IB 

Union Calendar No. 470 

114TH CONGRESS 

2D SESSION H. R. 5273 

[Report No. 114–604, Part I] 

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

relief under the Medicare program for certain providers of services and 

suppliers and increased transparency in hospital coding and enrollment 

data, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 18, 2016 

Mr. TIBERI (for himself and Mr. MCDERMOTT) 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 

JUNE 7, 2016 

Reported from the Committee on Ways and Means with an amendment 

[Strike out all after the enacting clause and insert the part printed in italic] 

JUNE 7, 2016 

The Committee on Energy and Commerce discharged; committed to the Committee of the Whole House on the State of the Union and ordered to be 

printed 

[For text of introduced bill, see copy of bill as introduced on May 18, 2016] 


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A BILL 

To amend title XVIII of the Social Security Act to provide 

for regulatory relief under the Medicare program for 

certain providers of services and suppliers and increased 

transparency in hospital coding and enrollment data, and 

for other purposes. 


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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 ‘‘Helping Hospitals Improve Patient Care Act of 2016’’. 

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

7 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—PROVISIONS RELATING TO MEDICARE PART A 

Sec. 101. Development of Medicare study for HCPCS version of MS–DRG codes 

for similar hospital services. 

Sec. 102. Establishing beneficiary equity in the Medicare hospital readmission 

program. 

Sec. 103. Five-year extension of the rural community hospital demonstration program. 

Sec. 104. Regulatory relief for LTCHs. 

Sec. 105. Savings from IPPS MACRA pay-for through not applying documentation and coding adjustments. 

TITLE II—PROVISIONS RELATING TO MEDICARE PART B 

Sec. 201. Continuing Medicare payment under HOPD prospective payment system for services furnished by mid-build off-campus outpatient 

departments of providers. 

Sec. 202. Treatment of cancer hospitals in off-campus outpatient department of 

a provider policy. 

Sec. 203. Treatment of eligible professionals in ambulatory surgical centers for 

meaningful use and MIPS. 

TITLE III—OTHER MEDICARE PROVISIONS 

Sec. 301. Delay in authority to terminate contracts for Medicare Advantage plans 

failing to achieve minimum quality ratings. 

Sec. 302. Requirement for enrollment data reporting for Medicare. 

Sec. 303. Updating the Welcome to Medicare package. 


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1 TITLE I—PROVISIONS RELATING 

2 TO MEDICARE PART A 

3 SEC. 101. DEVELOPMENT OF MEDICARE STUDY FOR HCPCS 

4 VERSION OF MS–DRG CODES FOR SIMILAR 

5 HOSPITAL SERVICES. 

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

7 1395ww) is amended by adding at the end the following 

8 new subsection: 

9 ‘‘(t) RELATING SIMILAR INPATIENT AND OUTPATIENT

10 HOSPITAL SERVICES.— 

11 ‘‘(1) DEVELOPMENT OF HCPCS VERSION OF MS– 

12 DRG CODES.— 

13 ‘‘(A) IN GENERAL.—Not later than January 

14 1, 2018, the Secretary shall develop HCPCS 

15 versions for MS–DRGs that is similar to the 

16 ICD–10–PCS for such MS–DRGs such that, to 

17 the extent possible, the MS–DRG assignment 

18 shall be similar for a claim coded with the 

19 HCPCS version as an identical claim coded with 

20 a ICD–10–PCS code. 

21 ‘‘(B) COVERAGE OF SURGICAL MS–DRGS.— 

22 In carrying out subparagraph (A), the Secretary 

23 shall develop HCPCS versions of MS–DRG codes 

24 for not fewer than 10 surgical MS–DRGs. 


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1 ‘‘(C) PUBLICATION AND DISSEMINATION OF

2 THE HCPCS VERSIONS OF MS–DRGS.— 

3 ‘‘(i) IN GENERAL.—The Secretary shall 

4 develop a HCPCS MS–DRG definitions 

5 manual and software that is similar to the 

6 definitions manual and software for ICD– 

7 10–PCS codes for such MS–DRGs. The Sec8 retary shall post the HCPCS MS–DRG 

9 definitions manual and software on the 

10 Internet website of the Centers for Medicare 

11 & Medicaid Services. The HCPCS MS– 

12 DRG definitions manual and software shall 

13 be in the public domain and available for 

14 use and redistribution without charge. 

15 ‘‘(ii) USE OF PREVIOUS ANALYSIS

16 DONE BY MEDPAC.—In developing the 

17 HCPCS MS–DRG definitions manual and 

18 software under clause (i), the Secretary 

19 shall consult with the Medicare Payment 

20 Advisory Commission and shall consider the 

21 analysis done by such Commission in trans22 lating outpatient surgical claims into inpa23 tient surgical MS–DRGs in preparing 

24 chapter 7 (relating to hospital short-stay 

25 policy issues) of its ‘Medicare and the 


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1 Health Care Delivery System’ report sub2 mitted to Congress in June 2015. 

