IB 

Union Calendar No. 117 

114TH CONGRESS 

1ST SESSION H. R. 2581 

[Report No. 114–161, Part I] 

To amend title XVIII of the Social Security Act to establish a 3-year demonstration program to test the use of value-based insurance design methodologies under eligible Medicare Advantage plans, to preserve Medicare 

beneficiary choice under Medicare Advantage, to revise the treatment 

under the Medicare program of infusion drugs furnished through durable 

medical equipment, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 29, 2015 

Mr. BRADY of Texas 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 16, 2015 

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 16, 2015 

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 29, 2015] 


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A BILL 

To amend title XVIII of the Social Security Act to establish 

a 3-year demonstration program to test the use of valuebased insurance design methodologies under eligible 

Medicare Advantage plans, to preserve Medicare beneficiary choice under Medicare Advantage, to revise the 

treatment under the Medicare program of infusion drugs 

furnished through durable medical equipment, 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. 

4 This Act may be cited as the ‘‘Preservation of Access 

5 for Seniors in Medicare Advantage Act of 2015’’. 

6 SEC. 2. DEMONSTRATION PROGRAM. 

7 (a) IN GENERAL.—The Secretary of Health and 

8 Human Services (in this section referred to as the ‘‘Sec9 retary’’) shall establish a 3-year demonstration program to 

10 test the use of value-based insurance design methodologies 

11 (as defined in subsection (c)(1)) under eligible Medicare Ad12 vantage plans offered by Medicare Advantage organizations 

13 under part C of title XVIII of the Social Security Act (42 

14 U.S.C. 1395w–21 et seq.). The Secretary may extend the 

15 program to a duration of 4 or 5 years, as determined nec16 essary by the Secretary in coordination with the Centers 

17 for Medicare and Medicaid Innovation. 

18 (b) DEMONSTRATION PROGRAM DESIGN.— 

19 (1) SELECTION OF MEDICARE ADVANTAGE SITES

20 AND ELIGIBLE MEDICARE ADVANTAGE PLANS.—Not 

21 later than two years after the date of the enactment 

22 of this Act, the Secretary shall— 

23 (A) select at least two Medicare Advantage 

24 sites with respect to which to conduct the dem25 onstration program under this section; and 


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1 (B) approve eligible Medicare Advantage 

2 plans to participate in such demonstration pro3 gram. 

4 In selecting Medicare Advantage sites under subpara5 graph (A), the Secretary shall take into account area 

6 differences as well as the availability of health main7 tenance organization plans and preferred provider or8 ganization plans offered in such sites. 

9 (2) START OF DEMONSTRATION.—The dem10 onstration program shall begin not later than the 

11 third plan year beginning after the date of the enact12 ment of this Act. 

13 (3) ELIGIBLE MEDICARE ADVANTAGE PLANS.— 

14 For purposes of this section, the term ‘‘eligible Medi15 care Advantage plan’’ means a Medicare Advantage 

16 plan under part C of title XVIII of the Social Secu17 rity Act (42 U.S.C. 1395w–21 et seq.) that meets the 

18 following requirements: 

19 (A) The plan is an Medicare Advantage re20 gional plan (as defined in paragraph (4) of sec21 tion 1859(b) of such Act (42 U.S.C. 1395w– 

22 28(b))) or Medicare Advantage local plan (as de23 fined in paragraph (5) of such section) offered in 

24 the Medicare Advantage region selected under 

25 paragraph (1)(A). 


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1 (B) The plan has— 

2 (i)(I) a quality rating under section 

3 1853(o) of such Act (42 U.S.C. 1395w– 

4 23(o)) of 4 stars or higher based on the most 

5 recent data available for such year, or (II) 

6 in the case of a specialized Medicare Advan7 tage plan for special needs individuals, as 

8 defined in section 1859(b)(6)(A) of such Act 

9 (42 U.S.C. 1395w–28(b)(6)(A)), a quality 

10 rating under section 1853(o) of such Act (42 

11 U.S.C. 1395w–23(o)) equal to or higher 

12 than the national average for special needs 

13 plans (excluding Institutional-Special needs 

14 plans) based on the most recent data avail15 able for such year; and 

16 (ii) at least 20 percent of the popu17 lation to whom the plan is offered in a serv18 ice area consists of subsidy eligible individ19 uals (as defined in section 1860D– 

