I 
113TH CONGRESS 
2D SESSION 
H. R. 4814 
To improve the understanding of, and promote access to treatment for, 
chronic kidney disease, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JUNE 9, 2014 
Mr. MARINO (for himself and Mr. LEWIS) 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 provi-
sions as fall within the jurisdiction of the committee concerned 
A BILL 
To improve the understanding of, and promote access to 
treatment for, chronic kidney disease, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Chronic Kidney Dis-
ease Improvement in Research and Treatment Act of 
2014’’. 
SEC. 2. TABLE OF CONTENTS. 
The table of contents of this Act is as follows: 
Sec. 1. Short title. 
Sec. 2. Table of contents. 
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TITLE I—IMPROVING UNDERSTANDING OF CHRONIC KIDNEY 
DISEASE THROUGH EXPANDED RESEARCH AND COORDINATION 
Sec. 101. Identifying gaps in chronic kidney disease research. 
Sec. 102. Coordinating research on chronic kidney disease. 
Sec. 103. Understanding the progression of kidney disease and treatment of 
kidney failure in minority populations. 
TITLE II—PROMOTING ACCESS TO CHRONIC KIDNEY DISEASE 
TREATMENTS 
Sec. 201. Increasing access to Medicare kidney disease education benefit. 
Sec. 202. Improving access to chronic kidney disease treatment in underserved 
rural and urban areas. 
Sec. 203. Promoting access to home dialysis treatments. 
Sec. 204. Expand access for patients with acute kidney injury. 
TITLE III—CREATING ECONOMIC STABILITY FOR PROVIDERS 
CARING FOR INDIVIDUALS WITH CHRONIC KIDNEY DISEASE 
Sec. 301. Stabilizing Medicare payments for services provided to beneficiaries 
with stage V chronic kidney disease receiving dialysis services. 
Sec. 302. Allowing individuals with kidney failure to retain access to private in-
surance. 
Sec. 303. Providing individuals with kidney failure access to managed care and 
coordinated care programs. 
TITLE 
I—IMPROVING 
UNDER-
STANDING OF CHRONIC KID-
NEY DISEASE THROUGH EX-
PANDED RESEARCH AND CO-
ORDINATION 
SEC. 101. IDENTIFYING GAPS IN CHRONIC KIDNEY DISEASE 
RESEARCH. 
(a) REPORT.—Not later than one year after the date 
of enactment of this Act, the Comptroller General of the 
United States shall develop and submit to the Congress 
a comprehensive report assessing the adequacy of Federal 
expenditures in chronic kidney disease research relative to 
Federal expenditures for chronic kidney disease care. 
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(b) CONTENTS.—The report required by this section 
shall— 
(1) analyze the current chronic kidney disease 
research projects being funded by Federal agencies; 
(2) identify, including by surveying the kidney 
care community, areas of chronic kidney disease 
knowledge gaps that are not part of current Federal 
research efforts; 
(3) report on the level of Federal expenditures 
on kidney research as compared to the amount of 
Federal expenditures on treating individuals with 
chronic kidney disease; and 
(4) identify areas of kidney failure knowledge 
gaps in research to assess treatment patterns associ-
ated with providing care to minority populations 
that are disproportionately affected by kidney fail-
ure. 
SEC. 102. COORDINATING RESEARCH ON CHRONIC KIDNEY 
DISEASE. 
(a) INTERAGENCY COMMITTEE.—The Secretary of 
Health and Human Services shall establish and maintain 
an interagency committee for the purpose of improving the 
coordination of chronic kidney disease research. 
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(b) REPORTS.—For the purpose described in sub-
section (a), the interagency committee established under 
such subsection shall issue public reports that— 
(1) include a strategic plan, including rec-
ommendations for— 
(A) improving communication and coordi-
nation among Federal agencies; 
(B) procedures for monitoring Federal 
chronic kidney disease research activities; and 
(C) ways to maximize the efficiency of the 
Federal chronic kidney disease research invest-
ment and minimize the potential for unneces-
sary duplication; 
(2) include a portfolio analysis that provides in-
formation on chronic kidney disease research 
projects, organized by the strategic plan objectives; 
and 
(3) address such other topics as the interagency 
committee determines appropriate. 