3 ‘‘(D) DEFINITION AND REFERENCE.—In 

4 this paragraph: 

5 ‘‘(i) HCPCS.—The term ‘HCPCS’ 

6 means, with respect to hospital items and 

7 services, the code under the Healthcare 

8 Common Procedure Coding System 

9 (HCPCS) (or a successor code) for such 

10 items and services. 

11 ‘‘(ii) ICD–10–PCS.—The term ‘ICD– 

12 10–PCS’ means the International Classi13 fication of Diseases, 10th Revision, Proce14 dure Coding System, and includes a subse15 quent revision of such International Classi16 fication of Diseases, Procedure Coding Sys17 tem.’’. 

18 SEC. 102. ESTABLISHING BENEFICIARY EQUITY IN THE 

19 MEDICARE HOSPITAL READMISSION PRO20 GRAM. 

21 (a) TRANSITIONAL ADJUSTMENT FOR DUAL ELIGIBLE

22 POPULATION.—Section 1886(q)(3) of the Social Security 

23 Act (42 U.S.C. 1395ww(q)(3)) is amended— 


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1 (1) in subparagraph (A), by inserting ‘‘subject to 

2 subparagraph (D),’’ after ‘‘purposes of paragraph 

3 (1),’’; and 

4 (2) by adding at the end the following new sub5 paragraph: 

6 ‘‘(D) TRANSITIONAL ADJUSTMENT FOR

7 DUAL ELIGIBLES.— 

8 ‘‘(i) IN GENERAL.—In determining a 

9 hospital’s adjustment factor under this 

10 paragraph for purposes of making pay11 ments for discharges occurring during and 

12 after fiscal year 2019, and before the appli13 cation of clause (i) of subparagraph (E), the 

14 Secretary shall assign hospitals to groups 

15 (as defined by the Secretary under clause 

16 (ii)) and apply the applicable provisions of 

17 this subsection using a methodology in a 

18 manner that allows for separate comparison 

19 of hospitals within each such group, as de20 termined by the Secretary. 

21 ‘‘(ii) DEFINING GROUPS.—For pur22 poses of this subparagraph, the Secretary 

23 shall define groups of hospitals based on 

24 their overall proportion, of the inpatients 

25 who are entitled to, or enrolled for, benefits 


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1 under part A, who are full-benefit dual eli2 gible individuals (as defined in section 

3 1935(c)(6)). In defining groups, the Sec4 retary shall consult the Medicare Payment 

5 Advisory Commission and may consider the 

6 analysis done by such Commission in pre7 paring the portion of its report submitted to 

8 Congress in June 2013 relating to readmis9 sions. 

10 ‘‘(iii) MINIMIZING REPORTING BURDEN

11 ON HOSPITALS.—In carrying out this sub12 paragraph, the Secretary shall not impose 

13 any additional reporting requirements on 

14 hospitals. 

15 ‘‘(iv) BUDGET NEUTRAL DESIGN METH16 ODOLOGY.—The Secretary shall design the 

17 methodology to implement this subpara18 graph so that the estimated total amount of 

19 reductions in payments under this sub20 section equals the estimated total amount of 

21 reductions in payments that would other22 wise occur under this subsection if this sub23 paragraph did not apply.’’. 

24 (b) SUBSEQUENT ADJUSTMENTS BASED ON IMPACT 

25 REPORTS.—Section 1886(q)(3) of the Social Security Act 


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1 (42 U.S.C. 1395ww(q)(3)), as amended by subsection (a), 

2 is further amended by adding at the end the following new 

3 subparagraph: 

4 ‘‘(E) CHANGES IN RISK ADJUSTMENT.— 

5 ‘‘(i) CONSIDERATION OF RECOMMENDA6 TIONS IN IMPACT REPORTS.—The Secretary 

7 may take into account the studies conducted 

8 and the recommendations made by the Sec9 retary under section 2(d)(1) of the IMPACT 

10 Act of 2014 (Public Law 113–185; 42 

11 U.S.C. 1395lll note) with respect to the ap12 plication under this subsection of risk ad13 justment methodologies. Nothing in this 

14 clause shall be construed as precluding con15 sideration of the use of groupings of hos16 pitals.’’. 

