I 

116TH CONGRESS 

1ST SESSION H. R. 3912 

To amend title XVIII of the Social Security Act to increase awareness, 

expand preventative services, and improve care for individuals with endstage renal disease, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JULY 23, 2019 

Mr. LEWIS (for himself and Mr. BUCHANAN) 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 increase 

awareness, expand preventative services, and improve 

care for individuals with end-stage renal disease, and 

for other purposes. 

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

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Chronic Kidney Dis5 ease Improvement in Research and Treatment Act’’. 


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1 TITLE I—INCREASING AWARE2 NESS, EXPANDING PREVENT3 ATIVE SERVICES, AND IM4 PROVING CARE COORDINA5 TION 

6 SEC. 101. INCREASING ACCESS TO MEDICARE KIDNEY DIS7 EASE EDUCATION BENEFIT. 

8 (a) IN GENERAL.—Section 1861(ggg) of the Social 

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

10 (1) in paragraph (1)— 

11 (A) in subparagraph (A), by inserting ‘‘or 

12 stage V’’ after ‘‘stage IV’’; and 

13 (B) in subparagraph (B), by inserting ‘‘or 

14 of a physician assistant, nurse practitioner, or 

15 clinical nurse specialist (as defined in section 

16 1861(aa)(5)) assisting in the treatment of the 

17 individual’s kidney condition’’ after ‘‘kidney 

18 condition’’; and 

19 (2) in paragraph (2)— 

20 (A) by striking subparagraph (B); and 

21 (B) in subparagraph (A)— 

22 (i) by striking ‘‘(A)’’ after ‘‘(2)’’; 

23 (ii) by striking ‘‘and’’ at the end of 

24 clause (i); 


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1 (iii) by striking the period at the end 

2 of clause (ii) and inserting ‘‘; and’’; 

3 (iv) by redesignating clauses (i) and 

4 (ii) as subparagraphs (A) and (B), respec5 tively; and 

6 (v) by adding at the end the following: 

7 ‘‘(C) a renal dialysis facility subject to the 

8 requirements of section 1881(b)(1) with per9 sonnel who— 

10 ‘‘(i) provide the services described in 

11 paragraph (1); and 

12 ‘‘(ii) is a physician (as defined in sub13 section (r)(1)) or a physician assistant, 

14 nurse practitioner, or clinical nurse spe15 cialist (as defined in subsection (aa)(5)).’’. 

16 (b) PAYMENT TO RENAL DIALYSIS FACILITIES.— 

17 Section 1881(b) of the Social Security Act (42 U.S.C. 

18 1395rr(b)) is amended by adding at the end the following 

19 new paragraph: 

20 ‘‘(15) For purposes of paragraph (14), the sin21 gle payment for renal dialysis services under such 

22 paragraph shall not take into account the amount of 

23 payment for kidney disease education services (as 

24 defined in section 1861(ggg)). Instead, payment for 

25 such services shall be made to the renal dialysis faVerDate Sep 11 2014 02:56 Aug 07, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H3912.IH H3912

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1 cility on an assignment-related basis under section 

2 1848.’’. 

3 (c) EFFECTIVE DATE.—The amendments made by 

4 this section apply to kidney disease education services fur5 nished on or after January 1, 2020. 

6 SEC. 102. UNDERSTANDING CURRENT UTILIZATION OF PAL7 LIATIVE CARE SERVICES. 

8 (a) STUDY.— 

9 (1) IN GENERAL.—The Comptroller General of 

10 the United States (in this section referred to as the 

11 ‘‘Comptroller General’’) shall conduct a study on the 

12 utilization of palliative care in treating individuals 

13 with advanced kidney disease, from stage 4 through 

14 stage 5, including individuals with kidney failure on 

15 dialysis through any progression of the disease. Such 

16 study shall include an analysis of— 

17 (A) how palliative care can be utilized to 

18 improve the quality of life of those with kidney 

19 disease and facilitate care tailored to their indi20 vidual goals and values; 

21 (B) the successful use of palliative care in 

22 the care of patients with other chronic diseases 

23 and serious illnesses; 


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1 (C) the utilization of palliative care at any 

2 point in an illness, including when used at the 

3 same time as curative treatment; and 

4 (D) other areas determined appropriate by 

5 the Comptroller General. 

