I 

116TH CONGRESS 

1ST SESSION H. R. 3417 

To amend title XVIII of the Social Security Act to provide for patient 

improvements and rural and quality improvements under the Medicare 

program. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 21, 2019 

Mr. NEAL (for himself and Mr. BRADY) introduced the following bill; which 

was referred to the Committee on Ways and Means, and in addition to 

the Committee on Energy and Commerce, for a period to be subsequently 

determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend title XVIII of the Social Security Act to provide 

for patient improvements and rural and quality improvements under the Medicare program. 

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 ‘‘Beneficiary Education Tools, Telehealth, and Extenders 

6 Reauthorization Act of 2019’’ or the ‘‘BETTER Act of 

7 2019’’. 


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

2 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—PATIENT IMPROVEMENTS 

Sec. 101. Beneficiary enrollment notification and eligibility simplification. 

Sec. 102. Extension of funding outreach and assistance for low-income programs. 

Sec. 103. Medicare coverage of certain mental health telehealth services. 

Sec. 104. Requiring prescription drug plan sponsors to include real-time benefit 

information as part of such sponsor’s electronic prescription 

program under the Medicare program. 

Sec. 105. Transitional coverage and retroactive Medicare part D coverage for 

certain low-income beneficiaries. 

TITLE II—RURAL AND QUALITY IMPROVEMENTS 

Sec. 201. Medicare GME treatment of hospitals establishing new medical residency training programs after hosting medical resident rotators 

for short durations. 

Sec. 202. Extension of the work geographic index floor under the Medicare program. 

Sec. 203. Extension of funding for quality measure endorsement, input, and selection under Medicare program. 

Sec. 204. Improving measurements under the skilled nursing facility valuebased purchasing program under the Medicare program. 

3 TITLE I—PATIENT 

4 IMPROVEMENTS 

5 SEC. 101. BENEFICIARY ENROLLMENT NOTIFICATION AND 

6 ELIGIBILITY SIMPLIFICATION. 

7 (a) ELIGIBILITY AND ENROLLMENT NOTICES.— 

8 (1) AS PART OF SOCIAL SECURITY ACCOUNT

9 STATEMENT FOR INDIVIDUALS ATTAINING AGES 63

10 TO 65.—Section 1143(a) of the Social Security Act 

11 (42 U.S.C. 1320b–13(a)) is amended by adding at 

12 the end the following new paragraph: 

13 ‘‘(4) MEDICARE ELIGIBILITY INFORMATION.— 


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1 ‘‘(A) IN GENERAL.—In the case of statements 

2 provided on or after the date that is 2 years after 

3 the date of the enactment of this paragraph to indi4 viduals who are attaining ages 63, 64, and 65, the 

5 statement shall also include a notice containing the 

6 information described in subparagraph (B). 

7 ‘‘(B) CONTENTS OF NOTICE.—The notice re8 quired under subparagraph (A) shall include a clear, 

9 simple explanation of— 

10 ‘‘(i) eligibility for benefits under the Medi11 care program under title XVIII, and in par12 ticular benefits under part B of such title; 

13 ‘‘(ii) the reasons a late enrollment penalty 

14 for failure to timely enroll could be assessed 

15 and how such late enrollment penalty is cal16 culated, in particular for benefits under part B; 

17 ‘‘(iii) the availability of relief from the late 

18 enrollment penalty and retroactive enrollment 

19 under section 1837(h) (including as such sec20 tion is applied under sections 1818(c) and 

21 1818A(c)(3)), with examples of circumstances 

22 under which such relief may be granted and ex23 amples of circumstances under which such relief 

24 would not be granted; 


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1 ‘‘(iv) the need for coordination of benefits 

2 (including primary and secondary coverage sce3 narios) pursuant to section 1862, in particular 

4 for benefits under part B of such title; and 

5 ‘‘(v) populations, such as residents of 

6 Puerto Rico and veterans, for whom there are 

7 special considerations with respect to enroll8 ment under title XVIII. 

9 ‘‘(C) DEVELOPMENT OF NOTICE.— 

10 ‘‘(i) IN GENERAL.—The Secretary, in co11 ordination with the Commissioner of Social Se12 curity, and taking into consideration informa13 tion collected pursuant to clause (ii), shall, not 

14 later than 12 months after the last day of the 

15 period for the request of information described 

16 in clause (ii), develop the notice to be provided 

17 pursuant to subparagraph (A). 

18 ‘‘(ii) REQUEST FOR INFORMATION.—Not 

19 later than 6 months after the date of the enact20 ment of this paragraph, the Secretary shall re21 quest written information, including rec22 ommendations, from stakeholders (including the 

23 groups described in subparagraph (D)) on the 

24 information to be included in the notice. 


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1 ‘‘(iii) NOTICE IMPROVEMENT.—Beginning 

2 4 years after the date of enactment of this 

3 paragraph, and not less than once every two 

4 years thereafter, the Secretary, in coordination 

5 with the Commissioner of Social Security, 

6 shall— 

7 ‘‘(I) review the content of the notice 

8 to be provided under subparagraph (A); 

9 ‘‘(II) solicit recommendations on the 

10 notice through a request for information 

11 process as described in clause (ii); and 

12 ‘‘(III) update and revise such notice 

13 as the Secretary deems appropriate. 

14 ‘‘(D) GROUPS FOR CONSULTATION.—For pur15 poses of subparagraph (C)(ii), the groups described 

16 in this clause include the following: 

17 ‘‘(i) Individuals who are 60 years of age or 

18 older. 

19 ‘‘(ii) Veterans. 

20 ‘‘(iii) Individuals with disabilities. 