17 (c) MEDPAC STUDY ON READMISSIONS PROGRAM.— 

18 The Medicare Payment Advisory Commission shall conduct 

19 a study to review overall hospital readmissions described 

20 in section 1886(q)(5)(E) of the Social Security Act (42 

21 U.S.C. 1395ww(q)(5)(E)) and whether such readmissions 

22 are related to any changes in outpatient and emergency 

23 services furnished. The Commission shall submit to Con24 gress a report on such study in its report to Congress in 

25 June 2017. 


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1 (d) ADDRESSING ISSUE OF CERTAIN PATIENTS.—Sub2 paragraph (E) of section 1886(q)(3) of the Social Security 

3 Act (42 U.S.C. 1395ww(q)(3)), as added by subsection (b), 

4 is further amended by adding at the end the following new 

5 clause: 

6 ‘‘(ii) CONSIDERATION OF EXCLUSION

7 OF PATIENT CASES BASED ON V OR OTHER

8 APPROPRIATE CODES.—In promulgating 

9 regulations to carry out this subsection with 

10 respect to discharges occurring after fiscal 

11 year 2018, the Secretary may consider the 

12 use of V or other ICD-related codes for re13 moval of a readmission. The Secretary may 

14 consider modifying measures under this 

15 subsection to incorporate V or other ICD-re16 lated codes at the same time as other 

17 changes are being made under this subpara18 graph.’’. 

19 (e) REMOVAL OF CERTAIN READMISSIONS.—Subpara20 graph (E) of section 1886(q)(3) of the Social Security Act 

21 (42 U.S.C. 1395ww(q)(3)), as added by subsection (b) and 

22 amended by subsection (d), is further amended by adding 

23 at the end the following new clause: 

24 ‘‘(iii) REMOVAL OF CERTAIN READMIS25 SIONS.—In promulgating regulations to 


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1 carry out this subsection, with respect to 

2 discharges occurring after fiscal year 2018, 

3 the Secretary may consider removal as a re4 admission of an admission that is classified 

5 within one or more of the following: trans6 plants, end-stage renal disease, burns, trau7 ma, psychosis, or substance abuse. The Sec8 retary may consider modifying measures 

9 under this subsection to remove readmis10 sions at the same time as other changes are 

11 being made under this subparagraph.’’. 

12 SEC. 103. FIVE-YEAR EXTENSION OF THE RURAL COMMU13 NITY HOSPITAL DEMONSTRATION PROGRAM. 

14 (a) EXTENSION.—Section 410A of the Medicare Pre15 scription Drug, Improvement, and Modernization Act of 

16 2003 (Public Law 108–173; 42 U.S.C. 1395ww note), as 

17 amended by sections 3123 and 10313 of the Patient Protec18 tion and Affordable Care Act (Public Law 111–148), is 

19 amended— 

20 (1) in subsection (a)(5), by striking ‘‘5-year ex21 tension period’’ and inserting ‘‘10-year extension pe22 riod’’; and 

23 (2) in subsection (g)— 

24 (A) in the subsection heading, by striking 

25 ‘‘FIVE-YEAR’’ and inserting ‘‘TEN-YEAR’’; 


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1 (B) in paragraph (1), by striking ‘‘addi2 tional 5-year’’ and inserting ‘‘additional 10- 

3 year’’; 

4 (C) by striking ‘‘5-year extension period’’ 

5 and inserting ‘‘10-year extension period’’ each 

6 place it appears; 

7 (D) in paragraph (4)(B)— 

8 (i) in the matter preceding clause (i), 

9 by inserting ‘‘each 5-year period in’’ after 

10 ‘‘hospital during’’; and 

11 (ii) in clause (i), by inserting ‘‘each 

12 applicable 5-year period in’’ after ‘‘the first 

13 day of’’; and 

14 (E) by adding at the end the following new 

15 paragraphs: 

16 ‘‘(5) OTHER HOSPITALS IN DEMONSTRATION

17 PROGRAM.—During the second 5 years of the 10-year 

18 extension period, the Secretary shall apply the provi19 sions of paragraph (4) to rural community hospitals 

20 that are not described in paragraph (4) but are par21 ticipating in the demonstration program under this 

22 section as of December 30, 2014, in a similar manner 

23 as such provisions apply to rural community hos24 pitals described in paragraph (4). 


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1 ‘‘(6) EXPANSION OF DEMONSTRATION PROGRAM

2 TO RURAL AREAS IN ANY STATE.— 

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

4 notwithstanding subsection (a)(2) or paragraph 

5 (2) of this subsection, not later than 120 days 

6 after the date of the enactment of this paragraph, 

7 issue a solicitation for applications to select up 

8 to the maximum number of additional rural 

9 community hospitals located in any State to 

10 participate in the demonstration program under 

11 this section for the second 5 years of the 10-year 

12 extension period without exceeding the limitation 

13 under paragraph (3) of this subsection. 