(c) MEETINGS.—The interagency committee estab-
lished under subsection (a) shall meet not less than semi- 
annually. 
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SEC. 103. UNDERSTANDING THE PROGRESSION OF KIDNEY 
DISEASE AND TREATMENT OF KIDNEY FAIL-
URE IN MINORITY POPULATIONS. 
Not later than one year after the date of enactment 
of this Act, the Secretary of Health and Human Services 
shall— 
(1) complete a study on— 
(A) the social, behavioral, and biological 
factors leading to kidney disease; 
(B) efforts to slow the progression of kid-
ney disease in minority populations that are 
disproportionately affected by such disease; and 
(C) treatment patterns associated with 
providing care, under the Medicare program 
under title XVIII of the Social Security Act, the 
Medicaid program under title XIX of such Act, 
and through private health insurance, to minor-
ity populations that are disproportionately af-
fected by kidney failure; and 
(2) submit a report to the Congress on the re-
sults of such study. 
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TITLE II—PROMOTING ACCESS 
TO 
CHRONIC 
KIDNEY 
DIS-
EASE TREATMENTS 
SEC. 201. INCREASING ACCESS TO MEDICARE KIDNEY DIS-
EASE EDUCATION BENEFIT. 
(a) IN GENERAL.—Section 1861(ggg) of the Social 
Security Act (42 U.S.C. 1395x(ggg)) is amended— 
(1) in paragraph (1)— 
(A) in subparagraph (A), by inserting ‘‘ or 
stage V’’ after ‘‘stage IV’’; 
(B) in subparagraph (B), by inserting ‘‘or 
of a physician assistant, nurse practitioner, or 
clinical nurse specialist (as defined in section 
1861(aa)(5)) assisting in the treatment of the 
individual’s kidney condition’’ after ‘‘kidney 
condition’’; and 
(2) in paragraph (2)— 
(A) by striking subparagraph (B); and 
(B) in subparagraph (A)— 
(i) by striking ‘‘(A)’’ after ‘‘(2)’’; 
(ii) by striking ‘‘and’’ at the end of 
clause (i); 
(iii) by striking the period at the end 
of clause (ii) and inserting ‘‘; and’’; 
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(iv) by redesignating clauses (i) and 
(ii) as subparagraphs (A) and (B), respec-
tively; and 
(v) by adding at the end the following: 
‘‘(C) a renal dialysis facility subject to the 
requirements of section 1881(b)(1) with per-
sonnel who— 
‘‘(i) provide the services described in 
paragraph (1); and 
‘‘(ii) is a physician (as defined in sub-
section (r)(1)) or a physician assistant, 
nurse practitioner, or clinical nurse spe-
cialist (as defined in subsection (aa)(5)).’’. 
(b) PAYMENT TO RENAL DIALYSIS FACILITIES.— 
Section 1881(b) of such Act (42 U.S.C. 1395rr(b)) is 
amended by adding at the end the following new para-
graph: 
‘‘(15) For purposes of paragraph (14), the sin-
gle payment for renal dialysis services under such 
paragraph shall not take into account the amount of 
payment for kidney disease education services (as 
defined in section 1861(ggg)). Instead, payment for 
such services shall be made to the renal dialysis fa-
cility on an assignment-related basis under section 
1848.’’. 
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(c) EFFECTIVE DATE.—The amendments made by 
this section apply to kidney disease education services fur-
nished on or after January 1, 2015. 
SEC. 202. IMPROVING ACCESS TO CHRONIC KIDNEY DIS-
EASE TREATMENT IN UNDERSERVED RURAL 
AND URBAN AREAS. 
(a) DEFINITION OF PRIMARY CARE SERVICES.—Sec-
tion 331(a)(3)(D) of the Public Health Service Act (42 
U.S.C. 254d(a)(3)(D)) is amended by inserting ‘‘and in-
cludes renal dialysis services’’ before the period at the end. 
(b) NATIONAL HEALTH SERVICE CORPS SCHOLAR-
SHIP PROGRAM.—Section 338A(a)(2) of the Public Health 
Service Act (42 U.S.C. 254l(a)(2)) is amended by insert-
ing ‘‘, including nephrologists and non-physician practi-
tioners providing renal dialysis services’’ before the period 
at the end. 
