such department or agency shall furnish 

12 such information. 

13 ‘‘(4) POSTAL SERVICES.—The Commission may 

14 use the United States mails in the same manner and 

15 under the same conditions as other departments and 

16 agencies of the Federal Government. 

17 ‘‘(j) DETAIL.—Not more than 5 Federal Government 

18 employees employed by the Department of Labor, 5 Fed19 eral Government employees employed by the Social Secu20 rity Administration, and 10 Federal Government employ21 ees employed by the Department of Health and Human 

22 Services may be detailed to the Commission under this 

23 section without further reimbursement. Any detail of an 

24 employee shall be without interruption or loss of civil serv25 ice status or privilege. 


smartinez on DSK6TPTVN1PROD with BILLS
277 

•S 1871 PCS

1 ‘‘(k) TEMPORARY AND INTERMITTENT SERVICES.— 

2 The chairperson of the Commission may procure tem3 porary and intermittent services under section 3109(b) of 

4 title 5, United States Code, at rates for individuals which 

5 do not exceed the daily equivalent of the annual rate of 

6 basic pay prescribed for level V of the Executive Schedule 

7 under section 5316 of such title. 

8 ‘‘(l) ANNUAL REPORT.—Not later than 1 year after 

9 the date of enactment of this Act, and annually thereafter 

10 during the existence of the Commission, the Commission 

11 shall report to Congress and make public a detailed de12 scription of the expenditures of the Commission used to 

13 carry out its duties under this section. 

14 ‘‘(m) SUNSET OF COMMISSION.—The Commission 

15 shall terminate on the date that is 4 years after the date 

16 on which all the members of the Commission have been 

17 appointed under subsection (c)(1) and appropriations are 

18 first made available to carry out this section. 

19 ‘‘(n) ADMINISTRATION REVIEW AND COMMENTS.— 

20 Not later than 45 days after receiving the final rec21 ommendations of the Commission under subsection (h), 

22 the President shall submit a report to Congress which 

23 shall contain— 

24 ‘‘(1) additional views and comments on such 

25 recommendations; and 


smartinez on DSK6TPTVN1PROD with BILLS
278 

•S 1871 PCS

1 ‘‘(2) recommendations for such legislation and 

2 administrative action as the President considers ap3 propriate. 

4 ‘‘(o) REQUIRED CONGRESSIONAL ACTION.—Not later 

5 than 45 days after receiving the report submitted by the 

6 President under subsection (n), each committee of juris7 diction of Congress, the Committee on Finance of the Sen8 ate, the Committee on Health, Education, Labor, and 

9 Pensions of the Senate, the Committee on Ways and 

10 Means of the House of Representatives, the Committee on 

11 Energy and Commerce of the House of Representatives, 

12 and the Committee on Education and the Workforce of 

13 the House of Representatives, shall hold at least 1 hearing 

14 on such report and on the final recommendations of the 

15 Commission submitted under subsection (h). 

16 ‘‘(p) AUTHORIZATION OF APPROPRIATIONS.— 

17 ‘‘(1) IN GENERAL.—There are authorized to be 

18 appropriated to carry out this section, $3,000,000 

19 for each of fiscal years 2014 and 2015. 

20 ‘‘(2) REPORT TO THE AMERICAN PEOPLE ON

21 PATIENT DIRECTED HEALTH CARE.—There are au22 thorized to be appropriated for the preparation and 

23 dissemination of the Report to the American People 

24 on Patient Directed Health Care described in sub25 section (g)(5), such sums as may be necessary for 


smartinez on DSK6TPTVN1PROD with BILLS
279 

•S 1871 PCS

1 the fiscal year in which the report is required to be 

2 submitted.’’. 

3 SEC. 242. EXPANSION OF THE DEFINITION OF INPATIENT 

4 HOSPITAL SERVICES FOR CERTAIN CANCER 

5 HOSPITALS. 

6 Section 1861(b)(3) of the Social Security Act (42 

7 U.S.C. 1395x(b)(3)) is amended— 

8 (1) by inserting ‘‘(A)’’ after ‘‘(3)’’; and 

9 (2) by adding ‘‘and’’ after the semicolon at the 

10 end; and 

11 (3) by adding at the end the following new sub12 paragraph: 

13 ‘‘(B) with respect to a hospital that is described 

14 in section 1886(d)(1)(B)(v) and that, as of the date 

15 of the enactment of the SGR Repeal and Medicare 

16 Beneficiary Access Act of 2013, is located in the 

17 same building, or on the same campus, as another 

18 hospital, items and services described in paragraphs 

19 (1) and (2) furnished on or after such date of enact20 ment by the hospital described in such section or by 

21 others under arrangements with them made by the 

22 hospital;’’. 


smartinez on DSK6TPTVN1PROD with BILLS
280 

•S 1871 PCS

1 SEC. 243. QUALITY MEASURES FOR CERTAIN POST-ACUTE 

2 CARE PROVIDERS RELATING TO NOTICE AND 

3 TRANSFER OF PATIENT HEALTH INFORMA4 TION AND PATIENT CARE PREFERENCES. 

5 (a) DEVELOPMENT.—The Secretary of Health and 

6 Human Services (in this section referred to as the ‘‘Sec7 retary’’) shall provide for the development of one or more 

8 quality measures under title XVIII of the Social Security 

9 Act (42 U.S.C. 1395 et seq.) to accurately communicate 

10 the existence and provide for the transfer of patient health 

11 information and patient care preferences when an indi12 vidual transitions from a hospital to return home or move 

13 to other post-acute care settings. 

14 (b) USE OF MEASURE DEVELOPERS.—The Secretary 

15 shall arrange for the development of such measures by ap16 propriate measure developers. 

17 (c) ENDORSEMENT.—The Secretary shall arrange for 

18 such developed measures to be submitted for endorsement 

19 to a consensus-based entity as described in section 

20 1890(a) of the Social Security Act (42 U.S.C. 

21 1395aaa(a)), as amended by section 208. 

22 (d) USE OF MEASURES.—The Secretary shall, 

23 through notice and comment rulemaking, use such meas24 ures under the quality reporting programs with respect 

25 to— 


smartinez on DSK6TPTVN1PROD with BILLS
281 

•S 1871 PCS

1 (1) inpatient hospitals under section 

2 1886(b)(3)(B)(viii) of the Social Security Act (42 

3 U.S.C. 1395ww(b)(3)(B)(viii)); 

4 (2) skilled nursing facilities under section 

5 1888(e) of such Act (42 U.S.C. 1395yy(e)); 

6 (3) home health services under section 

7 1895(b)(3)(B)(v) of such Act (42 U.S.C. 

8 1395fff(b)(3)(B)(v)); and 

9 (4) other providers of services (as defined in 

10 section 1861(u) of such Act) and suppliers (as de11 fined in section 1861(d) of such Act) that the Sec12 retary determines appropriate. 