14 ‘‘(B) PRIORITY.—In determining which 

15 rural community hospitals that submitted an 

16 application pursuant to the solicitation under 

17 subparagraph (A) to select for participation in 

18 the demonstration program, the Secretary— 

19 ‘‘(i) shall give priority to rural com20 munity hospitals located in one of the 20 

21 States with the lowest population densities 

22 (as determined by the Secretary using the 

23 2015 Statistical Abstract of the United 

24 States); and 

25 ‘‘(ii) may consider— 


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1 ‘‘(I) closures of hospitals located 

2 in rural areas in the State in which 

3 the rural community hospital is lo4 cated during the 5-year period imme5 diately preceding the date of the enact6 ment of this paragraph; and 

7 ‘‘(II) the population density of the 

8 State in which the rural community 

9 hospital is located.’’. 

10 (b) CHANGE IN TIMING FOR REPORT.—Subsection (e) 

11 of such section 410A is amended— 

12 (1) by striking ‘‘Not later than 6 months after 

13 the completion of the demonstration program under 

14 this section’’ and inserting ‘‘Not later than August 1, 

15 2018’’; and 

16 (2) by striking ‘‘such program’’ and inserting 

17 ‘‘the demonstration program under this section’’. 

18 SEC. 104. REGULATORY RELIEF FOR LTCHS. 

19 (a) TECHNICAL CHANGE TO THE MEDICARE LONG20 TERM CARE HOSPITAL MORATORIUM EXCEPTION.— 

21 (1) IN GENERAL.—Section 114(d)(7) of the Medi22 care, Medicaid, and SCHIP Extension Act of 2007 

23 (42 U.S.C. 1395ww note), as amended by sections 

24 3106(b) and 10312(b) of Public Law 111–148, section 

25 1206(b)(2) of the Pathway for SGR Reform Act of 


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1 2013 (division B of Public Law 113–67), and section 

2 112 of the Protecting Access to Medicare Act of 2014, 

3 is amended by striking ‘‘The moratorium under para4 graph (1)(A)’’ and inserting ‘‘Any moratorium under 

5 paragraph (1)’’. 

6 (2) EFFECTIVE DATE.—The amendment made by 

7 paragraph (1) shall take effect as if included in the 

8 enactment of section 112 of the Protecting Access to 

9 Medicare Act of 2014. 

10 (b) MODIFICATION TO MEDICARE LONG-TERM CARE

11 HOSPITAL HIGH COST OUTLIER PAYMENTS.—Section 

12 1886(m) of the Social Security Act (42 U.S.C. 1395ww(m)) 

13 is amended by adding at the end the following new para14 graph: 

15 ‘‘(7) TREATMENT OF HIGH COST OUTLIER PAY16 MENTS.— 

17 ‘‘(A) ADJUSTMENT TO THE STANDARD FED18 ERAL PAYMENT RATE FOR ESTIMATED HIGH

19 COST OUTLIER PAYMENTS.—Under the system 

20 described in paragraph (1), for fiscal years be21 ginning on or after October 1, 2017, the Sec22 retary shall reduce the standard Federal pay23 ment rate as if the estimated aggregate amount 

24 of high cost outlier payments for standard Fed25 eral payment rate discharges for each such fiscal 


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1 year would be equal to 8 percent of estimated ag2 gregate payments for standard Federal payment 

3 rate discharges for each such fiscal year. 

4 ‘‘(B) LIMITATION ON HIGH COST OUTLIER

5 PAYMENT AMOUNTS.—Notwithstanding subpara6 graph (A), the Secretary shall set the fixed loss 

7 amount for high cost outlier payments such that 

8 the estimated aggregate amount of high cost 

9 outlier payments made for standard Federal 

10 payment rate discharges for fiscal years begin11 ning on or after October 1, 2017, shall be equal 

12 to 99.6875 percent of 8 percent of estimated ag13 gregate payments for standard Federal payment 

14 rate discharges for each such fiscal year. 

15 ‘‘(C) WAIVER OF BUDGET NEUTRALITY.— 

16 Any reduction in payments resulting from the 

17 application of subparagraph (B) shall not be 

18 taken into account in applying any budget neu19 trality provision under such system. 

20 ‘‘(D) NO EFFECT ON SITE NEUTRAL HIGH

21 COST OUTLIER PAYMENT RATE.—This paragraph 

22 shall not apply with respect to the computation 

23 of the applicable site neutral payment rate under 

24 paragraph (6).’’. 