21 ‘‘(iv) Individuals with end stage renal dis22 ease. 

23 ‘‘(v) Low-income individuals and families. 

24 ‘‘(vi) Employers (including human re25 sources professionals). 


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1 ‘‘(vii) States (including representatives of 

2 State-run Health Insurance Exchanges, Med3 icaid offices, and Departments of Insurance). 

4 ‘‘(viii) State Health Insurance Assistance 

5 Programs. 

6 ‘‘(ix) Health insurers. 

7 ‘‘(x) Health insurance agents and brokers. 

8 ‘‘(xi) Such other groups as specified by the 

9 Secretary. 

10 ‘‘(E) POSTING OF NOTICE ON WEBSITES.—The 

11 Commissioner of Social Security and the Secretary 

12 shall ensure that the notice being used under sub13 paragraph (A) is posted in a prominent location on 

14 the public Internet website of the Social Security 

15 Administration and on the public Internet website of 

16 the Centers for Medicare & Medicaid Services, re17 spectively. 

18 ‘‘(F) REIMBURSEMENT OF COSTS.— 

19 ‘‘(i) IN GENERAL.—Effective for fiscal 

20 years beginning in the year in which the date 

21 of enactment of this paragraph occurs, the 

22 Commissioner of Social Security and the Sec23 retary shall enter into an agreement which shall 

24 provide funding to cover the administrative 


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1 costs of the Commissioner’s activities under this 

2 paragraph. Such agreement shall— 

3 ‘‘(I) provide funds to the Commis4 sioner for the full cost of the Social Secu5 rity Administration’s work related to the 

6 implementation of this paragraph, includ7 ing any initial costs incurred prior to the 

8 finalization of such agreement; 

9 ‘‘(II) provide such funding quarterly 

10 in advance of the applicable quarter based 

11 on estimating methodology agreed to by 

12 the Commissioner and the Secretary; and 

13 ‘‘(III) require an annual accounting 

14 and reconciliation of the actual costs in15 curred and funds provided under this para16 graph. 

17 ‘‘(ii) LIMITATION.—In no case shall funds 

18 from the Social Security Administration’s Limi19 tation on Administrative Expenses be used to 

20 carry out activities related to the implementa21 tion of this paragraph. 

22 ‘‘(G) NO EFFECT ON OBLIGATION TO MAIL

23 STATEMENTS.—Nothing in this paragraph shall be 

24 construed to relieve the Commissioner of Social Se25 curity from any requirement under subsection (c), 


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1 including the requirement to mail a statement on an 

2 annual basis to each eligible individual who is not re3 ceiving benefits under title II and for whom a mail4 ing address can be determined through such meth5 ods as the Commissioner determines to be appro6 priate.’’. 

7 (2) INDIVIDUALS IN MEDICARE WAITING PE8 RIOD.—Title XI of the Social Security Act (42 

9 U.S.C. 1301 et seq.) is amended by inserting after 

10 section 1144 the following new section: 

11 ‘‘MEDICARE ENROLLMENT NOTIFICATION AND ELIGI12 BILITY NOTICES FOR INDIVIDUALS IN MEDICARE

13 WAITING PERIOD

14 ‘‘Notices 

15 ‘‘SEC. 1144A. (a) 

16 ‘‘(1) IN GENERAL.—The Commissioner of So17 cial Security shall distribute the notice to be pro18 vided pursuant to section 1143(a)(4), as may be 

19 modified under paragraph (2), to individuals in the 

20 24-month waiting period under section 226(b). 

21 ‘‘(2) AUTHORITY TO MODIFY NOTICE.—The 

22 Secretary, in coordination with the Commissioner of 

23 Social Security, may modify the notice to be distrib24 uted under paragraph (1) as necessary to take into 

25 account the individuals described in such paragraph. 


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1 ‘‘(3) POSTING OF NOTICE ON WEBSITES.—The 

2 Commissioner of Social Security and the Secretary 

3 shall ensure that the notice being used under para4 graph (1) is posted in a prominent location on the 

5 public Internet website of the Social Security Ad6 ministration and on the public Internet website of 

7 the Centers for Medicare & Medicaid Services, re8 spectively. 

9 ‘‘Timing 

10 ‘‘(b) Beginning not later than 2 years after the date 

11 of the enactment of this section, a notice required under 

12 subsection (a)(1) shall be mailed to an individual no less 

13 than two times in accordance with the following: 

14 ‘‘(1) The notice shall be provided to such indi15 vidual not later than 3 months prior to the date on 

16 which such individual’s enrollment period begins as 

17 provided under section 1837. 

18 ‘‘(2) The notice shall subsequently be provided 

19 to such individual not later than one month prior to 

20 such date. 

21 ‘‘Reimbursement of Costs 

22 ‘‘(c) 

23 ‘‘(1) IN GENERAL.—Effective for fiscal years 

24 beginning in the year in which the date of enactment 

25 of this section occurs, the Commissioner of Social 


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1 Security and the Secretary shall enter into an agree2 ment which shall provide funding to cover the ad3 ministrative costs of the Commissioner’s activities 

4 under this section. Such agreement shall— 

5 ‘‘(A) provide funds to the Commissioner 

6 for the full cost of the Social Security Adminis7 tration’s work related to the implementation of 

8 this section, including any initial costs incurred 

9 prior to the finalization of such agreement; 

10 ‘‘(B) provide such funding quarterly in ad11 vance of the applicable quarter based on esti12 mating methodology agreed to by the Commis13 sioner and the Secretary; and 

14 ‘‘(C) require an annual accounting and 

15 reconciliation of the actual costs incurred and 

16 funds provided under this section. 