6 (2) DEFINITION OF PALLIATIVE CARE.—In this 

7 section, the term ‘‘palliative care’’ means patient 

8 and family centered care that optimizes quality of 

9 life by anticipating, preventing, and treating suf10 fering. Such term includes care that is furnished 

11 throughout the continuum of the illness that ad12 dresses physical, intellectual, emotional, social, and 

13 spiritual needs and that facilitates patient autonomy, 

14 access to information and choice. 

15 (b) REPORT.—Not later than 1 year after the date 

16 of the enactment of this Act, the Comptroller General shall 

17 submit to the Congress a report on the study conducted 

18 under subsection (a), together with such recommendations 

19 as the Comptroller General determines to be appropriate. 

20 SEC. 103. IMPROVING ACCESS IN UNDERSERVED AREAS. 

21 (a) DEFINITION OF PRIMARY CARE SERVICES.—Sec22 tion 331(a)(3)(D) of the Public Health Service Act (42 

23 U.S.C. 254d(a)(3)(D)) is amended by inserting ‘‘and in24 cludes renal dialysis services’’ before the period at the end. 


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1 (b) NATIONAL HEALTH SERVICE CORPS SCHOLAR2 SHIP PROGRAM.—Section 338A(a)(2) of the Public Health 

3 Service Act (42 U.S.C. 254l(a)(2)) is amended by insert4 ing ‘‘, including nephrology health professionals’’ before 

5 the period at the end. 

6 (c) NATIONAL HEALTH SERVICE CORPS LOAN RE7 PAYMENT PROGRAM.—Section 338B(a)(2) of the Public 

8 Health Service Act (42 U.S.C. 254l–1(a)(2)) is amended 

9 by inserting ‘‘, including nephrology health professionals’’ 

10 before the period at the end. 

11 SEC. 104. IMPROVING CARE COORDINATION FOR DIALYSIS 

12 PATIENTS. 

13 (a) HOSPITALS REQUIRED TO PROVIDE INFORMA14 TION.—Section 1881 of the Social Security Act (42 U.S.C. 

15 1395rr) is amended by adding at the end the following 

16 new subsection: 

17 ‘‘(i) HOSPITALS REQUIRED TO PROVIDE INFORMA18 TION.— 

19 ‘‘(1) IN GENERAL.—The Secretary shall estab20 lish a process under which a hospital or a critical ac21 cess hospital shall provide a renal dialysis facility 

22 with health and treatment information with respect 

23 to an individual who is discharged from the hospital 

24 or critical access hospital and who subsequently re25 ceives treatment at facility. 


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1 ‘‘(2) ELEMENTS.—Under the process estab2 lished under paragraph (1)— 

3 ‘‘(A) the request for the health information 

4 may be initiated by the individual prior to dis5 charge or upon request by the renal dialysis fa6 cility after the patient is discharged; and 

7 ‘‘(B) the information must be provided to 

8 the facility within 7 days of the request being 

9 made.’’. 

10 TITLE II—INCENTIVIZING INNO11 VATION FOR TRULY INNOVA12 TIVE NEW DRUGS, 

13 BIOLOGICALS, DEVICES, AND 

14 OTHER TECHNOLOGIES. 

15 SEC. 201. MAINTAIN AN ECONOMICALLY STABLE DIALYSIS 

16 INFRASTRUCTURE. 

17 (a) IN GENERAL.—Section 1881(b)(14) of the Social 

18 Security Act (42 U.S.C. 1395rr(b)(14)) is amended— 

19 (1) in subparagraph (D), in the matter pre20 ceding clause (i), by striking ‘‘Such system’’ and in21 serting ‘‘Subject to subparagraph (J), such system’’; 

22 and 

23 (2) by adding at the end the following new sub24 paragraph: 


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1 ‘‘(J) For payment for renal dialysis services 