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1 SEC. 105. SAVINGS FROM IPPS MACRA PAY-FOR THROUGH 

2 NOT APPLYING DOCUMENTATION AND COD3 ING ADJUSTMENTS. 

4 Section 7(b)(1)(B)(iii) of the TMA, Abstinence Edu5 cation, and QI Programs Extension Act of 2007 (Public 

6 Law 110–90), as amended by section 631(b) of the Amer7 ican Taxpayer Relief Act of 2012 (Public Law 122–240) 

8 and section 414(1)(B)(iii) of the Medicare Access and CHIP 

9 Reauthorization Act of 2015 (Public Law 114–10), is 

10 amended by striking ‘‘an increase of 0.5 percentage points 

11 for discharges occurring during each of fiscal years 2018 

12 through 2023’’ and inserting ‘‘an increase of 0.4590 per13 centage points for discharges occurring during fiscal year 

14 2018 and 0.5 percentage points for discharges occurring 

15 during each of fiscal years 2019 through 2023’’. 

16 TITLE II—PROVISIONS 

17 RELATING TO MEDICARE PART B 

18 SEC. 201. CONTINUING MEDICARE PAYMENT UNDER HOPD 

19 PROSPECTIVE PAYMENT SYSTEM FOR SERV20 ICES FURNISHED BY MID-BUILD OFF-CAMPUS 

21 OUTPATIENT DEPARTMENTS OF PROVIDERS. 

22 (a) IN GENERAL.—Section 1833(t)(21) of the Social 

23 Security Act (42 U.S.C. 1395l(t)(21)) is amended— 

24 (1) in subparagraph (B)— 


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1 (A) in clause (i), by striking ‘‘clause (ii)’’ 

2 and inserting ‘‘the subsequent provisions of this 

3 subparagraph’’; and 

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

5 clauses: 

6 ‘‘(iii) DEEMED TREATMENT FOR

7 2017.—For purposes of applying clause (ii) 

8 with respect to applicable items and services 

9 furnished during 2017, a department of a 

10 provider (as so defined) not described in 

11 such clause is deemed to be billing under 

12 this subsection with respect to covered OPD 

13 services furnished prior to November 2, 

14 2015, if the Secretary received from the pro15 vider prior to December 2, 2015, an attesta16 tion (pursuant to section 413.65(b)(3) of 

17 title 42 of the Code of Federal Regulations) 

18 that such department was a department of 

19 a provider (as so defined). 

20 ‘‘(iv) ALTERNATIVE EXCEPTION BEGIN21 NING WITH 2018.—For purposes of para22 graph (1)(B)(v) and this paragraph with 

23 respect to applicable items and services fur24 nished during 2018 or a subsequent year, 

25 the term ‘off-campus outpatient department 


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1 of a provider’ also shall not include a de2 partment of a provider (as so defined) that 

3 is not described in clause (ii) if— 

4 ‘‘(I) the Secretary receives from 

5 the provider an attestation (pursuant 

6 to such section 413.65(b)(3)) not later 

7 than December 31, 2016 (or, if later, 

8 60 days after the date of the enactment 

9 of this clause), that such department 

10 met the requirements of a department 

11 of a provider specified in section 

12 413.65 of title 42 of the Code of Fed13 eral Regulations; 

14 ‘‘(II) the provider includes such 

15 department as part of the provider on 

16 its enrollment form in accordance with 

17 the enrollment process under section 

18 1866(j); and 

19 ‘‘(III) the department met the 

20 mid-build requirement of clause (v) 

21 and the Secretary receives, not later 

22 than 60 days after the date of the en23 actment of this clause, from the chief 

24 executive officer or chief operating offi25 cer of the provider a written certifiVerDate Sep 11 2014 20:44 Jun 07, 2016 Jkt 059200 PO 00000 Frm 00019 Fmt 6652 Sfmt 6203 E:\BILLS\H5273.RH H5273

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1 cation that the department met such 

2 requirement. 

3 ‘‘(v) MID-BUILD REQUIREMENT DE4 SCRIBED.—The mid-build requirement of 

5 this clause is, with respect to a department 

6 of a provider, that before November 2, 2015, 

7 the provider had a binding written agree8 ment with an outside unrelated party for 

9 the actual construction of such department. 

10 ‘‘(vii) AUDIT.—Not later than Decem11 ber 31, 2018, the Secretary shall audit the 

12 compliance with requirements of clause (iv) 

13 with respect to each department of a pro14 vider to which such clause applies. If the 

15 Secretary finds as a result of an audit 

16 under this clause that the applicable re17 quirements were not met with respect to 

18 such department, the department shall not 

19 be excluded from the term ‘off-campus out20 patient department of a provider’ under 

21 such clause. 