13 SEC. 244. CRITERIA FOR MEDICALLY NECESSARY, SHORT 

14 INPATIENT HOSPITAL STAYS. 

15 (a) IN GENERAL.—The Secretary of Health and 

16 Human Services shall consult with, and seek input from, 

17 interested stakeholders to determine appropriate criteria 

18 for payment under the Medicare program under title VIII 

19 of the Social Security Act of an inpatient hospital admis20 sion that— 

21 (1) is medically necessary; and 

22 (2) is an inpatient hospital stay that is less 

23 than two midnights, as described in section 412.3 of 

24 title 42, Code of Federal Regulation, as finalized in 

25 the final rule published by the Centers for Medicare 


smartinez on DSK6TPTVN1PROD with BILLS
282 

•S 1871 PCS

1 & Medicaid Services in the Federal Register on Au2 gust 19, 2013 (78 Federal Register 50496) entitled 

3 ‘‘Medicare Program; Hospital Inpatient Prospective 

4 Payment Systems for Acute Care Hospitals and the 

5 Long-Term Care Hospital Prospective Payment Sys6 tem and Fiscal Year 2014 Rates; Quality Reporting 

7 Requirements for Specific Providers; Hospital Con8 ditions of Participation; Payment Policies Related to 

9 Patient Status’’. 

10 (b) INTERESTED STAKEHOLDERS.—In subsection 

11 (a), the term ‘‘interested stakeholders’’ means the fol12 lowing: 

13 (1) Hospitals. 

14 (2) Physicians 

15 (3) Medicare administrative contractors under 

16 section 1874A of the Social Security Act (42 U.S.C. 

17 1395kk–1). 

18 (4) Recovery audit contractors under section 

19 1893(h) of such Act (42 U.S.C. 1395ddd(h)). 

20 (5) Other parties determined appropriate by the 

21 Secretary. 


smartinez on DSK6TPTVN1PROD with BILLS
283 

•S 1871 PCS

1 SEC. 245. TRANSPARENCY OF REASONS FOR EXCLUDING 

2 ADDITIONAL PROCEDURES FROM THE MEDI3 CARE AMBULATORY SURGICAL CENTER (ASC) 

4 APPROVED LIST. 

5 Section 1833(i)(1) of the Social Security Act (42 

6 U.S.C. 1395l(i)(1)) is amended by adding at the end the 

7 following: ‘‘In updating such lists for application in years 

8 beginning after December 31, 2014, for each procedure 

9 that was requested to be included on such lists during the 

10 public comment period but which the Secretary does not 

11 propose (in the final rule updating such lists) to so in12 clude, the Secretary shall describe in such final rule the 

13 specific safety criteria for not including such procedure on 

14 such lists.’’. 

15 SEC. 246. SUPERVISION IN CRITICAL ACCESS HOSPITALS. 

16 (a) GENERAL SUPERVISION IN CRITICAL ACCESS

17 HOSPITALS.—Section 1834(g) of the Social Security Act 

18 (42 U.S.C. 1395m(g)) is amended by adding at the end 

19 the following new paragraph: 

20 ‘‘(6) SUPERVISION.—In the case of services fur21 nished on or after the date of the enactment of this 

22 paragraph, the level of supervision with respect to 

23 outpatient critical access hospital services shall be 

24 general supervision (as defined by the Secretary).’’. 

25 (b) SUPERVISION OF CARDIAC AND PULMONARY RE26 HABILITATION PROGRAMS IN CRITICAL ACCESS HOSVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00283 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
284 

•S 1871 PCS

1 PITALS.—Section 1861(eee)(2)(B) of the Social Security 

2 Act (42 U.S.C. 1395x(eee)(2)(B)) is amended by inserting 

3 ‘‘, or in the case of a critical access hospital, a physician, 

4 or (beginning on the date of enactment of the SGR Repeal 

5 and Medicare Beneficiary Access Act of 2013) a nurse 

6 practitioner, clinical nurse specialist, or physician assist7 ant (as such terms are defined in subsection (aa)(5)),’’ 

8 after ‘‘a physician’’. 

9 SEC. 247. REQUIRING STATE LICENSURE OF BIDDING ENTI10 TIES UNDER THE COMPETITIVE ACQUISITION 

11 PROGRAM FOR CERTAIN DURABLE MEDICAL 

12 EQUIPMENT, PROSTHETICS, ORTHOTICS, AND 

13 SUPPLIES (DMEPOS). 

14 Section 1847(a)(1) of the Social Security Act (42 

15 U.S.C. 1395w–3(a)(1)) is amended by adding at the end 

16 the following new subparagraph: 

17 ‘‘(G) REQUIRING STATE LICENSURE OF

18 BIDDING ENTITIES.—With respect to rounds of 

19 competitions beginning on or after the date of 

20 enactment of this subparagraph, the Secretary 

21 may only accept a bid from an entity for an 

22 area if the entity meets applicable State licen23 sure requirements for such area for all items in 

24 such bid.’’. 


smartinez on DSK6TPTVN1PROD with BILLS
285 

•S 1871 PCS

1 SEC. 248. RECOGNITION OF ATTENDING PHYSICIAN ASSIST2 ANTS AS ATTENDING PHYSICIANS TO SERVE 

3 HOSPICE PATIENTS. 

4 (a) RECOGNITION OF ATTENDING PHYSICIAN AS5 SISTANTS AS ATTENDING PHYSICIANS TO SERVE HOS6 PICE PATIENTS.— 

7 (1) IN GENERAL.—Section 1861(dd)(3)(B) of 

8 the Social Security Act (42 U.S.C. 1395x(dd)(3)(B)) 

9 is amended— 

10 (A) by striking ‘‘or nurse’’ and inserting ‘‘, 

11 the nurse’’; and 

12 (B) by inserting ‘‘, or the physician assist13 ant (as defined in such subsection)’’ after ‘‘sub14 section (aa)(5))’’. 

15 (2) CLARIFICATION OF HOSPICE ROLE OF PHY16 SICIAN ASSISTANTS.—Section 1814(a)(7)(A)(i)(I) of 

17 the Social Security Act (42 U.S.C. 

18 1395f(a)(7)(A)(i)(I)) is amended by inserting ‘‘or a 

19 physician assistant’’ after ‘‘a nurse practitioner’’. 

20 (b) EFFECTIVE DATE.—The amendments made by 

21 this section shall apply to items and services furnished on 

22 or after January 1, 2015. 

23 SEC. 249. REMOTE PATIENT MONITORING PILOT 

24 PROJECTS. 

25 (a) PILOT PROJECTS.— 


smartinez on DSK6TPTVN1PROD with BILLS
286 

•S 1871 PCS

1 (1) IN GENERAL.—Not later than 9 months 

2 after the date of the enactment of this Act, the Sec3 retary shall conduct pilot projects under title XVIII 

4 of the Social Security Act for the purpose of pro5 viding incentives to home health agencies to furnish 

6 remote patient monitoring services that reduce ex7 penditures under such title. 

8 (2) SITE REQUIREMENTS.— 

9 (A) URBAN AND RURAL.—The Secretary 

10 shall conduct the pilot projects under this sec11 tion in both urban and rural areas. 

12 (B) SITE IN A SMALL STATE.—The Sec13 retary shall conduct at least 1 of the pilot 

14 projects in a State with a population of less 

15 than 1,000,000. 