(c) NATIONAL HEALTH SERVICE CORPS LOAN RE-
PAYMENT PROGRAM.—Section 338B(a)(2) of the Public 
Health Service Act (42 U.S.C. 254l–1(a)(2)) is amended 
by inserting ‘‘, including nephrologists and non-physician 
practitioners providing renal dialysis services’’ before the 
period at the end. 
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SEC. 203. PROMOTING ACCESS TO HOME DIALYSIS TREAT-
MENTS. 
(a) MONTHLY CAPITATION PAYMENTS.—Notwith-
standing any other provision of law, with respect to dialy-
sis services furnished on or after January 1, 2015, the 
Secretary of Health and Human Services shall apply with 
respect to visits by a physician provided within a month 
to an end stage renal disease patient receiving dialysis 
services at home, the alternative Medicare billing proce-
dures, as described in the final rule promulgated by the 
Secretary in the Federal Register on November 7, 2003 
(68 Fed. Reg. 63216), for physicians managing patients 
on dialysis, with respect to visits by such a physician pro-
vided within a month to an end stage renal disease patient 
who is hospitalized during the month. 
(b) TELEHEALTH.—Section 1834(m)(4)(C)(ii) of the 
Social Security Act (42 U.S.C. 1395m(m)(4)(C)(ii)) is 
amended by adding at the end the following new sub-
clause: 
‘‘(IX) A renal dialysis facility (as 
defined in section 1881).’’. 
SEC. 204. EXPAND ACCESS FOR PATIENTS WITH ACUTE KID-
NEY INJURY. 
Section 1881(b) of the Social Security Act (42 U.S.C. 
1395rr(b)) is amended— 
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(1) in paragraph (1), by inserting ‘‘or acute 
kidney injury’’ after ‘‘individuals who have been de-
termined to have end stage renal disease’’; 
(2) in paragraph (2)(A), by inserting ‘‘or acute 
kidney injury’’ after ‘‘end stage renal disease’’; 
(3) in paragraph (2)(B), by inserting ‘‘or acute 
kidney injury’’ after ‘‘end stage renal disease’’; 
(4) in paragraph (3), in the matter preceding 
subparagraph (A), by inserting ‘‘or acute kidney in-
jury’’ after ‘‘end stage renal disease’’; 
(5) in paragraph (11)(A), by inserting ‘‘or 
acute kidney injury’’ after ‘‘end stage renal disease’’; 
(6) in paragraph (11)(B), by inserting ‘‘or 
acute kidney injury’’ after ‘‘end stage renal disease’’; 
(7) in paragraph (14)(B)— 
(A) in clause (ii), by inserting ‘‘or acute 
kidney injury’’ after ‘‘end stage renal disease’’; 
(B) in clause (iii), by inserting ‘‘or acute 
kidney injury’’ after ‘‘end stage renal disease’’; 
and 
(C) in clause (iv), by inserting ‘‘or acute 
kidney injury’’ after ‘‘end stage renal disease’’; 
and 
(8) in paragraph (14)(H)(i), by inserting ‘‘or 
acute kidney injury’’ after ‘‘end stage renal disease’’. 
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TITLE III—CREATING ECONOMIC 
STABILITY FOR PROVIDERS 
CARING 
FOR 
INDIVIDUALS 
WITH CHRONIC KIDNEY DIS-
EASE 
SEC. 301. STABILIZING MEDICARE PAYMENTS FOR SERV-
ICES PROVIDED TO BENEFICIARIES WITH 
STAGE V CHRONIC KIDNEY DISEASE RECEIV-
ING DIALYSIS SERVICES. 
Section 1881(b)(14) of the Social Security Act (42 
U.S.C. 1395rr(b)(14)) is amended— 
(1) in subparagraph (D), in the matter pre-
ceding clause (i), by striking ‘‘Such system’’ and in-
serting ‘‘Subject to subparagraph (J), such system’’; 
and 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(J)(i) For payment for renal dialysis services fur-
nished on or after January 1, 2015, under the system 
under this paragraph— 
‘‘(I) the payment adjustment described in 
clause (i) of subparagraph (D) shall not take into 
account comorbidities; 
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‘‘(II) the payment adjustment described in 
clause (ii) of such subparagraph shall not be in-
cluded; 
‘‘(III) the standardization factor described in 
the final rule published in the Federal Register on 
November 8, 2012 (77 Fed. Reg. 67470), shall be 
established using the most currently available data 
(and not historical data) and adjusted on an annual 
basis, based on such available data, to account for 
any change in utilization of drugs and any modifica-
tion in adjustors applied under this paragraph; and 
‘‘(IV) the Secretary shall take into account rea-
sonable costs consistent with paragraph (2)(B) when 
calculating such payments. 