20 14(a)(3)(A) of the Social Security Act (42 

21 U.S.C. 1395w–114(a)(3)(A))). 

22 (4) DISCLOSURE TO BENEFICIARIES.—The Sec23 retary shall provide to each individual eligible to en24 roll under a Medicare Advantage plan approved to 


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1 participate under the demonstration program during 

2 a plan year for which the plan is so selected— 

3 (A) notification that the plan is partici4 pating in such demonstration program; 

5 (B) background information on the dem6 onstration program; 

7 (C) clinical data derived from the studies 

8 resulting from the demonstration program; and 

9 (D) notification of the potential benefits 

10 that the individual will receive, and of the other 

11 potential impacts that the individual will expe12 rience, on account of the participation of the 

13 plan in the demonstration program. 

14 (c) VALUE-BASED INSURANCE DESIGN METHODOLO15 GIES.— 

16 (1) DEFINITION.—For purposes of this section, 

17 the term ‘‘value-based insurance design methodology’’ 

18 means a methodology for identifying specific prescrip19 tion medications, and clinical services that are pay20 able under title XVIII of the Social Security Act, for 

21 which the reduction of copayments, coinsurance, or 

22 both, would improve the management of specific 

23 chronic clinical conditions because of the high value 

24 and effectiveness of such medications and services for 


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1 such specific chronic clinical conditions, as approved 

2 by the Secretary. 

3 (2) USE OF METHODOLOGIES TO REDUCE COPAY4 MENTS AND COINSURANCE.—A Medicare Advantage 

5 organization offering an eligible Medicare Advantage 

6 plan approved to participate under the demonstration 

7 program, for each plan year for which the plan is so 

8 selected and using value-based insurance design meth9 odologies— 

10 (A) shall identify each prescription medica11 tion and clinical service covered under such plan 

12 for which the plan proposes to reduce or elimi13 nate the copayment or coinsurance, with respect 

14 to the management of specific chronic clinical 

15 conditions (as specified by the Secretary) of 

16 Medicare Advantage eligible individuals (as de17 fined in section 1851(a)(3) of the Social Security 

18 Act (42 U.S.C. 1395w–21(a)(3))) enrolled under 

19 such plans, for such plan year; 

20 (B) may, for such plan year, reduce or 

21 eliminate copayments, coinsurance, or both for 

22 such prescription medication and clinical serv23 ices so identified with respect to the management 

24 of such conditions of such individuals— 


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1 (i) if such reduction or elimination is 

2 evidence-based and for the purpose of en3 couraging such individuals in such plan to 

4 use such prescription medications and clin5 ical services (such as preventive care, pri6 mary care, specialty visits, diagnostic tests, 

7 procedures, and durable medical equipment) 

8 with respect to such conditions; and 

9 (ii) for the purpose of encouraging 

10 such individuals in such plan to use health 

11 care providers that such organization has 

12 identified with respect to such plan year as 

13 being high value providers; and 

14 (C) if a reduction or elimination is applied 

15 pursuant to subparagraph (B), with respect to 

16 such medication and clinical services, shall, for 

17 such plan year, count toward the deductible ap18 plicable to such individual under such plan 

19 amounts that would have been payable by the in20 dividual as copayment or coinsurance for such 

21 medication and services if the reduction or elimi22 nation had not been applied. 

23 (3) PROHIBITION OF INCREASES OF COPAYMENTS

24 AND COINSURANCE.—In no case may any Medicare 

25 Advantage plan participating in the demonstration 


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1 program increase, for any plan year for which the 

2 plan is so participating, the amount of copayments or 

3 coinsurance for any item or service covered under 

4 such plan for purposes of discouraging the use of such 

5 item or service. 