16 (b) MEDICARE BENEFICIARIES WITHIN THE SCOPE

17 OF PROJECTS.— 

18 (1) IN GENERAL.—The Secretary shall specify 

19 the criteria for identifying those Medicare bene20 ficiaries who shall be considered within the scope of 

21 the pilot projects under this section for purposes of 

22 the application of subsection (c) and for the assess23 ment of the effectiveness of the home health agency 

24 in achieving the objectives of this section. 


smartinez on DSK6TPTVN1PROD with BILLS
287 

•S 1871 PCS

1 (2) CRITERIA.—The criteria specified under 

2 paragraph (1)— 

3 (A) shall include conditions and clinical 

4 circumstances, including congestive heart fail5 ure, diabetes, and chronic pulmonary obstruc6 tive disease, and other conditions determined 

7 appropriate by the Secretary; and 

8 (B) may provide for the inclusion in the 

9 projects of Medicare beneficiaries who begin re10 ceiving home health services under title XVIII 

11 of the Social Security Act after the date of the 

12 implementation of the projects. 

13 (c) INCENTIVES.— 

14 (1) PERFORMANCE TARGETS.—The Secretary 

15 shall establish for each home health agency partici16 pating in a pilot project under this section a per17 formance target using one of the following meth18 odologies, as determined appropriate by the Sec19 retary: 

20 (A) ADJUSTED HISTORICAL PERFORMANCE

21 TARGET.—The Secretary shall establish for the 

22 agency— 

23 (i) a base expenditure amount equal 

24 to the average total payments made under 

25 parts A, B, and D of title XVIII of the SoVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00287 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
288 

•S 1871 PCS

1 cial Security Act for Medicare beneficiaries 

2 determined to be within the scope of the 

3 pilot project in a base period determined 

4 by the Secretary; and 

5 (ii) an annual per capita expenditure 

6 target for such beneficiaries, reflecting the 

7 base expenditure amount adjusted for risk, 

8 changes in costs, and growth rates. 

9 (B) COMPARATIVE PERFORMANCE TAR10 GET.—The Secretary shall establish for the 

11 agency a comparative performance target equal 

12 to the average total payments made under such 

13 parts A, B, and D during the pilot project for 

14 comparable individuals in the same geographic 

15 area that are not determined to be within the 

16 scope of the pilot project. 

17 (2) PAYMENT.—Subject to paragraph (3), the 

18 Secretary shall pay to each home health agency par19 ticipating in a pilot project a payment for each year 

20 under the pilot project equal to a 75 percent share 

21 of the total Medicare cost savings realized for such 

22 year relative to the performance target under para23 graph (1). 

24 (3) LIMITATION ON EXPENDITURES.—The Sec25 retary shall limit payments under this section in 


smartinez on DSK6TPTVN1PROD with BILLS
289 

•S 1871 PCS

1 order to ensure that the aggregate expenditures 

2 under title XVIII of the Social Security Act (includ3 ing payments under this subsection) do not exceed 

4 the amount that the Secretary estimates would have 

5 been expended if the pilot projects under this section 

6 had not been implemented, including any reasonable 

7 costs incurred by the Secretary in the administration 

8 of the pilot projects. 

9 (4) NO DUPLICATION IN PARTICIPATION IN

10 SHARED SAVINGS PROGRAMS.—A home health agen11 cy that participates in any of the following shall not 

12 be eligible to participate in the pilot projects under 

13 this section: 

14 (A) A model tested or expanded under sec15 tion 1115A of the Social Security Act (42 

16 U.S.C. 1315a) that involves shared savings 

17 under title XVIII of such Act or any other pro18 gram or demonstration project that involves 

19 such shared savings. 

20 (B) The independence at home medical 

21 practice demonstration program under section 

22 1866E of such Act (42 U.S.C. 1395cc–5). 

23 (d) WAIVER AUTHORITY.—The Secretary may waive 

24 such provisions of titles XI and XVIII of the Social SecuVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00289 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
290 

•S 1871 PCS

1 rity Act as the Secretary determines to be appropriate for 

2 the conduct of the pilot projects under this section. 

3 (e) REPORT TO CONGRESS.—Not later than 3 years 

4 after the date that the first pilot project under this section 

5 is implemented, the Secretary shall submit to Congress a 

6 report on the projects. Such report shall contain— 

7 (1) a detailed description of the projects, in8 cluding any changes in clinical outcomes for Medi9 care beneficiaries under the projects, Medicare bene10 ficiary satisfaction under the projects, utilization of 

11 items and services under parts A, B, and D of title 

12 XVIII of the Social Security Act by Medicare bene13 ficiaries under the projects, and Medicare per-bene14 ficiary and Medicare aggregate spending under the 

15 projects; 

16 (2) a detailed description of issues related to 

17 the expansion of the projects under subsection (f); 

18 (3) recommendations for such legislation and 

19 administrative actions as the Secretary considers ap20 propriate; and 

21 (4) other items considered appropriate by the 

22 Secretary. 

23 (f) EXPANSION.—If the Secretary determines that 

24 any of the pilot projects under this section enhance health 

25 outcomes for Medicare beneficiaries and reduce expendiVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00290 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
291 

•S 1871 PCS

1 tures under title XVIII of the Social Security Act, the Sec2 retary shall initiate comparable projects in additional 

3 areas. 

4 (g) PAYMENTS HAVE NO EFFECT ON OTHER MEDI5 CARE PAYMENTS TO HOME HEALTH AGENCIES.—A pay6 ment under this section shall have no effect on the amount 

7 of payments that a home health agency would otherwise 

8 receive under title XVIII of the Social Security Act for 

9 the provision of home health services. 

10 (h) STUDY AND REPORT ON THE APPROPRIATE

11 VALUATION FOR REMOTE PATIENT MONITORING SERV12 ICES UNDER THE MEDICARE PHYSICIAN FEE SCHED13 ULE.— 

14 (1) STUDY.—The Secretary shall conduct a 

15 study on the appropriate valuation for remote pa16 tient monitoring services under the Medicare physi17 cian fee schedule under section 1848 of the Social 

18 Security Act (42 U.S.C. 1395w–4) in order to accu19 rately reflect the resources involved in furnishing 

20 such services. 

21 (2) REPORT.—Not later than 6 months after 

22 the date of the enactment of this Act, the Secretary 

23 shall submit to Congress a report on the study con24 ducted under paragraph (1), together with such recVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00291 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
292 

•S 1871 PCS

1 ommendations as the Secretary determines appro2 priate. 

3 (i) DEFINITIONS.—In this section: 

4 (1) HOME HEALTH AGENCY.—The term ‘‘home 

5 health agency’’ has the meaning given that term in 

6 section 1861(o) of the Social Security Act (42 

7 U.S.C. 1395x(o)). 

8 (2) REMOTE PATIENT MONITORING SERV9 ICES.— 

10 (A) IN GENERAL.—The term ‘‘remote pa11 tient monitoring services’’ means services fur12 nished in the home using remote patient moni13 toring technology which— 

14 (i) shall include patient monitoring or 

15 patient assessment; and 

16 (ii) may include in-home technology17 based professional consultations, patient 

18 training services, clinical observation, 

19 treatment, and any additional services that 

20 utilize technologies specified by the Sec21 retary. 

22 (B) LIMITATION.—The term ‘‘remote pa23 tient monitoring services’’ shall not include a 

24 telecommunication that consists solely of a tele25 phone audio conversation, facsimile, or elecVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00292 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
293 

•S 1871 PCS

1 tronic text mail between a health care profes2 sional and a patient. 