22 ‘‘(viii) IMPLEMENTATION.—For pur23 poses of implementing clauses (iii) through 

24 (vii): 


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1 ‘‘(I) Notwithstanding any other 

2 provision of law, the Secretary may 

3 implement such clauses by program in4 struction or otherwise. 

5 ‘‘(II) Subchapter I of chapter 35 

6 of title 44, United States Code, shall 

7 not apply. 

8 ‘‘(III) For purposes of carrying 

9 out this subparagraph with respect to 

10 clauses (iii) and (iv) (and clause (vii) 

11 insofar as it relates to clause (iv)), the 

12 Secretary shall provide for the transfer 

13 from the Supplementary Medical In14 surance Trust Fund under section 

15 1841, of $10,000,000 to the Centers for 

16 Medicare & Medicaid Services Pro17 gram Management Account to remain 

18 available until December 31, 2018.’’; 

19 and 

20 (2) in subparagraph (E), by adding at the end 

21 the following new clause: 

22 ‘‘(iv) The determination of an audit 

23 under subparagraph (B)(vii).’’. 

24 (b) EFFECTIVE DATE.—The amendments made by this 

25 section shall be effective as if included in the enactment of 


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1 section 603 of the Bipartisan Budget Act of 2015 (Public 

2 Law 114–74). 

3 SEC. 202. TREATMENT OF CANCER HOSPITALS IN OFF-CAM4 PUS OUTPATIENT DEPARTMENT OF A PRO5 VIDER POLICY. 

6 (a) IN GENERAL.—Section 1833(t)(21)(B) of the So7 cial Security Act (42 U.S.C. 1395l(t)(21)(B)), as amended 

8 by section 201(a), is amended— 

9 (1) by inserting after clause (v) the following 

10 new clause: 

11 ‘‘(vi) EXCLUSION FOR CERTAIN CANCER

12 HOSPITALS.—For purposes of paragraph 

13 (1)(B)(v) and this paragraph with respect 

14 to applicable items and services furnished 

15 during 2017 or a subsequent year, the term 

16 ‘off-campus outpatient department of a pro17 vider’ also shall not include a department of 

18 a provider (as so defined) that is not de19 scribed in clause (ii) if the provider is a 

20 hospital described in section 

21 1886(d)(1)(B)(v) and— 

22 ‘‘(I) in the case of a department 

23 that met the requirements of section 

24 413.65 of title 42 of the Code of Fed25 eral Regulations after November 1, 


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1 2015, and before the date of the enact2 ment of this clause, the Secretary re3 ceives from the provider an attestation 

4 that such department met such require5 ments not later than 60 days after 

6 such date of enactment; or 

7 ‘‘(II) in the case of a department 

8 that meets such requirements after such 

9 date of enactment, the Secretary re10 ceives from the provider an attestation 

11 that such department meets such re12 quirements not later than 60 days 

13 after the date such requirements are 

14 first met with respect to such depart15 ment.’’; 

16 (2) in clause (vii), by inserting after the first 

17 sentence the following: ‘‘Not later than 2 years after 

18 the date the Secretary receives an attestation under 

19 clause (vi) relating to compliance of a department of 

20 a provider with requirements referred to in such 

21 clause, the Secretary shall audit the compliance with 

22 such requirements with respect to the department.’’; 

23 and 

24 (3) in clause (viii)(III), by adding at the end the 

25 following: ‘‘For purposes of carrying out this subVerDate Sep 11 2014 20:44 Jun 07, 2016 Jkt 059200 PO 00000 Frm 00023 Fmt 6652 Sfmt 6203 E:\BILLS\H5273.RH H5273

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1 paragraph with respect to clause (vi) (and clause 

2 (vii) insofar as it relates to such clause), the Sec3 retary shall provide for the transfer from the Supple4 mentary Medical Insurance Trust Fund under section 

5 1841, of $2,000,000 to the Centers for Medicare & 

6 Medicaid Services Program Management Account to 

7 remain available until expended.’’ 

8 (b) OFFSETTING SAVINGS.—Section 1833(t)(18) of the 

9 Social Security Act (42 U.S.C. 1395l(t)(18)) is amended— 

10 (1) in subparagraph (B), by inserting ‘‘, subject 

11 to subparagraph (C),’’ after ‘‘shall’’; and 

12 (2) by adding at the end the following new sub13 paragraph: 

14 ‘‘(C) TARGET PCR ADJUSTMENT.—In apply15 ing section 419.43(i) of title 42 of the Code of 

16 Federal Regulations to implement the appro17 priate adjustment under this paragraph for serv18 ices furnished on or after January 1, 2018, the 

19 Secretary shall use a target PCR that is 1.0 per20 centage points less than the target PCR that 

21 would otherwise apply. In addition to the per22 centage point reduction under the previous sen23 tence, the Secretary may consider making an ad24 ditional percentage point reduction to such tar25 get PCR that takes into account payment rates 


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1 for applicable items and services described in 

2 paragraph (21)(C) other than for services fur3 nished by hospitals described in section 

4 1886(d)(1)(B)(v). In making any budget neu5 trality adjustments under this subsection for 

6 2018 or a subsequent year, the Secretary shall 

7 not take into account the reduced expenditures 

8 that result from the application of this subpara9 graph.’’. 