17 ‘‘(2) LIMITATION.—In no case shall funds from 

18 the Social Security Administration’s Limitation on 

19 Administrative Expenses be used to carry out activi20 ties related to the implementation of this section.’’. 

21 (b) BENEFICIARY ENROLLMENT SIMPLIFICATION.— 

22 (1) EFFECTIVE DATE OF COVERAGE.—Section 

23 1838(a) of the Social Security Act (42 U.S.C. 

24 1395q(a)) is amended— 


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1 (A) by amending paragraph (2) to read as 

2 follows: 

3 ‘‘(2)(A) in the case of an individual who enrolls 

4 pursuant to subsection (d) of section 1837 before 

5 the month in which he first satisfies paragraph (1) 

6 or (2) of section 1836, the first day of such month, 

7 ‘‘(B) in the case of an individual who first sat8 isfies such paragraph in a month beginning before 

9 January 2021 and who enrolls pursuant to such 

10 subsection (d)— 

11 ‘‘(i) in such month in which he first satis12 fies such paragraph, the first day of the month 

13 following the month in which he so enrolls, 

14 ‘‘(ii) in the month following such month in 

15 which he first satisfies such paragraph, the first 

16 day of the second month following the month in 

17 which he so enrolls, or 

18 ‘‘(iii) more than one month following such 

19 month in which he satisfies such paragraph, the 

20 first day of the third month following the 

21 month in which he so enrolls, 

22 ‘‘(C) in the case of an individual who first satis23 fies such paragraph in a month beginning on or 

24 after January 1, 2021, and who enrolls pursuant to 

25 such subsection (d) in such month in which he first 


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1 satisfies such paragraph or in any subsequent month 

2 of his initial enrollment period, the first day of the 

3 month following the month in which he so enrolls, or 

4 ‘‘(D) in the case of an individual who enrolls 

5 pursuant to subsection (e) of section 1837 in a 

6 month beginning— 

7 ‘‘(i) before January 1, 2021, the July 1 

8 following the month in which he so enrolls, or 

9 ‘‘(ii) on or after January 1, 2021, the first 

10 day of the month following the month in which 

11 he so enrolls, or’’; and 

12 (B) by amending paragraph (3) to read as 

13 follows: 

14 ‘‘(3) in the case of an individual who is deemed 

15 to have enrolled— 

16 ‘‘(A) on or before the last day of the third 

17 month of his initial enrollment period, the first 

18 day of the month in which he first meets the 

19 applicable requirements of section 1836 or July 

20 1, 1973, whichever is later, or 

21 ‘‘(B) on or after the first day of the fourth 

22 month of his initial enrollment period, and 

23 where such month begins— 

24 ‘‘(i) before January 1, 2021, as pre25 scribed under subparagraphs (B)(i), 


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1 (B)(ii), (B)(iii), and (D) of paragraph (2), 

2 or 

3 ‘‘(ii) on or after January 1, 2021, as 

4 prescribed under paragraph (2)(C).’’. 

5 (2) SPECIAL ENROLLMENT PERIODS FOR EX6 CEPTIONAL CIRCUMSTANCES.— 

7 (A) ENROLLMENT.—Section 1837 of the 

8 Social Security Act (42 U.S.C. 1395p) is 

9 amended by adding at the end the following 

10 new subsection: 

11 ‘‘(m) Beginning January 1, 2021, the Secretary may 

12 establish special enrollment periods in the case of individ13 uals who meet such exceptional conditions as the Secretary 

14 may provide, such as individuals who reside in an area 

15 with an emergency or disaster as determined by the Sec16 retary.’’. 

17 (B) COVERAGE PERIOD.—Section 1838 of 

18 the Social Security Act (42 U.S.C. 1395q) is 

19 amended by adding at the end the following 

20 new subsection: 

21 ‘‘(g) Notwithstanding subsection (a), in the case of 

22 an individual who enrolls during a special enrollment pe23 riod pursuant to section 1837(m), the coverage period 

24 shall begin on a date the Secretary provides in a manner 


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1 consistent (to the extent practicable) with protecting con2 tinuity of health benefit coverage.’’. 

3 (C) CONFORMING AMENDMENT.—Section 

4 1839(b) of the Social Security Act (42 U.S.C. 

5 1395r(b)) is amended, in the first sentence, by 

6 striking ‘‘or (l)’’ and inserting ‘‘, (l), or (m)’’. 

7 (3) TECHNICAL CORRECTION.—Section 1839(b) 

8 of the Social Security Act (42 U.S.C. 1395r(b)) is 

9 amended by adding at the end the following new 

10 sentence: ‘‘For purposes of determining any increase 

11 under this subsection for individuals whose enroll12 ment occurs on or after January 1, 2021, the second 

13 sentence of this subsection shall be applied by sub14 stituting ‘close of the month’ for ‘close of the enroll15 ment period’ each place it appears.’’. 

16 (4) REPORT.—Not later than January 1, 2021, 

17 the Secretary of Health and Human Services shall 

18 submit to the Committee on Ways and Means and 

19 Committee on Energy and Commerce of the House 

20 of Representatives and the Committee on Finance 

21 and Special Committee on Aging of the Senate a re22 port including recommendations on how to align ex23 isting Medicare enrollment periods under title XVIII 

24 of the Social Security Act, including the general en25 rollment period under part B of such title and the 


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1 annual election period under the Medicare Advan2 tage program under part C of such title and under 

3 the prescription drug program under part D of such 

4 title. Such recommendations shall be consistent with 

5 the goals of maximizing coverage continuity and 

6 choice and easing beneficiary transition. 