3 (3) REMOTE PATIENT MONITORING TECH4 NOLOGY.—The term ‘‘remote patient monitoring 

5 technology’’ means a coordinated system that uses 

6 one or more home-based or mobile monitoring de7 vices that automatically transmit vital sign data or 

8 information on activities of daily living and may in9 clude responses to assessment questions collected on 

10 the devices wirelessly or through a telecommuni11 cations connection to a server that complies with the 

12 Federal regulations (concerning the privacy of indi13 vidually identifiable health information) promulgated 

14 under section 264(c) of the Health Insurance Port15 ability and Accountability Act of 1996, as part of an 

16 established plan of care for that patient that in17 cludes the review and interpretation of that data by 

18 a health care professional. 

19 (4) SECRETARY.—The term ‘‘Secretary’’ means 

20 the Secretary of Health and Human Services. 

21 SEC. 250. COMMUNITY-BASED INSTITUTIONAL SPECIAL 

22 NEEDS PLAN DEMONSTRATION PROGRAM. 

23 (a) IN GENERAL.—The Secretary of Health and 

24 Human Services (referred to in this section as the ‘‘Sec25 retary’’) shall establish a Community-Based Institutional 


smartinez on DSK6TPTVN1PROD with BILLS
294 

•S 1871 PCS

1 Special Needs Plan (CBI-SNP) demonstration program to 

2 prevent and delay institutionalization under Medicaid 

3 among targeted low-income Medicare beneficiaries. 

4 (b) ESTABLISHMENT.—The Secretary shall enter into 

5 agreements with not more than 5 specialized MA plans 

6 for special needs individuals, as defined in section 

7 1859(b)(6)(B)(i) of the Social Security Act (42 U.S.C. 

8 1395w–28(b)(6)(B)(i)), to conduct the CBI-SNP dem9 onstration program. Under the CBI-SNP demonstration 

10 program, a targeted low-income Medicare beneficiary shall 

11 receive, as supplemental benefits under section 1852(a)(3) 

12 of such Act (42 U.S.C. 1395w-22(a)(3)), long-term care 

13 services or supports that— 

14 (1) the Secretary determines appropriate for 

15 the purposes of the CBI-SNP demonstration pro16 gram; and 

17 (2) for which payment may be made under the 

18 State plan under title XIX of such Act (42 U.S.C. 

19 1396 et seq.) of the State in which the targeted low20 income Medicare beneficiary is located. 

21 (c) ELIGIBLE PLANS.—To be eligible to participate 

22 in the CBI-SNP demonstration program, a specialized MA 

23 plan for special needs individuals must— 


smartinez on DSK6TPTVN1PROD with BILLS
295 

•S 1871 PCS

1 (1) serve special needs individuals (as defined 

2 in section 1859(b)(6)(B)(i) of the Social Security 

3 Act (42 U.S.C. 1395w–28(b)(6)(B)(i)); 

4 (2) have experience in offering special needs 

5 plans for nursing home-eligible, non-institutionalized 

6 Medicare beneficiaries who live in the community; 

7 (3) be located in a State that the Secretary has 

8 determined will participate in the CBI-SNP dem9 onstration program by agreeing to make available 

10 data necessary for purposes of conducting the inde11 pendent evaluation required under subsection (f); 

12 and 

13 (4) meet such other criteria as the Secretary 

14 may require. 

15 (d) TARGETED LOW-INCOME MEDICARE BENE16 FICIARY DEFINED.—In this section, the term ‘‘targeted 

17 low-income Medicare beneficiary’’ means a Medicare bene18 ficiary who— 

19 (1) is enrolled in a specialized MA plan for spe20 cial needs individuals that has been selected to par21 ticipate in the CBI-SNP demonstration program; 

22 (2) is a subsidy eligible individual (as defined in 

23 section 1860D–14(a)(3)(A) of the Social Security 

24 Act (42 U.S.C. 1395w-114(a)(3)(A)); and 


smartinez on DSK6TPTVN1PROD with BILLS
296 

•S 1871 PCS

1 (3) is unable to perform 2 or more activities of 

2 daily living (as defined in section 7702B(c)(2)(B) of 

3 the Internal Revenue Code of 1986). 

4 (e) IMPLEMENTATION DEADLINE; DURATION.—The 

5 CBI-SNP demonstration program shall be implemented 

6 not later than January 1, 2016, and shall be conducted 

7 for a period of 3 years. 

8 (f) INDEPENDENT EVALUATION AND REPORTS.— 

9 (1) INDEPENDENT EVALUATION.—Not later 

10 than 2 years after the completion of the CBI-SNP 

11 demonstration program, the Secretary shall provide 

12 for the evaluation of the CBI-SNP demonstration 

13 program by an independent third party. The evalua14 tion shall determine whether the CBI-SNP dem15 onstration program has improved patient care and 

16 quality of life for the targeted low-income Medicare 

17 beneficiaries participating in the CBI-SNP dem18 onstration program. Specifically, the evaluation shall 

19 determine if the CBI-SNP demonstration program 

20 has— 

21 (A) reduced hospitalizations or re-hos22 pitalizations; 

23 (B) reduced Medicaid nursing home facility 

24 stays; and 


smartinez on DSK6TPTVN1PROD with BILLS
297 

•S 1871 PCS

1 (C) reduced spenddown of income and as2 sets for purposes of becoming eligible for Med3 icaid. 

4 (2) REPORTS.—Not later than 3 years after the 

5 completion of the CBI-SNP demonstration program, 

6 the Secretary shall submit to Congress a report con7 taining the results of the evaluation conducted under 

8 paragraph (1), together with such recommendations 

9 for legislative or administrative action as the Sec10 retary determines appropriate. 

11 (g) FUNDING.— 

12 (1) FUNDING FOR IMPLEMENTATION.—For 

13 purposes of carrying out the demonstration program 

14 under this section (other than the evaluation and re15 port under subsection (f)), the Secretary shall pro16 vide for the transfer from the Federal Hospital In17 surance Trust Fund under section 1817 of the So18 cial Security Act (42 U.S.C. 1395i) and the Federal 

19 Supplementary Medical Insurance Trust Fund under 

20 section 1841 of such Act (42 U.S.C. 1395t), in such 

21 proportion as the Secretary determines appropriate, 

22 of $3,000,000 to the Centers for Medicare & Med23 icaid Services Program Management Account. 

24 (2) FUNDING FOR EVALUATION AND REPORT.— 

25 For purposes of carrying out the evaluation and reVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00297 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
298 

•S 1871 PCS

1 port under subsection (f), the Secretary shall provide 

2 for the transfer from the Federal Hospital Insurance 

3 Trust Fund under such section 1817 and the Fed4 eral Supplementary Medical Insurance Trust Fund 

5 under such section 1841, in such proportion as the 

6 Secretary determines appropriate, of $500,000. 

7 (3) AVAILABILITY.—Amounts transferred under 

8 paragraph (1) or (2) shall remain available until ex9 pended. 

10 (h) BUDGET NEUTRALITY.—In conducting the CBI11 SNP demonstration program, the Secretary shall ensure 

12 that the aggregate payments made by the Secretary do 

13 not exceed the amount which the Secretary estimates 

14 would have been expended under titles XVIII and XIX 

15 of the Social Security Act (42 U.S.C. 1395 et seq., 1396 

16 et seq.) if the CBI-SNP demonstration program had not 

17 been implemented. 