10 (c) EFFECTIVE DATE.—The amendments made by this 

11 section shall be effective as if included in the enactment of 

12 section 603 of the Bipartisan Budget Act of 2015 (Public 

13 Law 114–74). 

14 SEC. 203. TREATMENT OF ELIGIBLE PROFESSIONALS IN AM15 BULATORY SURGICAL CENTERS FOR MEAN16 INGFUL USE AND MIPS. 

17 (a) IN GENERAL.—Section 1848(a)(7)(D) of the Social 

18 Security Act (42 U.S.C. 1395w–4(a)(7)(D)) is amended— 

19 (1) by striking ‘‘HOSPITAL-BASED ELIGIBLE PRO20 FESSIONALS’’ and all that follows through ‘‘No pay21 ment’’ and inserting the following: ‘‘HOSPITAL-BASED

22 AND AMBULATORY SURGICAL CENTER-BASED ELIGI23 BLE PROFESSIONALS.— 

24 ‘‘(i) HOSPITAL-BASED.—No payment’’; 

25 and 


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1 (2) by adding at the end the following new 

2 clauses: 

3 ‘‘(ii) AMBULATORY SURGICAL CENTER4 BASED.—Subject to clause (iv), no payment 

5 adjustment may be made under subpara6 graph (A) for 2017 and 2018 in the case of 

7 an eligible professional with respect to 

8 whom substantially all of the covered profes9 sional services furnished by such profes10 sional are furnished in an ambulatory sur11 gical center. 

12 ‘‘(iii) DETERMINATION.—The deter13 mination of whether an eligible professional 

14 is an eligible professional described in 

15 clause (ii) may be made on the basis of— 

16 ‘‘(I) the site of service (as defined 

17 by the Secretary); or 

18 ‘‘(II) an attestation submitted by 

19 the eligible professional. 

20 Determinations made under subclauses (I) 

21 and (II) shall be made without regard to 

22 any employment or billing arrangement be23 tween the eligible professional and any other 

24 supplier or provider of services. 


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1 ‘‘(iv) SUNSET.—Clause (ii) shall no 

2 longer apply as of the first year that begins 

3 more than 3 years after the date on which 

4 the Secretary determines, through notice 

5 and comment rulemaking, that certified 

6 EHR technology applicable to the ambula7 tory surgical center setting is available.’’. 

8 (b) CONTINUED APPLICATION OF CERTAIN PROVISIONS

9 UNDER MIPS.—Section 1848(o)(2)(D) of the Social Secu10 rity Act (42 U.S.C. 1395w–4(o)(2)(D)) is amended by add11 ing at the end the following new sentence: ‘‘The provisions 

12 of subparagraphs (B) and (D) of subsection (a)(7), includ13 ing the application of clause (iv) of such subparagraph (D), 

14 shall apply to assessments of MIPS eligible professionals 

15 under subsection (q) with respect to the performance cat16 egory described in subsection (q)(2)(A)(iv) in a manner 

17 similar to the manner in which such provisions apply with 

18 respect to payment adjustments made under subsection 

19 (a)(7)(A).’’. 


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1 TITLE III—OTHER MEDICARE 

2 PROVISIONS 

3 SEC. 301. DELAY IN AUTHORITY TO TERMINATE CONTRACTS 

4 FOR MEDICARE ADVANTAGE PLANS FAILING 

5 TO ACHIEVE MINIMUM QUALITY RATINGS. 

6 (a) FINDINGS.—Consistent with the studies provided 

7 under the IMPACT Act of 2014 (Public Law 113–185), it 

8 is the intent of Congress— 

9 (1) to continue to study and request input on the 

10 effects of socioeconomic status and dual-eligible popu11 lations on the Medicare Advantage STARS rating 

12 system before reforming such system with the input of 

13 stakeholders; and 

14 (2) pending the results of such studies and input, 

15 to provide for a temporary delay in authority of the 

16 Centers for Medicare & Medicaid Services (CMS) to 

17 terminate Medicare Advantage plan contracts solely 

18 on the basis of performance of plans under the 

19 STARS rating system. 

20 (b) DELAY IN MA CONTRACT TERMINATION AUTHOR21 ITY FOR PLANS FAILING TO ACHIEVE MINIMUM QUALITY

22 RATINGS.—Section 1857(h) of the Social Security Act (42 

23 U.S.C. 1395w–27(h)) is amended by adding at the end the 

24 following new paragraph: 