7 SEC. 102. EXTENSION OF FUNDING OUTREACH AND ASSIST8 ANCE FOR LOW-INCOME PROGRAMS. 

9 (a) ADDITIONAL FUNDING FOR STATE HEALTH IN10 SURANCE PROGRAMS.—Subsection (a)(1)(B) of section 

11 119 of the Medicare Improvements for Patients and Pro12 viders Act of 2008 (42 U.S.C. 1395b–3 note), as amended 

13 by section 3306 of the Patient Protection and Affordable 

14 Care Act (Public Law 111–148), section 610 of the Amer15 ican Taxpayer Relief Act of 2012 (Public Law 112–240), 

16 section 1110 of the Pathway for SGR Reform Act of 2013 

17 (Public Law 113–67), section 110 of the Protecting Ac18 cess to Medicare Act of 2014 (Public Law 113–93), sec19 tion 208 of the Medicare Access and CHIP Reauthoriza20 tion Act of 2015 (Public Law 114–10), and section 50207 

21 of the Bipartisan Budget Act of 2018 (Public Law 115– 

22 123), is amended— 

23 (1) in clause (vii), by striking ‘‘and’’ at the end; 

24 (2) in clause (viii), by striking ‘‘and’’ at the 

25 end; 


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1 (3) in clause (ix), by striking the period at the 

2 end and inserting ‘‘; and’’; and 

3 (4) by inserting after clause (ix) the following 

4 new clause: 

5 ‘‘(x) for each of fiscal years 2020 

6 through 2022, of $15,000,000.’’. 

7 (b) ADDITIONAL FUNDING FOR AREA AGENCIES ON

8 AGING.—Subsection (b)(1)(B) of such section 119, as so 

9 amended, is amended— 

10 (1) in clause (vii), by striking ‘‘and’’ at the end; 

11 (2) in clause (viii), by striking ‘‘and’’ at the 

12 end; 

13 (3) in clause (ix), by striking the period at the 

14 end and inserting ‘‘; and’’; and 

15 (4) by inserting after clause (ix) the following 

16 new clause: 

17 ‘‘(x) for each of fiscal years 2020 

18 through 2022, of $15,000,000.’’. 

19 (c) ADDITIONAL FUNDING FOR AGING AND DIS20 ABILITY RESOURCE CENTERS.—Subsection (c)(1)(B) of 

21 such section 119, as so amended, is amended— 

22 (1) in clause (vii), by striking ‘‘and’’ at the end; 

23 (2) in clause (viii), by striking ‘‘and’’ at the 

24 end; 


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1 (3) in clause (ix), by striking the period at the 

2 end and inserting ‘‘; and’’; and 

3 (4) by inserting after clause (ix) the following 

4 new clause: 

5 ‘‘(x) for each of fiscal years 2020 

6 through 2022, of $5,000,000.’’. 

7 (d) ADDITIONAL FUNDING FOR CONTRACT WITH

8 THE NATIONAL CENTER FOR BENEFITS AND OUTREACH

9 ENROLLMENT.—Subsection (d)(2) of such section 119, as 

10 so amended, is amended— 

11 (1) in clause (vii), by striking ‘‘and’’ at the end; 

12 (2) in clause (viii), by striking ‘‘and’’ at the 

13 end; 

14 (3) in clause (ix), by striking the period at the 

15 end and inserting ‘‘; and’’; and 

16 (4) by inserting after clause (ix) the following 

17 new clause: 

18 ‘‘(x) for each of fiscal years 2020 

19 through 2022, of $15,000,000.’’. 

20 SEC. 103. MEDICARE COVERAGE OF CERTAIN MENTAL 

21 HEALTH TELEHEALTH SERVICES. 

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

23 U.S.C. 1395m(m)) is amended— 


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1 (1) in paragraph (2)(B)(i), by striking ‘‘and 

2 paragraph (6)(C)’’ and inserting ‘‘, paragraph 

3 (6)(C), and paragraph (8)(C)’’; 

4 (2) in paragraph (4)(C)(i), by striking ‘‘and 

5 (7)’’ and inserting ‘‘(7), and (8)’’; 

6 (3) in paragraph (4)(F)(i), by inserting ‘‘serv7 ices identified by CPT codes 90834 and 90837 (and 

8 as subsequently modified by the Secretary),’’ before 

9 ‘‘and any additional service’’; 

10 (4) in paragraph (6)(A), by striking ‘‘paragraph 

11 (4)(C)’’ and inserting ‘‘paragraph (4)(C)(i)’’; 

12 (5) in paragraph (7), by striking ‘‘The geo13 graphic requirements’’ and inserting ‘‘Subject to 

14 paragraph (8)(D), the geographic requirements’’; 

15 and 

16 (6) by adding at the end the following new 

17 paragraph: 

18 ‘‘(8) TREATMENT OF MENTAL HEALTH TELE19 HEALTH SERVICES.— 

20 ‘‘(A) NON-APPLICATION OF ORIGINATING

21 SITE REQUIREMENTS.—The requirements de22 scribed in paragraph (4)(C)(i) shall not apply 

23 with respect to telehealth services furnished on 

24 or after January 1, 2020, that are mental 

25 health telehealth services. Nothing in the preVerDate Sep 11 2014 03:37 Jun 27, 2019 Jkt 089200 PO 00000 Frm 00018 Fmt 6652 Sfmt 6201 E:\BILLS\H3417.IH H3417

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1 vious sentence shall waive any applicable State 

2 law requirements. 

3 ‘‘(B) INCLUSION OF CERTAIN SITES.— 

4 With respect to telehealth services described in 

5 subparagraph (A), the term ‘originating site’ 

6 shall include the home of the eligible telehealth 

7 individual at which the individual is located at 

8 the time the service is furnished via a tele9 communications system. 