18 (i) PAPERWORK REDUCTION ACT.—Chapter 35 of 

19 title 44, United States Code, shall not apply to the testing 

20 and evaluation of the CBI-SNP demonstration program 

21 under this section. 


smartinez on DSK6TPTVN1PROD with BILLS
299 

•S 1871 PCS

1 SEC. 251. APPLYING CMMI WAIVER AUTHORITY TO PACE IN 

2 ORDER TO FOSTER INNOVATIONS. 

3 (a) CMMI WAIVER AUTHORITY.—Subsection (d)(1) 

4 of section 1115A of the Social Security Act (42 U.S.C. 

5 1315a) is amended— 

6 (1) by inserting ‘‘(other than subsections 

7 (b)(1)(A) and (c)(5) of section 1894)’’ after 

8 ‘‘XVIII’’; and 

9 (2) by striking ‘‘and 1903(m)(2)(A)(iii)’’ and 

10 inserting ‘‘1903(m)(2)(A)(iii), and 1934 (other than 

11 subsections (b)(1)(A) and (c)(5) of such section)’’. 

12 (b) SENSE OF THE SENATE.—It is the sense of the 

13 Senate that the Secretary of Health and Human Services 

14 should use the waiver authority provided under the 

15 amendments made by this section to provide, in a budget 

16 neutral manner, programs of all-inclusive care for the el17 derly (PACE programs) with increased operational flexi18 bility to support the ability of such programs to improve 

19 and innovate and to reduce technical and administrative 

20 barriers that have hindered enrollment in such programs. 

21 SEC. 252. IMPROVE AND MODERNIZE MEDICAID DATA SYS22 TEMS AND REPORTING. 

23 (a) IN GENERAL.—The Secretary of Health and 

24 Human Services shall implement a strategic plan to in25 crease the usefulness of data about State Medicaid pro26 grams reported by States to the Centers for Medicare & 


smartinez on DSK6TPTVN1PROD with BILLS
300 

•S 1871 PCS

1 Medicaid Services. The strategic plan shall address 

2 redundancies and gaps in Medicaid data systems and re3 porting through improvements to, and modernization of, 

4 computer and data systems. Areas for improvement under 

5 the plan shall include (but not be limited to) the following: 

6 (1) The reporting of encounter data by man7 aged care plans. 

8 (2) The timeliness and quality of reported data, 

9 including enrollment data. 

10 (3) The consistency of data reported from mul11 tiple sources. 

12 (4) Information about State program policies. 

13 (b) IMPLEMENTATION STATUS REPORT.—Not later 

14 than 1 year after the date of enactment of this Act, the 

15 Secretary of Health and Human Services shall submit a 

16 report to Congress on the status of the implementation 

17 of the strategic plan required under subsection (a). 

18 (c) AUTHORIZATION OF APPROPRIATIONS.—There is 

19 authorized to be appropriated to the Secretary of Health 

20 and Human Services for the period of fiscal years 2015 

21 through 2109, such sums as may be necessary to carry 

22 out this section. 


smartinez on DSK6TPTVN1PROD with BILLS
301 

•S 1871 PCS

1 SEC. 253. FAIRNESS IN MEDICAID SUPPLEMENTAL NEEDS 

2 TRUSTS. 

3 (a) IN GENERAL.—Section 1917(d)(4)(A) of the So4 cial Security Act (42 U.S.C. 1396p(d)(4)(A)) is amended 

5 by inserting ‘‘the individual,’’ after ‘‘for the benefit of such 

6 individual by’’. 

7 (b) EFFECTIVE DATE.—The amendment made by 

8 subsection (a) shall apply to trusts established on or after 

9 the date of the enactment of this Act. 

10 SEC. 254. HELPING ENSURE LIFE- AND LIMB-SAVING AC11 CESS TO PODIATRIC PHYSICIANS. 

12 (a) INCLUDING PODIATRISTS AS PHYSICIANS UNDER

13 THE MEDICAID PROGRAM.— 

14 (1) IN GENERAL.—Section 1905(a)(5)(A) of the 

15 Social Security Act (42 U.S.C. 1396d(a)(5)(A)) is 

16 amended by striking ‘‘section 1861(r)(1)’’ and in17 serting ‘‘paragraphs (1) and (3) of section 1861(r)’’. 

18 (2) EFFECTIVE DATE.— 

19 (A) IN GENERAL.—Except as provided in 

20 subparagraph (B), the amendment made by 

21 paragraph (1) shall apply to services furnished 

22 on or after the date of enactment of this Act. 

23 (B) EXTENSION OF EFFECTIVE DATE FOR

24 STATE LAW AMENDMENT.—In the case of a 

25 State plan under title XIX of the Social Secu26 rity Act (42 U.S.C. 1396 et seq.) which the 


smartinez on DSK6TPTVN1PROD with BILLS
302 

•S 1871 PCS

1 Secretary of Health and Human Services deter2 mines requires State legislation in order for the 

3 plan to meet the additional requirement im4 posed by the amendment made by paragraph 

5 (1), the State plan shall not be regarded as fail6 ing to comply with the requirements of such 

7 title solely on the basis of its failure to meet 

8 these additional requirements before the first 

9 day of the first calendar quarter beginning after 

10 the close of the first regular session of the 

11 State legislature that begins after the date of 

12 enactment of this Act. For purposes of the pre13 vious sentence, in the case of a State that has 

14 a 2-year legislative session, each year of the ses15 sion is considered to be a separate regular ses16 sion of the State legislature. 

17 (b) MODIFICATIONS TO REQUIREMENTS FOR DIA18 BETIC SHOES TO BE INCLUDED UNDER MEDICAL AND

19 OTHER HEALTH SERVICES UNDER MEDICARE.— 

20 (1) IN GENERAL.—Section 1861(s)(12) of the 

21 Social Security Act (42 U.S.C. 1395x(s)(12)) is 

22 amended to read as follows: 

23 ‘‘(12) subject to section 4072(e) of the Omni24 bus Budget Reconciliation Act of 1987, extra-depth 

25 shoes with inserts or custom molded shoes (in this 


smartinez on DSK6TPTVN1PROD with BILLS
303 

•S 1871 PCS

1 paragraph referred to as ‘therapeutic shoes’) with 

2 inserts for an individual with diabetes, if— 

3 ‘‘(A) the physician who is managing the in4 dividual’s diabetic condition— 

5 ‘‘(i) documents that the individual has 

6 diabetes; 

7 ‘‘(ii) certifies that the individual is 

8 under a comprehensive plan of care related 

9 to the individual’s diabetic condition; and 

10 ‘‘(iii) documents agreement with the 

11 prescribing podiatrist or other qualified 

12 physician (as established by the Secretary) 

13 that it is medically necessary for the indi14 vidual to have such extra-depth shoes with 

15 inserts or custom molded shoes with in16 serts; 

17 ‘‘(B) the therapeutic shoes are prescribed 

18 by a podiatrist or other qualified physician (as 

19 established by the Secretary) who— 

20 ‘‘(i) examines the individual and de21 termines the medical necessity for the indi22 vidual to receive the therapeutic shoes; and 

23 ‘‘(ii) communicates in writing the 

24 medical necessity to the physician de25 scribed in subparagraph (A) for the indiVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00303 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
304 

•S 1871 PCS

1 vidual to have therapeutic shoes along with 

2 findings that the individual has peripheral 

3 neuropathy with evidence of callus forma4 tion, a history of pre-ulcerative calluses, a 

5 history of previous ulceration, foot deform6 ity, previous amputation, or poor circula7 tion; and 

8 ‘‘(C) the therapeutic shoes are fitted and 

9 furnished by a podiatrist or other qualified sup10 plier (as established by the Secretary), such as 

11 a pedorthist or orthotist, who is not the physi12 cian described in subparagraph (A) (unless the 

13 Secretary finds that the physician is the only 

14 such qualified individual in the area);’’. 