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1 ‘‘(3) DELAY IN CONTRACT TERMINATION AU2 THORITY FOR PLANS FAILING TO ACHIEVE MINIMUM

3 QUALITY RATING.—During the period beginning on 

4 the date of the enactment of this paragraph and 

5 through the end of plan year 2018, the Secretary may 

6 not terminate a contract under this section with re7 spect to the offering of an MA plan by a Medicare Ad8 vantage organization solely because the MA plan has 

9 failed to achieve a minimum quality rating under the 

10 5-star rating system under section 1853(o)(4).’’. 

11 SEC. 302. REQUIREMENT FOR ENROLLMENT DATA REPORT12 ING FOR MEDICARE. 

13 Section 1874 of the Social Security Act (42 U.S.C. 

14 1395kk) is amended by adding at the end the following new 

15 subsection: 

16 ‘‘(g) REQUIREMENT FOR ENROLLMENT DATA REPORT17 ING.— 

18 ‘‘(1) IN GENERAL.—Each year (beginning with 

19 2016), the Secretary shall submit to the Committees 

20 on Ways and Means and Energy and Commerce of 

21 the House of Representatives and the Committee on 

22 Finance of the Senate a report on Medicare enroll23 ment data (and, in the case of part A, on data on in24 dividuals receiving benefits under such part) as of a 


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1 date in such year specified by the Secretary. Such 

2 data shall be presented— 

3 ‘‘(A) by Congressional district and State; 

4 and 

5 ‘‘(B) in a manner that provides for such 

6 data based on— 

7 ‘‘(i) fee-for-service enrollment (as de8 fined in paragraph (2)); 

9 ‘‘(ii) enrollment under part C (includ10 ing separate for aggregate enrollment in 

11 MA–PD plans and aggregate enrollment in 

12 MA plans that are not MA–PD plans); and 

13 ‘‘(iii) enrollment under part D. 

14 ‘‘(2) FEE-FOR-SERVICE ENROLLMENT DE15 FINED.—For purpose of paragraph (1)(B)(i), the term 

16 ‘fee-for-service enrollment’ means aggregate enrollment 

17 (including receipt of benefits other than through en18 rollment) under— 

19 ‘‘(A) part A only; 

20 ‘‘(B) part B only; and 

21 ‘‘(C) both part A and part B.’’. 

22 SEC. 303. UPDATING THE WELCOME TO MEDICARE PACK23 AGE. 

24 (a) IN GENERAL.—Not later than 12 months after the 

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1 scribed in subsection (b), the Secretary of Health and 

2 Human Services shall, taking into consideration informa3 tion collected pursuant to subsection (b), update the infor4 mation included in the Welcome to Medicare package to in5 clude information, presented in a clear and simple manner, 

6 about options for receiving benefits under the Medicare pro7 gram under title XVIII of the Social Security Act (42 

8 U.S.C. 1395 et seq.), including through the original medi9 care fee-for-service program under parts A and B of such 

10 title (42 U.S.C. 1395c et seq., 42 U.S.C. 1395j et seq.), Medi11 care Advantage plans under part C of such title (42 U.S.C. 

12 1395w–21 et seq.), and prescription drug plans under part 

13 D of such title (42 U.S.C. 1395w–101 et seq.)). The Sec14 retary shall make subsequent updates to the information in15 cluded in the Welcome to Medicare package as appropriate. 

16 (b) REQUEST FOR INFORMATION.—Not later than six 

17 months after the date of the enactment of this Act, the Sec18 retary of Health and Human Services shall request infor19 mation, including recommendations, from stakeholders (in20 cluding patient advocates, issuers, and employers) on infor21 mation included in the Welcome to Medicare package, in22 cluding pertinent data and information regarding enroll23 ment and coverage for Medicare eligible individuals. 


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Union Calendar No. 470 

114TH CONGRESS 

2D SESSION H. R. 5273 

[Report No. 114–604, Part I] 

A BILL 

To amend title XVIII of the Social Security Act to 

poses. coding and enrollment data, and for other pursuppliers and increased transparency in hospital program for certain providers of services and provide for regulatory relief under the Medicare 

JUNE 7, 2016 

Reported from the Committee on Ways and Means with 

J

an amendment 

UNE 7, 2016 

The Committee on Energy and Commerce discharged; 

the State of the Union and ordered to be printed committed to the Committee of the Whole House on 


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