10 ‘‘(C) NO ORIGINATING SITE FACILITY

11 FEE.—No facility fee shall be paid under para12 graph (2)(B) to an originating site with respect 

13 to a telehealth service described in subpara14 graph (A) if the originating site does not other15 wise meet the requirements for an originating 

16 site under paragraph (4)(C). 

17 ‘‘(D) FACE-TO-FACE INITIAL ASSESSMENT; 

18 REASSESSMENTS.—Payment may not be made 

19 for mental health telehealth services under this 

20 paragraph (if such payment would not other21 wise be allowed under this subsection without 

22 application of this paragraph or paragraph (7)) 

23 furnished to an eligible telehealth individual un24 less— 


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1 ‘‘(i) within the 6-month period prior 

2 to the provision of such mental health tele3 health services, the individual receives a 

4 face-to-face clinical assessment, without 

5 the use of telehealth, by a physician de6 scribed in subparagraph (F)(i) or a practi7 tioner described in subparagraph (F)(ii) of 

8 the needs of such individual for such serv9 ices; and 

10 ‘‘(ii) the individual receives a reassess11 ment (at a frequency specified by the Sec12 retary) by a physician so described or a 

13 practitioner so described of the needs of 

14 such individual for such services. 

15 ‘‘(E) MENTAL HEALTH TELEHEALTH

16 SERVICES DEFINED.—For purposes of this 

17 paragraph, the term ‘mental health telehealth 

18 service’ means services identified by CPT codes 

19 90834 and 90837 (and as subsequently modi20 fied by the Secretary). 

21 ‘‘(F) PHYSICIAN AND PRACTITIONER DE22 SCRIBED.—For purposes of subparagraph (D): 

23 ‘‘(i) PHYSICIAN.—A physician de24 scribed in this clause is a physician, as de25 fined in section 1861(r)(1). 


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1 ‘‘(ii) PRACTITIONER.—A practitioner 

2 described in this clause is a practitioner 

3 described in any of clauses (i), (iv), or (v) 

4 of section 1842(b)(18)(C).’’. 

5 SEC. 104. REQUIRING PRESCRIPTION DRUG PLAN SPON6 SORS TO INCLUDE REAL-TIME BENEFIT IN7 FORMATION AS PART OF SUCH SPONSOR’S 

8 ELECTRONIC PRESCRIPTION PROGRAM 

9 UNDER THE MEDICARE PROGRAM. 

10 Section 1860D–4(e)(2) of the Social Security Act (42 

11 U.S.C. 1395w–104(e)(2)) is amended— 

12 (1) in subparagraph (D), by striking ‘‘To the 

13 extent’’ and inserting ‘‘Except as provided in sub14 paragraph (F), to the extent’’; and 

15 (2) by adding at the end the following new sub16 paragraph: 

17 ‘‘(F) REAL-TIME BENEFIT INFORMA18 TION.— 

19 ‘‘(i) IN GENERAL.—Not later than 

20 January 1, 2021, the program shall pro21 vide for the real-time electronic trans22 mission to prescribing health care profes23 sionals, using technology capable of inte24 grating with such professionals’ electronic 

25 prescribing and electronic health record 


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1 systems, of individual-specific formulary 

2 and benefit information under a prescrip3 tion drug plan with respect to an indi4 vidual enrolled in such plan. Such informa5 tion shall include, with respect to the pre6 scribing of a covered part D drug to such 

7 individual, the following: 

8 ‘‘(I) A description of any clini9 cally-appropriate alternatives to such 

10 drug included in the formulary of 

11 such plan. 

12 ‘‘(II) Information relating to ap13 plicable cost-sharing requirements for 

14 such drug and such alternatives, in15 cluding a description of any variance 

16 in such requirements based on the 

17 pharmacy dispensing such drug or 

18 such alternatives. 

19 ‘‘(III) Information relating to 

20 any prior authorization or other utili21 zation management requirements ap22 plicable to such drug and such alter23 natives within the formulary of such 

24 plan. 


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1 ‘‘(ii) SPECIAL RULE FOR 2021.—The 

2 program shall be deemed to be in compli3 ance with clause (i) for 2021 if the pro4 gram complies with the provisions of sec5 tion 423.160(b)(7) of title 42, Code of 

6 Federal Regulations (or a successor regula7 tion), for such year.’’. 

8 SEC. 105. TRANSITIONAL COVERAGE AND RETROACTIVE 

9 MEDICARE PART D COVERAGE FOR CERTAIN 

10 LOW-INCOME BENEFICIARIES. 

11 Section 1860D–14 of the Social Security Act (42 

12 U.S.C. 1395w–114) is amended— 

13 (1) by redesignating subsection (e) as sub14 section (f); and 

15 (2) by adding after subsection (d) the following 

16 new subsection: 

17 ‘‘(e) LIMITED INCOME NEWLY ELIGIBLE TRANSI18 TION PROGRAM.— 

19 ‘‘(1) IN GENERAL.—Beginning not later than 

20 January 1, 2021, the Secretary shall carry out a 

21 program to provide transitional coverage for covered 

22 part D drugs for LI NET eligible individuals in ac23 cordance with this subsection. 

24 ‘‘(2) LI NET ELIGIBLE INDIVIDUAL DEFINED.— 

25 For purposes of this subsection, the term ‘LI NET 


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1 eligible individual’ means a part D eligible individual 

2 who— 

3 ‘‘(A) meets the requirements of clauses (ii) 

4 and (iii) of subsection (a)(3)(A); and 

5 ‘‘(B) has not yet enrolled in a prescription 

6 drug plan or an MA–PD plan, or, who has so 

7 enrolled, but with respect to whom coverage 

8 under such plan has not yet taken effect. 