15 (2) EFFECTIVE DATE.—The amendment made 

16 by paragraph (1) shall apply with respect to items 

17 and services furnished on or after January 1, 2015. 

18 SEC. 255. DEMONSTRATION PROGRAM TO IMPROVE COM19 MUNITY MENTAL HEALTH SERVICES. 

20 (a) ESTABLISHMENT.—Not later than January 1, 

21 2016, the Secretary of Health and Human Services (re22 ferred to in this section as the ‘‘Secretary’’), in coordina23 tion with the Administrator of the Substance Abuse and 

24 Mental Health Services Administration, shall award plan25 ning grants to not to exceed 10 States to enable such 


smartinez on DSK6TPTVN1PROD with BILLS
305 

•S 1871 PCS

1 States to carry out 5-year demonstration programs to im2 prove the provision of behavioral health services provided 

3 by certified community behavioral health clinics in the 

4 State. 

5 (b) ELIGIBILITY.— 

6 (1) APPLICATION.—To be eligible to receive a 

7 grant under subsection (a), a State shall— 

8 (A) submit to the Secretary an application 

9 at such time, in such manner, and containing 

10 such information as the Secretary may require; 

11 (B) certify to the Secretary that behavioral 

12 health providers that are provided assistance 

13 under the demonstration program meet the cri14 teria for certified community behavioral health 

15 clinics under subsection (c); 

16 (C) conduct a financial assessment of the 

17 demonstration program to be carried out under 

18 the grant by providing a detailed estimate of el19 igible clinics and Medicaid expenditures over 

20 the entire projected period of the demonstration 

21 program; and 

22 (D) comply with any other requirement de23 termined appropriate by the Secretary. 

24 (2) WAIVER OF MEDICAID REQUIREMENT.—In 

25 approving States to conduct demonstration programs 


smartinez on DSK6TPTVN1PROD with BILLS
306 

•S 1871 PCS

1 under this section, the Secretary shall waive section 

2 1902(a)(1) of the Social Security Act (42 U.S.C. 

3 1396a(a)(1)) (relating to statewideness) as may be 

4 necessary to conduct the demonstration program in 

5 accordance with the requirements of this section 

6 (c) CRITERIA.— 

7 (1) CRITERIA FOR CERTIFIED COMMUNITY BE8 HAVIORAL HEALTH CLINICS.—The criteria referred 

9 to in subsection (b)(1)(B) are that the center per10 forms each of the following: 

11 (A) Provide services in locations that en12 sure services will be available and accessible 

13 promptly and in a manner which preserves 

14 human dignity and assures continuity of care. 

15 (B) Provide services in a mode of service 

16 delivery appropriate for the target population. 

17 (C) Provide individuals with a choice of 

18 service options, including developmentally ap19 propriate evidence based interventions, where 

20 there is more than one efficacious treatment. 

21 (D) Employ a core clinical staff that is 

22 trained to provide evidence-based practices and 

23 is multidisciplinary and culturally and linguis24 tically competent, including the availability of 

25 translation or similar services and arrangeVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00306 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
307 

•S 1871 PCS

1 ments if the clinic is located in a geographic 

2 area of limited English-speaking ability. 

3 (E) Establish an emergency plan to sup4 port continuity of services for individuals during 

5 an emergency or disaster. 

6 (F) Demonstrate the capacity to comply 

7 with behavioral health and related health care 

8 quality measures promulgated by such entities 

9 as the National Quality Forum, the National 

10 Committee for Quality Assurance, or other na11 tionally recognized accrediting bodies. 

12 (G) Provide services to any individual re13 siding or employed in the service area of the 

14 clinic and ensure that no patient or consumer 

15 will be denied mental health or other health 

16 care services due to an individual’s inability to 

17 pay for such services. 

18 (H) Ensure that any fees or payments re19 quired by the clinic for such services will be im20 posed for individuals eligible for medical assist21 ance under the State Medicaid plan under title 

22 XIX of the Social Security Act in accordance 

23 with the requirements of such State plan and 

24 for any other individuals will be reduced or 

25 waived to enable the clinic to comply with subVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00307 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
308 

•S 1871 PCS

1 paragraph (G), including preparing a schedule 

2 of fees or payments for the provision of services 

3 that is consistent with locally prevailing rates or 

4 charges designed to cover the reasonable costs 

5 to the clinic of operation along with a cor6 responding schedule of discounts to be applied 

7 to the payment of such fees or payments, such 

8 discounts to be adjusted on the basis of the pa9 tient’s ability to pay. 

10 (I) Report required encounter data, clinical 

11 outcomes data, and quality data. 

12 (J) Provide, directly or through contract, 

13 to the extent covered for adults in the State 

14 Medicaid plan under title XIX of the Social Se15 curity Act and for children in accordance with 

16 section 1905(r) of such Act regarding early and 

17 periodic screening, diagnosis, and treatment, 

18 each of the following services: 

19 (i) Screening, assessment, and diag20 nosis, including risk assessment. 

21 (ii) Person-centered treatment plan22 ning or similar processes, including risk as23 sessment and crisis planning. 

24 (iii) Outpatient mental health and 

25 substance use services, including screening, 


smartinez on DSK6TPTVN1PROD with BILLS
309 

•S 1871 PCS

1 assessment, diagnosis, psychotherapy, cog2 nitive behavioral therapy, applied behav3 ioral analysis, medication management, 

4 and integrated treatment for trauma, men5 tal illness, and substance abuse which shall 

6 be evidence-based (including cognitive be7 havioral therapy, long acting injectable 

8 medications, and other such therapies 

9 which are evidence-based). 

10 (iv) Outpatient clinic primary care 

11 screening and monitoring of key health in12 dicators and health risk (including screen13 ing for diabetes, hypertension, and cardio14 vascular disease and monitoring of weight, 

15 height, body mass index (BMI), blood pres16 sure, blood glucose or HbA1C, and lipid 

17 profile). 

18 (v) Crisis mental health services, in19 cluding 24-hour mobile crisis teams, emer20 gency crisis intervention services, and cri21 sis stabilization. 

22 (vi) Targeted case management (serv23 ices to assist individuals gaining access to 

24 needed medical, social, educational, and 

25 other services and applying for income seVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00309 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
310 

•S 1871 PCS

1 curity and other benefits to which they 

2 may be entitled), and care coordination. 

3 (vii) Psychiatric rehabilitation services 

4 including skills training, assertive commu5 nity treatment, family psychoeducation, 

6 disability self-management, supported em7 ployment, supported housing services, 

8 therapeutic foster care services, and such 

9 other evidence-based practices as the Sec10 retary may require. 

11 (viii) Peer support and counselor serv12 ices and family supports. 