2 furnished on or after January 1, 2020, under the 

3 system under this paragraph— 

4 ‘‘(i) the payment adjustment described in 

5 clause (i) of subparagraph (D)— 

6 ‘‘(I) shall not take into account 

7 comorbidities; and 

8 ‘‘(II) shall only take into account age 

9 for purposes of distinguishing between in10 dividuals who are under 18 years of age 

11 and those who are 18 years of age and 

12 older but shall not include any other ad13 justment for age; 

14 ‘‘(ii) the Secretary shall reassess any ad15 justments related to patient weight under such 

16 clause; 

17 ‘‘(iii) the payment adjustment described in 

18 clause (ii) of such subparagraph shall not be in19 cluded; 

20 ‘‘(iv) the standardization factor described 

21 in the final rule published in the Federal Reg22 ister on November 8, 2012 (77 Fed. Reg. 

23 67470), shall be established using the most cur24 rently available data (and not historical data) 

25 and adjusted on an annual basis, based on such 


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1 available data, to account for any change in uti2 lization of drugs and any modification in adjus3 tors applied under this paragraph; and 

4 ‘‘(v) take into account reasonable costs for 

5 determining the payment rate consistent with 

6 paragraph (2)(B).’’. 

7 (b) INCLUSION OF NETWORK FEE AS AN ALLOW8 ABLE COST.—Section 1881(b)(14) of the Social Security 

9 Act (42 U.S.C. 1395rr(b)(14)), as amended by subsection 

10 (a), is amended by adding at the end the following new 

11 subparagraph: 

12 ‘‘(K) Not later than January 1, 2020, the Sec13 retary shall amend the ESRD facility cost report to 

14 include the per treatment network fee (as described 

15 in paragraph (7)) as an allowable cost or offset to 

16 revenue.’’. 

17 (c) AFFIRMATION OF AVAILABILITY OF BAD DEBT

18 REIMBURSEMENT FOR NON-COMPOSITE RATE SERV19 ICES.— 

20 (1) REPEAL OF MIPPA BAD DEBT RULE OF

21 CONTRUCTION.—Section 153(b)(4) of the Medicare 

22 Improvements for Patients and Providers Act (42 

23 U.S.C. 1395rr note) is repealed. 

24 (2) BAD DEBT PAYMENTS.—Section 

25 1881(b)(14) of the Social Security Act (42 U.S.C. 


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1 1395rr(b)), as amended by subsections (a) and (b), 

2 is further amended by adding at the end the fol3 lowing new subparagraphs: 

4 ‘‘(L) Notwithstanding any other provision of 

5 this title, the Secretary shall provide payments for 

6 any unrecovered amount for any bad debt attrib7 utable to deductible and coinsurance for any item or 

8 service reimbursed under the system under this 

9 paragraph or bad debt described in section 

10 153(b)(4) of the Medicare Improvements for Pa11 tients and Providers Act of 2008. Such payments for 

12 any unrecovered amount shall be made in addition 

13 to payments made under such system and such drug 

14 designation process. 

15 ‘‘(M) The additional payments made under sub16 paragraph (L)— 

17 ‘‘(i) shall not be considered an adjustment 

18 under subparagraph (D); and 

19 ‘‘(ii) shall not be implemented in a budget 

20 neutral manner.’’. 

21 (3) EFFECTIVE DATE.—Paragraph (1) and the 

22 amendments made by paragraph (2) shall apply to 

23 payments beginning on January 1, 2020. 


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1 (d) PRODUCTIVITY ADJUSTMENT.—Section 

2 1886(b)(3)(B)(xi) of the Social Security Act (42 U.S.C. 

3 1395ww(b)(3)(B)(xi)) is amended— 

4 (1) in subclause (I), by striking ‘‘For 2012’’ 

5 and inserting ‘‘Subject to subclause (IV), for 2012’’; 

6 and 

7 (2) by adding at the end, the following new sub8 clause: 

9 ‘‘(IV) For 2020 through 2024, 

10 the productivity adjustment described 

11 in subclause (II) shall be zero for a 

12 payment system for any year in which 

13 the Medicare Payment Advisory Com14 mission established under section 

15 1805 estimates that payments pro16 vided under such payment system, on 

17 an aggregate national basis, exceed 

18 costs, on an aggregate national basis, 

19 by 3.0 percent or less.’’. 