9 ‘‘(3) TRANSITIONAL COVERAGE.—For purposes 

10 of this subsection, the term ‘transitional coverage’ 

11 means with respect to an LI NET eligible indi12 vidual— 

13 ‘‘(A) immediate access to covered part D 

14 drugs at the point of sale during the period 

15 that begins on the first day of the month such 

16 individual is determined to meet the require17 ments of clauses (ii) and (iii) of subsection 

18 (a)(3)(A) and ends on the date that coverage 

19 under a prescription drug plan or MA–PD plan 

20 takes effect with respect to such individual; and 

21 ‘‘(B) in the case of an LI NET eligible in22 dividual who is a full-benefit dual eligible indi23 vidual (as defined in section 1935(c)(6)) or a 

24 recipient of supplemental security income bene25 fits under title XVI, retroactive coverage (in the 


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1 form of reimbursement of the amounts that 

2 would have been paid under this part had such 

3 individual been enrolled in a prescription drug 

4 plan or MA–PD plan) of covered part D drugs 

5 purchased by such individual during the period 

6 that begins on the date that is the later of— 

7 ‘‘(i) the date that such individual was 

8 first eligible for a low-income subsidy 

9 under this part; or 

10 ‘‘(ii) the date that is 36 months prior 

11 to the date such individual enrolls in a pre12 scription drug plan or MA–PD plan, 

13 and ends on the date that coverage under such 

14 plan takes effect. 

15 ‘‘(4) PROGRAM ADMINISTRATION.— 

16 ‘‘(A) SINGLE POINT OF CONTACT.—The 

17 Secretary shall, to the extent feasible, admin18 ister the program under this subsection through 

19 a contract with a single program administrator. 

20 ‘‘(B) BENEFIT DESIGN.—The Secretary 

21 shall ensure that the transitional coverage pro22 vided to LI NET eligible individuals under this 

23 subsection— 

24 ‘‘(i) provides access to all covered part 

25 D drugs under an open formulary; 


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1 ‘‘(ii) permits all pharmacies deter2 mined by the Secretary to be in good 

3 standing to process claims under the pro4 gram; 

5 ‘‘(iii) is consistent with such require6 ments as the Secretary considers necessary 

7 to improve patient safety and ensure ap8 propriate dispensing of medication; and 

9 ‘‘(iv) meets such other requirements 

10 as the Secretary may establish. 

11 ‘‘(5) RELATIONSHIP TO OTHER PROVISIONS OF

12 THIS TITLE; WAIVER AUTHORITY.— 

13 ‘‘(A) IN GENERAL.—The following provi14 sions shall not apply with respect to the pro15 gram under this subsection: 

16 ‘‘(i) Paragraphs (1) and (3)(B) of sec17 tion 1860D–4(a) (relating to dissemination 

18 of general information; availability of infor19 mation on changes in formulary through 

20 the Internet). 

21 ‘‘(ii) Subparagraphs (A) and (B) of 

22 section 1860D–4(b)(3) (relating to require23 ments on development and application of 

24 formularies; formulary development). 


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1 ‘‘(iii) Paragraphs (1)(C) and (2) of 

2 section 1860D–4(c) (relating to medication 

3 therapy management program). 

4 ‘‘(B) WAIVER AUTHORITY.—The Secretary 

5 may waive such other requirements of title XI 

6 and this title as may be necessary to carry out 

7 the purposes of the program established under 

8 this subsection.’’. 

9 TITLE II—RURAL AND QUALITY 

10 IMPROVEMENTS 

11 SEC. 201. MEDICARE GME TREATMENT OF HOSPITALS ES12 TABLISHING NEW MEDICAL RESIDENCY 

13 TRAINING PROGRAMS AFTER HOSTING MED14 ICAL RESIDENT ROTATORS FOR SHORT DU15 RATIONS. 

16 (a) REDETERMINATION OF APPROVED FTE RESI17 DENT AMOUNT.—Section 1886(h)(2)(F) of the Social Se18 curity Act (42 U.S.C. 1395ww(h)(2)(F)) is amended— 

19 (1) by inserting ‘‘(i)’’ before ‘‘In the case of’’; 

20 and 

21 (2) by adding at the end the following: 

22 ‘‘(ii) In applying this subparagraph in the 

23 case of a hospital that, on or after the date of 

24 the enactment of this clause, begins to train 

25 residents and has not entered into a GME afVerDate Sep 11 2014 03:37 Jun 27, 2019 Jkt 089200 PO 00000 Frm 00027 Fmt 6652 Sfmt 6201 E:\BILLS\H3417.IH H3417

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1 filiation agreement (as defined by the Secretary 

2 for purposes of paragraph (4)(H)(ii)), the Sec3 retary shall not establish an FTE resident 

4 amount until such time as the Secretary deter5 mines that the hospital has trained at least 1.0 

6 full-time-equivalent resident in an approved 

7 medical residency training program in a cost re8 porting period. 

9 ‘‘(iii) In applying this subparagraph for 

10 cost reporting periods beginning on or after the 

11 date of enactment of this clause, in the case of 

12 a hospital that, as of such date of enactment, 

13 has an approved FTE resident amount based 

14 on the training in an approved medical resi15 dency program of— 

16 ‘‘(I) less than 1.0 full-time-equivalent 

17 resident in any cost reporting period begin18 ning before October 1, 1997, as deter19 mined by the Secretary; or 

20 ‘‘(II) no more than 3.0 full-time21 equivalent residents in any cost reporting 

22 period beginning on or after October 1, 

23 1997, and before the date of the enactment 

24 of this clause, as determined by the Sec25 retary, 


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1 in lieu of such FTE resident amount the Sec2 retary shall, in accordance with the method3 ology described in section 413.77(e) of title 42 

4 of the Code of Federal Regulations (or any suc5 cessor regulation), establish a new FTE resi6 dent amount if the hospital trains at least 1.0 

7 full-time-equivalent resident (in the case of a 

8 hospital described in subclause (I)) or more 

9 than 3.0 full-time-equivalent residents (in the 

10 case of a hospital described in subclause (II)) in 

11 a cost reporting period beginning on or after 

12 such date of enactment and before the date that 

13 is 5 years after such date of enactment. 