6 (d) REPORT ON IMPLEMENTATION.— 

7 (1) IN GENERAL.—Not later than 1 year after 

8 the date on which the demonstration program under 

9 this section begins under subsection (b)(2), the Sec10 retary shall submit to Congress a report on the status 

11 of the implementation of the demonstration program. 

12 (2) ELEMENTS.—The report required by para13 graph (1) shall, with respect to eligible Medicare Ad14 vantage plans participating in the demonstration 

15 program for the first plan year of such program, in16 clude the following: 

17 (A) A list of each medication and service 

18 identified pursuant to subsection (c)(2)(A) for 

19 such plan with respect to such plan year. 

20 (B) For each such medication or service so 

21 identified, the amount of the copayment or coin22 surance required under such plan with respect to 

23 such plan year for such medication or service 

24 and the amount of the reduction of such copay25 ment or coinsurance from a previous plan year. 


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1 (C) For each provider identified pursuant 

2 to subsection (c)(2)(B)(ii) for such plan with re3 spect to such plan year, a statement of the 

4 amount of the copayment or coinsurance re5 quired under such plan with respect to such plan 

6 year and the amount of the reduction of such co7 payment or coinsurance from the previous plan 

8 year. 

9 (e) REVIEW AND ASSESSMENT OF UTILIZATION OF

10 VALUE-BASED INSURANCE DESIGN METHODOLOGIES.— 

11 (1) IN GENERAL.—The Secretary shall enter into 

12 a contract or agreement with an independent entity 

13 to review and assess the implementation of the dem14 onstration program under this section. The review 

15 and assessment shall include the following: 

16 (A) An assessment of the utilization of 

17 value-based insurance design methodologies by 

18 Medicare Advantage plans participating under 

19 such program. 

20 (B) An analysis of whether reducing or 

21 eliminating the copayment or coinsurance for 

22 each medication and clinical service identified 

23 pursuant to subsection (c)(2)(A) resulted in in24 creased adherence to medication regimens, in25 creased service utilization, improvement in qualVerDate Sep 11 2014 23:39 Jun 16, 2015 Jkt 049200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6203 E:\BILLS\H2581.RH H2581

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1 ity metrics, better health outcomes, and enhanced 

2 beneficiary experience. 

3 (C) An analysis of the extent to which costs 

4 to Medicare Advantage plans under part C of 

5 title XVIII of the Social Security Act partici6 pating in the demonstration program is less 

7 than costs to Medicare Advantage plans under 

8 such part that are not participating in the dem9 onstration program. 

10 (D) An analysis of whether reducing or 

11 eliminating the copayment or coinsurance for 

12 providers identified pursuant to subsection 

13 (c)(2)(B)(ii) resulted in improvement in quality 

14 metrics, better health outcomes, and enhanced 

15 beneficiary experience. 

16 (E) An analysis, for each provider so iden17 tified, the extent to which costs to Medicare Ad18 vantage plans under part C of title XVIII of the 

19 Social Security Act participating in the dem20 onstration program is less than costs to Medicare 

21 Advantage plans under such part that are not 

22 participating in the demonstration program. 

23 (F) Such other matters as the Secretary 

24 considers appropriate. 


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1 (2) REPORT.—The contract or agreement entered 

2 into under paragraph (1) shall require such entity to 

3 submit to the Secretary a report on the review and 

4 assessment conducted by the entity under such para5 graph in time for the inclusion of the results of such 

6 report in the report required by paragraph (3). Such 

7 report shall include a description, in clear language, 

8 of the manner in which the entity conducted the re9 view and assessment. 

10 (3) REPORT TO CONGRESS.—Not later than 4 

11 years after the date on which the demonstration pro12 gram begins under subsection (b)(2), the Secretary 

13 shall submit to Congress a report on the review and 

14 assessment of the demonstration program conducted 

15 under this subsection. The report shall include the fol16 lowing: 

17 (A) A description of the results of the review 

18 and assessment included in the report submitted 

19 pursuant to paragraph (2). 