20 (e) PAYMENT FOR NEW AND INNOVATIVE DRUGS

21 AND BIOLOGICALS THAT ARE RENAL DIALYSIS SERV22 ICES.—Section 1881(b)(14) of the Social Security Act (42 

23 U.S.C. 1395ww(b)(14)), as amended by subsections (a), 

24 (b), and (c), is further amended by adding the following 

25 new subparagraph: 


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1 ‘‘(N) PAYMENT FOR NEW AND INNOVATIVE

2 DRUGS, BIOLOGICALS, AND DEVICES THAT ARE

3 RENAL DIALYSIS SERVICES.— 

4 ‘‘(i) IN GENERAL.—For drugs or 

5 biologicals determined to be within a func6 tional category, the Secretary, in consulta7 tion with stakeholders, shall ensure that 

8 the single payment amount is adequate to 

9 cover the cost of new innovative drugs or 

10 biologicals and increase the single payment 

11 amount if it is not. The Secretary shall use 

12 the cost and utilization data collected dur13 ing the two-year transitional period, as set 

14 forth in the final regulation entitled ‘Medi15 care Program; End-Stage Renal Disease 

16 Prospective Payment System, Payment for 

17 Renal Dialysis Services Furnished to Indi18 viduals With Acute Kidney Injury, End19 Stage Renal Disease Quality Incentive Pro20 gram, Durable Medical Equipment, Pros21 thetics, Orthotics and Supplies (DMEPOS) 

22 Competitive Bidding Program (CBP) and 

23 Fee Schedule Amounts, and Technical 

24 Amendments To Correct Existing Regula25 tions Related to the CBP for Certain 


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1 DMEPOS’ published on November 14, 

2 2018 (83 Fed. Reg. 56922 et seq.). 

3 ‘‘(ii) MONEY TO FOLLOW THE PA4 TIENT.—The Secretary through notice and 

5 comment rulemaking shall implement a 

6 policy for any drug or biological that is not 

7 provided to the average patient that results 

8 in the amount by which the single payment 

9 amount is increased pursuant to this 

10 clause shall be paid only when a provider 

11 or renal dialysis facility has demonstrated 

12 that it has administered the drug or bio13 logical to a patient.’’. 

14 (f) NEW DEVICES AND OTHER TECHNOLOGIES.—As 

15 part of the promulgation of the annual rule for the Medi16 care end-stage renal disease prospective payment system 

17 under section 1881(b)(14) of the Social Security Act (42 

18 U.S.C. 1395rr(b)(14)) for calendar year 2021 and in con19 sultation with stakeholders, the Secretary of Health and 

20 Human Services shall establish a process for identifying 

21 and determining appropriate payment amounts for incor22 porating new devices and technologies into the bundled 

23 payment under such system. 


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1 TITLE III—IMPROVING THE AC2 CURACY AND TRANSPARENCY 

3 OF END-STAGE RENAL DIS4 EASE QUALITY PROGRAMS 

5 SEC. 301. IMPROVE PATIENT DECISION MAKING AND 

6 TRANSPARENCY BY CONSOLIDATING AND 

7 MODERNIZING QUALITY PROGRAMS. 

8 (a) MEASURES.—Section 1881(h)(2) of the Social 

9 Security Act (42 U.S.C. 1395rr(h)(2)) is amended— 

10 (1) by striking subparagraph (A) and inserting 

11 the following: 

12 ‘‘(A) IN GENERAL.—The measures speci13 fied under this paragraph with respect to the 

14 year involved shall be selected in consultation 

15 with stakeholders to promote improvement in 

16 beneficiary outcomes and shared decision-mak17 ing with beneficiaries and their caregivers. 

18 When selecting measures specified under this 

19 paragraph, the Secretary shall take into ac20 count clinical gaps in care, underutilization that 

21 may lead to beneficiary harm, patient safety, 

22 and outcomes.’’. 