13 (K) Maintain linkages, and where possible 

14 enter into formal contracts, agreements, or 

15 partnerships with at least one federally quali16 fied health center, unless there is no such cen17 ter serving the service area, in order to ensure 

18 that the delivery of behavioral health care is in19 tegrated with primary and preventive care serv20 ices, so long as such linkages, contract, agree21 ment, or partnership meets requirements as 

22 prescribed by the Secretary; 

23 (L) Maintain additional linkages and 

24 where possible enter into formal contracts with 

25 the following: 


smartinez on DSK6TPTVN1PROD with BILLS
311 

•S 1871 PCS

1 (i) Inpatient psychiatric facilities and 

2 substance use detoxification, post-detoxi3 fication step-down services, and residential 

4 programs. 

5 (ii) Adult and youth peer support and 

6 counselor services. 

7 (iii) Family support services for fami8 lies of children with serious mental or sub9 stance use disorders. 

10 (iv) Other community or regional 

11 services, supports, and providers, including 

12 schools, child welfare agencies, juvenile and 

13 criminal justice agencies and facilities, In14 dian Health Service youth regional treat15 ment centers, housing agencies and pro16 grams, employers, State licensed and na17 tionally accredited child placing agencies 

18 for therapeutic foster care service, and 

19 other social and human services. 

20 (v) Onsite or offsite access to primary 

21 care services. 

22 (vi) Enabling services, including out23 reach, transportation, and translation. 

24 (vii) Health and wellness services, in25 cluding services for tobacco cessation. 


smartinez on DSK6TPTVN1PROD with BILLS
312 

•S 1871 PCS

1 (viii) Department of Veterans Affairs 

2 medical centers, independent outpatient 

3 clinics, drop-in centers, and other facilities 

4 of the Department as defined in section 

5 1801 of title 38, United States Code. 

6 (ix) Inpatient acute care hospitals and 

7 hospital outpatient clinics. 

8 (M) Where feasible, provide outreach and 

9 engagement to encourage individuals who could 

10 benefit from mental health care to freely par11 ticipate in receiving the administrative services 

12 described in this subsection. 

13 (N) Where feasible, provide intensive, com14 munity-based mental health care for members 

15 of the armed forces and veterans, particularly 

16 those members and veterans located in rural 

17 areas, such care to be consistent with minimum 

18 clinical mental health guidelines promulgated by 

19 the Veterans Health Administration including 

20 clinical guidelines contained in the Uniform 

21 Mental Health Services Handbook of such Ad22 ministration. 

23 (O) Where feasible, require certified com24 munity behavioral health clinics to provide valid 

25 and reliable trauma screening and functional or 


smartinez on DSK6TPTVN1PROD with BILLS
313 

•S 1871 PCS

1 developmental assessment to determine need, 

2 match services to needs, and to measure 

3 progress over time. 

4 (2) REGULATIONS.—Prior to the selection of 

5 participating States, and not later than 18 months 

6 after the date of the enactment of this Act, the Sec7 retary, in consultation with the Substance Abuse 

8 and Mental Health Services Administration and the 

9 State Mental Health and Substance Abuse Authori10 ties, shall issue final regulations for certifying non11 profit and local government behavioral health au12 thorities and Indian Health Service tribal facilities 

13 as community behavioral health clinics. 

14 (d) REQUIREMENTS.—In awarding grants under this 

15 section, the Secretary shall— 

16 (1) ensure the geographic diversity of grantee 

17 States; 

18 (2) ensure that certified community behavioral 

19 health clinics in such States that are located in rural 

20 areas, as defined by the Secretary, and other mental 

21 health professional shortage areas are fairly and ap22 propriately considered with the objective of facili23 tating access to mental health services in such areas; 

24 (3) take into account the ability of clinics in 

25 such States to provide required services, and the 


smartinez on DSK6TPTVN1PROD with BILLS
314 

•S 1871 PCS

1 ability of such clinics to report required data as re2 quired under this section; and 

3 (4) take into account the ability of such States 

4 to provide such required services on a statewide 

5 basis. 

6 (e) EXEMPTION.—For purposes of this section, cer7 tified community behavioral health clinics that receive pay8 ments under section 1902(bb) of the Social Security Act 

9 which are located in rural areas, as defined by the Sec10 retary, shall be exempt from the requirements contained 

11 in subparagraphs (A) and (J)(v) of subsection (c)(1). 

12 (f) TREATMENT OF CERTAIN SERVICES PROVIDED

13 BY COMMUNITY BEHAVIORAL HEALTH CLINICS AS MED14 ICAL ASSISTANCE.— 

15 (1) IN GENERAL.—For purposes of the dem16 onstration program under this section, community 

17 behavioral health clinic services (as defined in sub18 section (h)(1)) that are provided by certified commu19 nity behavioral health clinics receiving assistance 

20 under this section shall be considered medical assist21 ance for purposes of payments to States under para22 graph (3)(C). 

23 (2) GRANT CONDITION.—As a condition of re24 ceiving a grant under this section, a State shall 

25 agree to provide for payment for community behavVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00314 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
315 

•S 1871 PCS

1 ioral health clinic services in accordance with the 

2 prospective payment system established by the Sec3 retary under paragraph (3). 

4 (3) PROSPECTIVE PAYMENT SYSTEM.— 

5 (A) IN GENERAL.—Not later than 18 

6 months after the date of enactment of this Act, 

7 the Secretary shall establish a prospective pay8 ment system for community behavioral health 

9 clinic services furnished by a community behav10 ioral health clinic receiving assistance under 

11 this section in the same manner as payments 

12 are required to be made under section 1902(bb) 

13 of the Social Security Act (42 U.S.C. 

14 1396a(bb)) for services described in section 

15 1905(a)(2)(C) of such Act (42 U.S.C. 

16 1396d(a)(2)(C)) furnished by a Federally-quali17 fied health center and services described in sec18 tion 1905(a)(2)(B) of such Act (42 U.S.C. 

19 1396d(a)(2)(B)) furnished by a rural health 

20 clinic. 

21 (B) REQUIREMENTS.—The prospective 

22 payment system established by the Secretary 

23 under subparagraph (A) shall provide that— 

24 (i) no payment shall be made for in25 patient care, residential treatment, room 


smartinez on DSK6TPTVN1PROD with BILLS
316 

•S 1871 PCS

1 and board expenses, or any other non-am2 bulatory services, as determined by the 

3 Secretary; and 

4 (ii) no payment shall be made to sat5 ellite facilities of community behavioral 

6 health clinics if such facilities are estab7 lished after the date of enactment of this 

8 Act. 

9 (C) PAYMENTS TO STATES.—The Sec10 retary shall pay each State awarded a grant 

11 under this section an amount each quarter 

12 equal to the enhanced FMAP (as defined in 

13 section 2105(b) of the Social Security Act (42 

14 U.S.C. 1397dd(b)) but without regard to the 

15 second and third sentences of that section) of 

16 the State’s expenditures in the quarter for med17 ical assistance for community behavioral health 

18 clinic services provided by certified community 

19 behavioral health clinics in the State that re20 ceive assistance under this section. Payments to 

21 States made under this subparagraph shall be 

22 considered to have been under, and are subject 

23 to the requirements of, section 1903 of the So24 cial Security Act (42 U.S.C. 1396b). 