14 ‘‘(iv) For purposes of carrying out this 

15 subparagraph for cost reporting periods begin16 ning on or after the date of the enactment of 

17 this clause, a hospital shall report full-time18 equivalent residents on its cost report for a cost 

19 reporting period if the hospital trains at least 

20 1.0 full-time-equivalent resident in an approved 

21 medical residency training program in such pe22 riod. 

23 ‘‘(v) As appropriate, the Secretary may 

24 consider information from any cost reporting 


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1 period necessary to establish a new FTE resi2 dent amount as described in clause (iii).’’. 

3 (b) REDETERMINATION OF FTE RESIDENT LIMITA4 TION.—Section 1886(h)(4)(H)(i) of the Social Security 

5 Act (42 U.S.C. 1395ww(h)(4)(H)(i)) is amended— 

6 (1) by inserting ‘‘(I)’’ before ‘‘The Secretary’’; 

7 and 

8 (2) by adding at the end the following: 

9 ‘‘(II) In applying this clause in the 

10 case of a hospital that, on or after the date 

11 of the enactment of this subclause, begins 

12 to train residents in a new approved med13 ical residency training program (as defined 

14 by the Secretary), the Secretary shall not 

15 determine a limitation applicable to the 

16 hospital under subparagraph (F) until 

17 such time as the Secretary determines that 

18 the hospital has trained at least 1.0 full19 time-equivalent resident in such new ap20 proved medical residency training program 

21 in a cost reporting period. 

22 ‘‘(III) In applying this clause in the 

23 case of a hospital that, as of the date of 

24 the enactment of this subclause, has a lim25 itation under subparagraph (F), based on 


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1 a cost reporting period beginning before 

2 October 1, 1997, of less than 1.0 full-time3 equivalent resident, the Secretary shall ad4 just the limitation in the manner applica5 ble to a new approved medical residency 

6 training program if the Secretary deter7 mines the hospital trains at least 1.0 full8 time-equivalent resident in a program year 

9 beginning on or after such date of enact10 ment and before the date that is 5 years 

11 after such date of enactment. 

12 ‘‘(IV) In applying this clause in the 

13 case of a hospital that, as of the date of 

14 the enactment of this subclause, has a lim15 itation under subparagraph (F), based on 

16 a cost reporting period beginning on or 

17 after October 1, 1997, and before such 

18 date of enactment, of no more than 3.0 

19 full-time-equivalent residents, the Sec20 retary shall adjust the limitation in the 

21 manner applicable to a new approved med22 ical residency training program if the Sec23 retary determines the hospital begins train24 ing more than 3.0 full-time-equivalent resi25 dents in a program year beginning on or 


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1 after such date of enactment and before 

2 the date that is 5 years after such date of 

3 enactment. 

4 ‘‘(V) An adjustment to the limitation 

5 applicable to a hospital made pursuant to 

6 subclause (III) or (IV) shall be made in a 

7 manner consistent with the methodology, 

8 as appropriate, in section 413.79(e) of title 

9 42, Code of Federal Regulations (or any 

10 successor regulation). As appropriate, the 

11 Secretary may consider information from 

12 any cost reporting periods necessary to 

13 make such an adjustment to the limita14 tion.’’. 

15 (c) TECHNICAL AND CONFORMING AMENDMENTS.— 

16 Section 1886 of the Social Security Act (42 U.S.C. 

17 1395ww) is amended— 

18 (1) in subsection (d)(5)(B)(viii), by striking 

19 ‘‘subsection (h)(4)(H)’’ and inserting ‘‘paragraphs 

20 (2)(F)(iv) and (4)(H) of subsection (h)’’; and 

21 (2) in subsection (h)— 

22 (A) in paragraph (4)(H)(iv), by striking 

23 ‘‘an rural area’’ and inserting ‘‘a rural area’’; 

24 and 


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1 (B) in paragraph (7)(E), by striking 

2 ‘‘under this’’ and all that follows through the 

3 period at the end and inserting the following: 

4 ‘‘under this paragraph, paragraph (8), clause 

5 (i), (ii), (iii), or (v) of paragraph (2)(F), or 

6 clause (i) or (vi) of paragraph (4)(H).’’. 

7 (d) EFFECTIVE DATE.—The amendments made by 

8 this section shall apply to payment under section 1886 of 

9 the Social Security Act (42 U.S.C. 1395ww) for cost re10 porting periods beginning on or after the date of the en11 actment of this Act. 

12 SEC. 202. EXTENSION OF THE WORK GEOGRAPHIC INDEX 

13 FLOOR UNDER THE MEDICARE PROGRAM. 

14 Section 1848(e)(1)(E) of the Social Security Act (42 

15 U.S.C. 1395w–4(e)(1)(E)) is amended by striking ‘‘2020’’ 

16 and inserting ‘‘2023’’. 