23 (2) by adding at the end the following new sub24 paragraphs: 


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1 ‘‘(F) WEIGHTING LIMITATION.—No single 

2 measure specified by the Secretary or individual 

3 measure within a composite measure so speci4 fied may be weighted less than 10 percent of 

5 the total performance score. 

6 ‘‘(G) STATISTICALLY VALID AND RELI7 ABLE.—In specifying measures under subpara8 graph (A), the Secretary shall only specify 

9 measures that have been shown to be statis10 tically valid and reliable through testing.’’. 

11 (b) ENDORSEMENT.—Section 1881(h)(2)(B) of the 

12 Social Security Act (42 U.S.C. 1395rr(h)(2)(B)) is 

13 amended— 

14 (1) in clause (ii), by adding at the end the fol15 lowing new sentence: ‘‘The exception under the pre16 ceding sentence shall not apply to a measure that 

17 the entity with a contract under section 1890(a) (or 

18 a similar entity) considered but failed to endorse.’’; 

19 and 

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

21 clause: 

22 ‘‘(iii) COMPOSITE MEASURES.— 

23 Clauses (i) and (ii) shall apply to com24 posite measures in the same manner as 


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1 such clauses apply to individual meas2 ures.’’. 

3 (c) REQUIREMENTS FOR DIALYSIS FACILITY COM4 PARE STAR RATING PROGRAM.—Section 1881(h)(6) of 

5 the Social Security Act (42 U.S.C. 1395rr(h)(6)) is 

6 amended by adding at the end the following new subpara7 graph: 

8 ‘‘(E) REQUIREMENTS FOR ANY DIALYSIS

9 FACILITY COMPARE STAR RATING PROGRAM.— 

10 To the extent that the Secretary maintains a 

11 dialysis facility compare star rating program, 

12 under such a program the Secretary shall— 

13 ‘‘(i) assign stars using the same meth14 odology and total performance score re15 sults from the quality incentive program 

16 under this subsection; 

17 ‘‘(ii) determine the stars using the 

18 same methodology used under such quality 

19 incentive program; and 

20 ‘‘(iii) not use a forced bell curve when 

21 determining the stars or rebaselining the 

22 stars.’’. 

23 (d) INCENTIVE PAYMENTS.— 

24 (1) IN GENERAL.—Section 1881(h)(1) of the 

25 Social Security Act (42 U.S.C. 1395rr(h)(1)) is 


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1 amended by adding at the end the following new 

2 subparagraph: 

3 ‘‘(D) INCENTIVE PAYMENTS.— 

4 ‘‘(i) IN GENERAL.—In the case of a 

5 provider of services or a renal dialysis fa6 cility that the Secretary determines exceeds 

7 the attainment performance standards 

8 under paragraph (4) with respect to a 

9 year, the Secretary may make a bonus 

10 payment to the provider or facility (pursu11 ant to a process established by the Sec12 retary). 

13 ‘‘(ii) FUNDING.—The total amount of 

14 bonus payments under clause (i) in a year 

15 shall be equal to the total amount of re16 duced payments in a year under subpara17 graph (A). 

18 ‘‘(iii) NO EFFECT IN SUBSEQUENT

19 YEARS.—The provisions of subparagraph 

20 (C) shall apply to a bonus payment under 

21 this subparagraph in the same manner 

22 subparagraph (C) applies to a reduction 

23 under such subparagraph.’’. 


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1 (2) EFFECTIVE DATE.—The amendments made 

2 by this section shall apply to items and services fur3 nished on or after January 1, 2020. 

