I 

116TH CONGRESS 

1ST SESSION H. R. 2282 

To amend title XVIII of the Social Security Act to modernize the physician 

self-referral prohibitions to promote care coordination in the merit-based 

incentive payment system and to facilitate physician practice participation 

in alternative payment models under the Medicare program, and for 

other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

APRIL 10, 2019 

Mr. RUIZ (for himself, Mr. BUCSHON, Mr. KIND, and Mr. MARCHANT) introduced the following bill; which was referred to the Committee on Energy 

and Commerce, and in addition to the Committee on Ways and Means, 

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 modernize 

the physician self-referral prohibitions to promote care 

coordination in the merit-based incentive payment system 

and to facilitate physician practice participation in alternative payment models under the Medicare program, and 

for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Medicare Care Coordi3 nation Improvement Act of 2019’’. 

4 SEC. 2. MODERNIZATION OF LIMITATIONS ON PHYSICIAN 

5 SELF-REFERRAL. 

6 (a) FACILITATION OF PARTICIPATION IN ALTER7 NATIVE PAYMENT MODELS.— 

8 (1) IN GENERAL.—Section 1833 of the Social 

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

10 (A) in subsection (z), as added by section 

11 101(e)(2) of the Medicare Access and CHIP 

12 Reauthorization Act of 2015 (Public Law 114– 

13 10), by adding at the end the following para14 graph: 

15 ‘‘(5) WAIVER AUTHORITY.— 

16 ‘‘(A) IN GENERAL.—The provisions of sub17 section (f) of section 1899 shall apply with re18 spect to covered APM entities to the same ex19 tent and in the same manner as such provisions 

20 apply with respect to accountable care organiza21 tions under such section. 

22 ‘‘(B) COVERED APM ENTITIES.— 

23 ‘‘(i) IN GENERAL.—For purposes of 

24 subparagraph (A), the term ‘covered APM 

25 entity’ means, subject to clause (ii) of this 


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1 subparagraph and subparagraph (C), each 

2 of the following: 

3 ‘‘(I) An eligible alternative pay4 ment entity as defined in paragraph 

5 (3)(D). 

6 ‘‘(II) An entity participating in 

7 an alternative payment model as de8 fined in paragraph (3)(C), including 

9 such participation that qualifies as a 

10 clinical practice improvement activity 

11 under section 1848(q)(2)(B)(iii)(VI). 

12 ‘‘(III) An entity participating in 

13 a physician-focused payment model 

14 for which comments and recommenda15 tions have, under subparagraph (C) of 

16 section 1868(c)(2), been submitted in17 dicating that such model meets the 

18 criteria described in subparagraph (A) 

19 of such section. 

20 ‘‘(IV) An entity participating in 

21 any other model that the Secretary 

22 determines is a covered APM entity 

23 for purposes of subparagraph (A), in24 cluding such a determination made 

25 pursuant to one or more physicians 


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1 submitting a proposal to the Secretary 

2 for an alternative payment model. 

3 ‘‘(ii) INCLUSION OF CERTAIN ENTI4 TIES.—Such term may include an entity 

5 engaging in activities that the Secretary 

6 has determined constitute significant 

7 progress toward establishing a model re8 ferred to in any of subclauses (I) through 

9 (IV). Any waiver under this paragraph 

10 with respect to an entity described in the 

11 preceding sentence may only be approved 

12 for three years. 

13 ‘‘(C) CERTAIN REQUIREMENTS.—A model 

14 referred to in any of subclauses (I) through 

15 (IV) of subparagraph (B)(i) may not be consid16 ered a covered APM entity for purposes of sub17 paragraph (A) unless the model meets the re18 quirements described in section 

19 1877(b)(6)(B).’’; and 

20 (B) by redesignating subsection (z), as 

21 added by section 514(a) of the Medicare Access 

22 and CHIP Reauthorization Act of 2015 (Public 

23 Law 114–10), as subsection (aa). 

24 (2) CONFORMING AMENDMENT.—Section 

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1 thorization Act of 2015 (Public Law 114–10) is 

2 amended by striking ‘‘subsection (z)’’ and inserting 

3 ‘‘subsection (aa)’’. 

4 (b) EXCEPTION FACILITATING THE DEVELOPMENT

5 AND OPERATION OF ALTERNATIVE PAYMENT MODELS.— 

6 Section 1877(b) of the Social Security Act (42 U.S.C. 

7 1395nn(b)) is amended by adding at the end the following 

8 new paragraph: 

9 ‘‘(6) DEVELOPMENT AND OPERATION OF AL10 TERNATIVE PAYMENT MODELS.— 

11 ‘‘(A) IN GENERAL.—In the case of items 

12 and services furnished pursuant to an arrange13 ment that meets the requirements described in 

14 subparagraph (B) entered into for the purpose 

15 of developing or operating a covered APM enti16 ty (as defined in section 1833(z)(5)(B)), includ17 ing— 

18 ‘‘(i) an advanced alternative payment 

19 model described in section 1833(z) (includ20 ing a physician-focused payment model re21 ferred to in section 1868(c)); 

22 ‘‘(ii) a MIPS APM (as defined by the 

23 Secretary); and 


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1 ‘‘(iii) any other alternative payment 

2 model that the Secretary may, by regula3 tion, specify. 

4 ‘‘(B) REQUIREMENTS.— 

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

6 (ii), the requirements described in this sub7 paragraph with respect to an arrangement 

8 relating to an alternative payment model 

9 are as follows: 

10 ‘‘(I) The arrangement is in writ11 ing, identifies the services, items, or 

12 actions subject to the arrangement 

13 and is signed by the parties to the ar14 rangement. 

15 ‘‘(II) The arrangement includes a 

16 description of the alternative payment 

17 model. 

18 ‘‘(III) Under the arrangement 

19 written reports are submitted to the 

20 Secretary on a semi-annual basis on 

21 the progress achieved in the develop22 ment and operation of the alternative 

23 payment model. 

24 ‘‘(IV) The arrangement meets 

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1 retary may impose by regulation as 

2 needed to protect against a significant 

3 risk of program or patient abuse. 

4 ‘‘(ii) CLARIFICATION.—The Secretary 

5 shall not prohibit or restrict an arrange6 ment from meeting the requirements de7 scribed in this subparagraph on the basis 

8 that the arrangement takes into account 

9 the volume or value of referrals if such ar10 rangement otherwise meets the require11 ments described in clause (i).’’. 

Æ 


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