17 SEC. 203. EXTENSION OF FUNDING FOR QUALITY MEASURE 

18 ENDORSEMENT, INPUT, AND SELECTION 

19 UNDER MEDICARE PROGRAM. 

20 (a) IN GENERAL.—Section 1890(d)(2) of the Social 

21 Security Act (42 U.S.C. 1395aaa(d)(2)) is amended— 

22 (1) by striking ‘‘and $7,500,000’’ and inserting 

23 ‘‘$7,500,000’’; and 


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1 (2) by striking ‘‘and 2019.’’ and inserting ‘‘and 

2 2019, and $30,000,000 for each of fiscal years 2020 

3 through 2022.’’. 

4 (b) INPUT FOR REMOVAL OF MEASURES.—Section 

5 1890(b) of the Social Security Act (42 U.S.C. 1395aaa(b)) 

6 is amended by inserting after paragraph (3) the following: 

7 ‘‘(4) REMOVAL OF MEASURES.—The entity may 

8 provide input to the Secretary on quality and effi9 ciency measures described in paragraph (7)(B) that 

10 could be considered for removal.’’. 

11 (c) PRIORITIZATION OF MEASURE ENDORSEMENT.— 

12 Section 1890(b) of the Social Security Act (42 U.S.C. 

13 1395aaa(b)) is amended by adding at the end the fol14 lowing: 

15 ‘‘(9) PRIORITIZATION OF MEASURE ENDORSE16 MENT.—The Secretary— 

17 ‘‘(A) during the period beginning on the 

18 date of the enactment of this paragraph and 

19 ending on December 31, 2023, shall prioritize 

20 the endorsement of measures relating to mater21 nal morbidity and mortality by the entity with 

22 a contract under subsection (a) in connection 

23 with endorsement of measures described in 

24 paragraph (2); and 


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1 ‘‘(B) on and after January 1, 2024, may 

2 prioritize the endorsement of such measures by 

3 such entity.’’. 

4 SEC. 204. IMPROVING MEASUREMENTS UNDER THE 

5 SKILLED NURSING FACILITY VALUE-BASED 

6 PURCHASING PROGRAM UNDER THE MEDI7 CARE PROGRAM. 

8 (a) IN GENERAL.—Section 1888(h) of the Social Se9 curity Act (42 U.S.C. 1395yy(h)) is amended— 

10 (1) in paragraph (1), by adding at the end the 

11 following new subparagraph: 

12 ‘‘(C) EXCLUSIONS.—With respect to pay13 ments for services furnished on or after October 

14 1, 2021, this subsection shall not apply to a fa15 cility for which there are not a minimum num16 ber (as determined by the Secretary) of— 

17 ‘‘(i) cases for the measures that apply 

18 to the facility for the performance period 

19 for the applicable fiscal year; or 

20 ‘‘(ii) measures that apply to the facil21 ity for the performance period for the ap22 plicable fiscal year.’’; 

23 (2) in paragraph (2)(A)— 

24 (A) by striking ‘‘The Secretary shall 

25 apply’’ and inserting ‘‘The Secretary— 


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1 ‘‘(i) shall apply’’; 

2 (B) by striking the period at the end and 

3 inserting ‘‘; and’’; and 

4 (C) by adding at the end the following: 

5 ‘‘(ii) may, with respect to payments 

6 for services furnished on or after October 

7 1, 2022, apply additional measures deter8 mined appropriate by the Secretary, which 

9 may include measures of functional status, 

10 patient safety, care coordination, or patient 

11 experience. 

12 Subject to the succeeding sentence, in the case 

13 that the Secretary applies additional measures 

14 under clause (ii), the Secretary shall consider 

15 and apply, as appropriate, quality measures 

16 specified under section 1899B(c)(1). In no case 

17 may the Secretary apply more than 10 meas18 ures under this subparagraph.’’; 

19 (3) in subparagraph (A) of each of paragraphs 

20 (3) and (4), by striking ‘‘measure’’ and inserting 

21 ‘‘measures’’; and 

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

23 paragraph: 

24 ‘‘(12) VALIDATION.— 


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

2 apply to the measures applied under this sub3 section and the data submitted under sub4 section (e)(6) a process to validate such meas5 ures and data, as appropriate, which may be 

6 similar to the process specified in section 

7 1886(b)(3)(B)(viii)(XI) for validating inpatient 

8 hospital measures. 

9 ‘‘(B) FUNDING.—For purposes of carrying 

10 out this paragraph, the Secretary shall provide 

11 for the transfer, from the Federal Hospital In12 surance Trust Fund established under section 

13 1817, of $5,000,000 to the Centers for Medi14 care & Medicaid Services Program Management 

15 Account for each of fiscal years 2022 through 

16 2024.’’. 

17 (b) REPORT BY MEDPAC.—Not later than March 

18 15, 2021, the Medicare Payment Advisory Commission 

19 shall submit to Congress a report on establishing a proto20 type value-based payment program under a unified pro21 spective payment system for post-acute care services under 

22 the Medicare program under title XVIII of the Social Se23 curity Act (42 U.S.C. 1395 et seq.). Such report— 

24 (1) shall— 

25 (A) consider design elements such as— 


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1 (i) measures that are important to the 

2 Medicare program and to beneficiaries 

3 under such program; 

4 (ii) methodologies for scoring provider 

5 performance and effects on payment; and 

6 (iii) other elements determined appro7 priate by the Commission; and 

8 (B) analyze the effects of implementing 

9 such prototype program; and 

10 (2) may— 

11 (A) discuss the possible effects, with re12 spect to the Medicare program, on program 

13 spending, post-acute care providers, patient out14 comes, and other effects determined appropriate 

15 by the Commission; and 

16 (B) include recommendations with respect 

17 to such prototype program, as determined ap18 propriate by the Commission, to Congress and 

19 the Secretary of Health and Human Services. 

Æ 


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