4 TITLE IV—EMPOWERING 

5 PATIENTS 

6 SEC. 401. MEDIGAP COVERAGE FOR BENEFICIARIES WITH 

7 END-STAGE RENAL DISEASE. 

8 (a) GUARANTEED AVAILABILITY OF MEDIGAP POLI9 CIES TO ALL ESRD MEDICARE BENEFICIARIES.— 

10 (1) IN GENERAL.—Section 1882(s) of the So11 cial Security Act (42 U.S.C. 1395ss(s)) is amend12 ed— 

13 (A) in paragraph (2)— 

14 (i) in subparagraph (A), by striking 

15 ‘‘is 65’’ and all that follows through the 

16 period at the end and inserting the fol17 lowing: ‘‘is— 

18 ‘‘(i) 65 years of age or older and is 

19 enrolled for benefits under part B; or 

20 ‘‘(ii) is entitled to benefits under 

21 226A(b) and is enrolled for benefits under 

22 part B.’’; and 

23 (ii) in subparagraph (D), in the mat24 ter preceding clause (i), by inserting ‘‘(or 


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1 is entitled to benefits under 226A(b))’’ 

2 after ‘‘is 65 years of age or older’’; and 

3 (B) in paragraph (3)(B)— 

4 (i) in clause (ii), by inserting ‘‘(or is 

5 entitled to benefits under 226A(b))’’ after 

6 is 65 years of age or older; and 

7 (ii) in clause (vi), by inserting ‘‘(or 

8 under 226A(b))’’ after ‘‘at age 65’’. 

9 (2) EFFECTIVE DATE.—The amendments made 

10 by paragraph (1) shall apply to Medicare supple11 mental policies effective on or after January 1, 

12 2021. 

13 (b) ADDITIONAL ENROLLMENT PERIOD FOR CER14 TAIN INDIVIDUALS.— 

15 (1) ONE-TIME ENROLLMENT PERIOD.— 

16 (A) IN GENERAL.—In the case of an indi17 vidual described in paragraph (2), the Secretary 

18 of Health and Human Services shall establish a 

19 one-time enrollment period during which such 

20 an individual may enroll in any Medicare sup21 plemental policy under section 1882 of the So22 cial Security Act (42 U.S.C. 1395ss) of the in23 dividual’s choosing. 

24 (B) ENROLLMENT PERIOD.—The enroll25 ment period established under subparagraph 


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1 (A) shall begin on January 1, 2021, and shall 

2 end June 30, 2021. 

3 (2) INDIVIDUAL DESCRIBED.—An individual de4 scribed in this paragraph is an individual who— 

5 (A) is entitled to hospital insurance bene6 fits under part A of title XVIII of the Social 

7 Security Act under section 226A(b) of such Act 

8 (42 U.S.C. 426–1(b)); 

9 (B) is enrolled for benefits under part B of 

10 such title XVIII; and 

11 (C) would not, but for the provisions of, 

12 and amendments made by, subsection (a) be eli13 gible for the guaranteed issue of a Medicare 

14 supplemental policy under paragraph (2) or (3) 

15 of section 1882(s) of such Act (42 U.S.C. 

16 1395ss(s)). 

17 SEC. 402. ALLOWING INDIVIDUALS WITH KIDNEY FAILURE 

18 TO RETAIN ACCESS TO PRIVATE INSURANCE. 

19 (a) IN GENERAL.—Section 1862(b)(1)(C) of the So20 cial Security Act (42 U.S.C. 1395y(b)(1)(C)) is amend21 ed— 

22 (1) in the last sentence, by inserting ‘‘and be23 fore January 1, 2020’’ after ‘‘prior to such date’’; 

24 and 


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1 (2) by adding at the end the following new sen2 tence: ‘‘Effective for items and services furnished on 

3 or after January 1, 2020 (with respect to periods 

4 beginning on or after the date that is 42 months 

5 prior to such date), clauses (i) and (ii) shall be ap6 plied by substituting ‘42-month’ for ‘12-month’ each 

7 place it appears.’’. 

8 (b) EFFECTIVE DATE.—The amendments made by 

9 this subsection shall take effect on the date of enactment 

10 of this Act. For purposes of determining an individual’s 

11 status under section 1862(b)(1)(C) of the Social Security 

12 Act (42 U.S.C. 1395y(b)(1)(C)), as amended by sub13 section (a), an individual who is within the coordinating 

14 period as of the date of enactment of this Act shall have 

15 that period extended to the full 42 months described in 

16 the last sentence of such section, as added by the amend17 ment made by subsection (a)(2). 

Æ 


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