20 (B) Such recommendations as the Secretary 

21 considers appropriate for enhancing the utiliza22 tion of the methodologies applied under the dem23 onstration program to all Medicare Advantage 

24 plans under part C of title XVIII of the Social 

25 Security Act so as to reduce copayments and coVerDate Sep 11 2014 23:39 Jun 16, 2015 Jkt 049200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6203 E:\BILLS\H2581.RH H2581

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1 insurance under such plans paid by Medicare 

2 beneficiaries for high-value prescription medica3 tions and clinical services for which coverage is 

4 provided under such plans and to otherwise im5 prove the quality of health care provided under 

6 such plans. 

7 (4) OVERSIGHT REPORT.—Not later than three 

8 years after the date of the enactment of this Act, the 

9 Comptroller General of the United States shall submit 

10 to Congress a report on the demonstration program 

11 that includes an assessment, with respect to individ12 uals enrolled under Medicare Advantage plans ap13 proved to participate under the demonstration pro14 gram, of the impact that the age, co-morbidities, and 

15 geographic regions of such individuals had upon the 

16 implementation of the demonstration program by the 

17 plans with respect to such individuals. 

18 (f) SAVINGS.—In no case may any reduction in bene19 ficiary copayments or coinsurance resulting from the imple20 mentation of the demonstration program under this section 

21 result in expenditures under parts A, B, and D of the title 

22 XVIII of the Social Security Act that are greater than such 

23 expenditures without application of this section. 

24 (g) EXPANSION OF DEMONSTRATION PROGRAM.—Tak25 ing into account the review and assessment conducted under 


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1 subsection (e), the Secretary may, through notice and com2 ment rulemaking, expand (including implementation on a 

3 nationwide basis) the duration and scope of the demonstra4 tion program under title XVIII of the Social Security Act, 

5 other than under the original medicare fee-for-service pro6 gram under parts A and B of such title, to the extent deter7 mined appropriate by the Secretary, if the requirements of 

8 paragraphs (1), (2) and (3) of subsection (c) of section 

9 1115A of the Social Security Act (42 U.S.C. 1315a), as ap10 plied to the testing of a model under subsection (b) of such 

11 section, applied to the demonstration under this section. 

12 (h) WAIVER AUTHORITY.—The Secretary may waive 

13 such provisions of titles XI and XVIII of the Social Security 

14 Act as may be necessary to carry out the demonstration 

15 program under this section. 

16 (i) IMPLEMENTATION FUNDING.—For purposes of car17 rying out the demonstration program under this section, 

18 the Secretary shall provide for the transfer from the Federal 

19 Hospital Insurance Trust Fund under section 1817 of the 

20 Social Security Act (42 U.S.C. 1395i) and the Federal Sup21 plementary Insurance Trust Fund under section 1841 of 

22 the Social Security Act (42 U.S.C. 1395t), including the 

23 Medicare Prescription Drug Account in such Trust Fund, 

24 in such proportion as determined appropriate by the Sec25 retary, of such sums as may be necessary. 


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1 SEC. 3. PRESERVATION OF MEDICARE BENEFICIARY 

2 CHOICE UNDER MEDICARE ADVANTAGE. 

3 Section 1851(e)(2) of the Social Security Act (42 

4 U.S.C. 1395w–21(e)(2)) is amended— 

5 (1) in subparagraph (C)— 

6 (A) in the heading, by inserting ‘‘FROM 2011

7 THROUGH 2015’’ after ‘‘45-DAY PERIOD’’; and 

8 (B) by inserting ‘‘and ending with 2015’’ 

9 after ‘‘beginning with 2011’’; and 

10 (2) by adding at the end the following new sub11 paragraph: 

12 ‘‘(G) CONTINUOUS OPEN ENROLLMENT AND

13 DISENROLLMENT FOR FIRST 3 MONTHS IN 2016

14 AND SUBSEQUENT YEARS.— 

15 ‘‘(i) IN GENERAL.—Subject to clause 

16 (ii) and subparagraph (D)— 

17 ‘‘(I) in the case of an MA eligible 

18 individual who is enrolled in an MA 

19 plan, at any time during the first 3 

20 months of a year (beginning with 

21 2016); or 

22 ‘‘(II) in the case of an individual 

23 who first becomes an MA eligible indi24 vidual during a year (beginning with 

25 2016) and enrolls in an MA plan, dur26 ing the first 3 months during such 


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1 year in which the individual is an MA 

2 eligible individual; 

3 such MA eligible individual may change the 

4 election under subsection (a)(1). 