25 (g) ANNUAL REPORT.— 


smartinez on DSK6TPTVN1PROD with BILLS
317 

•S 1871 PCS

1 (1) IN GENERAL.—Not later than 1 year after 

2 the date on which the first grants are awarded 

3 under this section, and annually thereafter, the Sec4 retary shall submit to Congress an annual report on 

5 the use of funds provided under the demonstration 

6 program. Each such report shall include— 

7 (A) an assessment of access to community8 based mental health services under the Med9 icaid program in the States awarded such 

10 grants; 

11 (B) an assessment of the quality and scope 

12 of services provided by certified community be13 havioral health clinics under the grants as com14 pared against community-based mental health 

15 services provided in States that are not receiv16 ing such grants; and 

17 (C) an assessment of the impact of the 

18 demonstration programs on the costs of a full 

19 range of mental health services (including inpa20 tient, emergency and ambulatory services). 

21 (2) RECOMMENDATIONS.—Not later than De22 cember 31, 2019, the Secretary shall submit to Con23 gress recommendations concerning whether the dem24 onstration programs under this section should be 

25 continued and expanded on a national basis. 


smartinez on DSK6TPTVN1PROD with BILLS
318 

•S 1871 PCS

1 (h) DEFINITIONS.—In this section: 

2 (1) COMMUNITY BEHAVIORAL HEALTH CLINIC

3 SERVICES.—The term ‘‘community behavioral health 

4 clinic services’’ means ambulatory behavioral health 

5 services of the type described in subparagraphs (J), 

6 (M), (N), and (O) of subsection (c)(1) that are pro7 vided by certified community behavioral health clin8 ics receiving assistance under this section. 

9 (2) STATE.—The term ‘‘State’’ has the mean10 ing given such term for purposes of title XIX of the 

11 Social Security Act (42 U.S.C. 1396 et seq.). 

12 (i) AUTHORIZATION OF APPROPRIATIONS.—There is 

13 authorized to be appropriated to carry out this section, 

14 $50,000,000 for fiscal year 2016, to remain available until 

15 expended. 

16 SEC. 256. ANNUAL MEDICAID DSH REPORT. 

17 Section 1923 of the Social Security Act (42 U.S.C. 

18 1396r–4) is amended by adding at the end the following: 

19 ‘‘(k) ANNUAL REPORT TO CONGRESS.— 

20 ‘‘(1) IN GENERAL.—Beginning January 1, 

21 2015, and annually thereafter, the Secretary shall 

22 submit a report to Congress on the program estab23 lished under this section for making payment adjust24 ments to disproportionate share hospitals for the 

25 purpose of providing Congress with information relVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00318 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
319 

•S 1871 PCS

1 evant to determining an appropriate level of overall 

2 funding for such payment adjustments during and 

3 after the period in which aggregate reductions in the 

4 DSH allotments to States are required under para5 graphs (7) and (8) of subsection (f). 

6 ‘‘(2) REQUIRED REPORT INFORMATION.—Ex7 cept as otherwise provided, each report submitted 

8 under this subsection shall include the following: 

9 ‘‘(A) Information and data relating to 

10 changes in the number of uninsured individuals 

11 for the most recent year for which such data 

12 are available as compared to 2013 and as com13 pared to the Congressional Budget Office esti14 mates of uninsured individuals made at the 

15 time of the enactment of the Patient Protection 

16 and Affordable Care Act (Public Law 111–148) 

17 and the Health Care and Education Reconcili18 ation Act of 2010 (Public Law 111–152). 

19 ‘‘(B) Information and data relating to the 

20 extent to which hospitals continue to incur un21 compensated care costs from providing unreim22 bursed or under-reimbursed services to individ23 uals who either are eligible for medical assist24 ance under the State plan under this title or 

25 under a waiver of such plan or who have no 


smartinez on DSK6TPTVN1PROD with BILLS
320 

•S 1871 PCS

1 health insurance (or other source of third party 

2 coverage) for such services. 

3 ‘‘(C) Information and data relating to the 

4 extent to which hospitals continue to provide 

5 charity care and unreimbursed or under-reim6 bursed services, or otherwise incur bad debt, 

7 under the program established under this title, 

8 the State Children’s Health Insurance Program 

9 established under title XXI, and State or local 

10 indigent care programs, as reported on cost re11 ports submitted under title XVIII or such other 

12 data as the Secretary determines appropriate. 

13 ‘‘(D) In the first report submitted under 

14 this section, a methodology for estimating the 

15 amount of unpaid patient deductibles, copay16 ments and coinsurance incurred by hospitals for 

17 patients enrolled in qualified health plans 

18 through an American Health Benefits Ex19 change, using existing data and minimizing the 

20 administrative burden on hospitals to the extent 

21 possible, and in subsequent reports, data re22 garding such uncompensated care costs col23 lected pursuant to such methodology. 

24 ‘‘(E) For each State, information and data 

25 relating to the difference between the DSH alVerDate Mar 15 2010 04:24 Dec 20, 2013 Jkt 039200 PO 00000 Frm 00320 Fmt 6652 Sfmt 6201 E:\BILLS\S1871.PCS S1871

smartinez on DSK6TPTVN1PROD with BILLS
321 

•S 1871 PCS

1 lotment for the State for the fiscal year that 

2 began on October 1 of the year preceding the 

3 year in which the report is submitted and the 

4 aggregate amount of uncompensated care costs 

5 for all disproportionate share hospitals in the 

6 State. 

7 ‘‘(F) Information and data relating to the 

8 extent to which there are certain vital hospital 

9 systems that are disproportionately experiencing 

10 high levels of uncompensated care and that 

11 have multiple other missions, such as a commit12 ment to graduate medical education, the provi13 sion of tertiary and trauma care services, pro14 viding public health and essential community 

15 services, and providing comprehensive, coordi16 nated care. 

17 ‘‘(G) Such other information and data rel18 evant to the determination of the level of fund19 ing for, and amount of, State DSH allotments 

20 as the Secretary determines appropriate 

21 ‘‘(3) AUTHORIZATION OF APPROPRIATIONS.— 

22 There is authorized to be appropriated to the Sec23 retary for the period of fiscal years 2015 through 

24 2109, such sums as may be necessary to carry out 

25 this subsection.’’. 


smartinez on DSK6TPTVN1PROD with BILLS
322 

•S 1871 PCS

1 SEC. 257. IMPLEMENTATION. 

2 To the extent the Secretary of Health and Human 

3 Services issues a regulation to carry out the provisions of 

4 this Act, the Secretary shall, unless otherwise specified in 

5 this Act— 

6 (1) issue a notice of proposed rulemaking that 

7 includes the proposed regulation; 

8 (2) provide a period of not less than 60 cal9 endar days for comments on the proposed regula10 tion; 

11 (3) not more than 24 months following the date 

12 of publication of the proposed rule, publish the final 

13 regulation or take alternative action (such as with14 drawing the rule or proposing a revised rule with a 

15 new comment period) on the proposed regulation; 

16 and 

17 (4) not less than 30 days before the effective 

18 date of the final regulation, publish the final regula19 tion or take alternative action (such as withdrawing 

20 the rule or proposing a revised rule with a new com21 ment period) on the proposed regulation. 


smartinez on DSK6TPTVN1PROD with BILLS

smartinez on DSK6TPTVN1PROD with BILLS
Calendar No. 280 

113TH CONGRESS 

1ST SESSION S. 1871 

A BILL 

To amend title XVIII of the Social Security Act to 

Medicare program, and for other purposes. mula and to improve beneficiary access under the repeal the Medicare sustainable growth rate forDECEMBER 19, 2013 

Read twice and placed on the calendar 


smartinez on DSK6TPTVN1PROD with BILLS