5 ‘‘(ii) LIMITATION OF ONE CHANGE

6 DURING OPEN ENROLLMENT PERIOD EACH

7 YEAR.—An individual may change the elec8 tion pursuant to clause (i) only once during 

9 the applicable 3-month period described in 

10 such clause in each year. The limitation 

11 under this clause shall not apply to changes 

12 in elections effected during an annual, co13 ordinated election period under paragraph 

14 (3) or during a special enrollment period 

15 under paragraph (4). 

16 ‘‘(iii) LIMITED APPLICATION TO PART

17 D.—Clauses (i) and (ii) of this subpara18 graph shall only apply with respect to 

19 changes in enrollment in a prescription 

20 drug plan under part D in the case of an 

21 individual who, previous to such change in 

22 enrollment, is enrolled in a Medicare Ad23 vantage plan. 

24 ‘‘(iv) LIMITATIONS ON MARKETING.— 

25 Pursuant to subsection (j), no unsolicited 


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1 marketing or marketing materials may be 

2 sent to an individual described in clause (i) 

3 during the continuous open enrollment and 

4 disenrollment period established for the in5 dividual under such clause, notwithstanding 

6 marketing guidelines established by the Cen7 ters for Medicare & Medicaid Services.’’. 

8 SEC. 4. TREATMENT OF INFUSION DRUGS FURNISHED 

9 THROUGH DURABLE MEDICAL EQUIPMENT. 

10 Section 1842(o)(1) of the Social Security Act (42 

11 U.S.C. 1395u(o)(1)) is amended— 

12 (1) in subparagraph (C), by inserting ‘‘(and in13 cluding a drug or biological described in subpara14 graph (D)(i) furnished on or after January 1, 2017)’’ 

15 after ‘‘2005’’; and 

16 (2) in subparagraph (D)— 

17 (A) by striking ‘‘infusion drugs’’ and insert18 ing ‘‘infusion drugs or biologicals’’ each place it 

19 appears; and 

20 (B) in clause (i)— 

21 (i) by striking ‘‘2004’’ and inserting 

22 ‘‘2004, and before January 1, 2017’’; and 

23 (ii) by striking ‘‘for such drug’’. 


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1 SEC. 5. SENSE OF CONGRESS REGARDING THE IMPLEMEN2 TATION AND DISTRIBUTION OF QUALITY IN3 CENTIVE PAYMENTS TO MEDICARE ADVAN4 TAGE PLANS. 

5 It is the sense of Congress that— 

6 (1) the Secretary of Health and Human Services 

7 has incorrectly interpreted subsection (n) of section 

8 1853 of the Social Security Act (42 U.S.C. 1395w– 

9 23) as prohibiting the provision of any Medicare 

10 quality incentive payments under subsection (o) of 

11 such section with respect to Medicare Advantage 

12 plans that exceed the payment benchmark cap under 

13 such subsection (n) for the area served by such plans; 

14 and 

15 (2) the Secretary should immediately apply 

16 quality incentive payments under such subsection (o) 

17 with respect to such Medicare Advantage plans with18 out regard to the limits set forth in such subsection 

19 (n). 


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Union Calendar No. 117 

114TH CONGRESS 

1ST SESSION H. R. 2581 

[Report No. 114–161, Part I] 

A BILL 

To amend title XVIII of the Social Security Act to 

ment, and for other purposes. drugs furnished through durable medical equipment under the Medicare program of infusion under Medicare Advantage, to revise the treatplans, to preserve Medicare beneficiary choice odologies under eligible Medicare Advantage the use of value-based insurance design methestablish a 3-year demonstration program to test 

JUNE 16, 2015 

Reported from the Committee on Ways and Means with 

J

an amendment 

UNE 16, 2015 

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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