‘‘(ii) Not later than January 1, 2015, the Secretary 
shall amend the ESRD facility cost report to— 
‘‘(I) include the per treatment network fee (as 
described in paragraph (7)) as an allowable cost; 
and 
‘‘(II) eliminate the limitation for reporting med-
ical director fees on such reports in order to take 
into account the wages of a board-certified 
nephrologist.’’. 
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SEC. 302. ALLOWING INDIVIDUALS WITH KIDNEY FAILURE 
TO RETAIN ACCESS TO PRIVATE INSURANCE. 
(a) IN GENERAL.—Section 1862(b)(1)(C) of the So-
cial Security Act (42 U.S.C.1395y(b)(1)(C) is amended— 
(1) in the last sentence, by inserting ‘‘and be-
fore January 1, 2015’’ after ‘‘prior to such date’’; 
and 
(2) by adding at the end the following new sen-
tence: ‘‘Effective for items and services furnished on 
or after January 1, 2015 (with respect to periods 
beginning on or after the date that is 42 months 
prior to such date), clauses (i) and (ii) shall be ap-
plied by substituting ‘42-month’ for ‘12-month’ each 
place it appears.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this subsection shall take effect on the date of enactment 
of this Act. For purposes of determining an individual’s 
status under section 1862(b)(1)(C) of the Social Security 
Act (42 U.S.C. 1395y(b)(1)(C)), as amended by sub-
section (a), an individual who is within the coordinating 
period as of the date of enactment of this Act shall have 
that period extended to the full 42 months described in 
the last sentence of such section, as added by the amend-
ment made by subsection (a)(2). 
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SEC. 303. PROVIDING INDIVIDUALS WITH KIDNEY FAILURE 
ACCESS TO MANAGED CARE AND COORDI-
NATED CARE PROGRAMS. 
(a) EXPANDING ACCESS
TO MEDICARE ADVAN-
TAGE.— 
(1) ELIGIBILITY
UNDER
MEDICARE
ADVAN-
TAGE.— 
(A) IN GENERAL.—Section 1851(a)(3) of 
the Social Security Act (42 U.S.C. 1395w– 
21(a)(3)) is amended— 
(i) by striking subparagraph (B); and 
(ii) by striking ‘‘ELIGIBLE
INDI-
VIDUAL.—’’ and all that follows through 
‘‘In this title’’ and inserting ‘‘ELIGIBLE IN-
DIVIDUAL.—In this title’’. 
(B) CONFORMING
AMENDMENT.—Section 
1852(b)(1) of the Social Security Act (42 
U.S.C. 1395w–22(b)(1)) is amended— 
(i) by striking subparagraph (B); and 
(ii) by striking ‘‘BENEFICIARIES.—’’ 
and 
all 
that 
follows 
through 
‘‘A 
Medicare+Choice organization’’ and in-
serting ‘‘BENEFICIARIES.—A Medicare Ad-
vantage organization’’. 
(C) EFFECTIVE DATE.—The amendments 
made by this paragraph shall apply with respect 
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to plan years beginning on or after January 1, 
2015. 
(2) EDUCATION.—Section 1851(d)(2)(A)(iii) of 
the Social Security Act (42 U.S.C. 1395w– 
21(d)(2)(A)(iii)) is amended by inserting before the 
period at the end the following ‘‘, including any ad-
ditional information that individuals determined to 
have end stage renal disease may need to make in-
formed decisions with respect to such an election’’. 
(3) QUALITY METRICS.—Section 1852(e)(3)(A) 
of the Social Security Act (42 U.S.C. 1395w– 
22(e)(3)(A)) is amended by adding at the end the 
following new clause: 
‘‘(v) REQUIREMENTS WITH RESPECT 
TO INDIVIDUALS WITH ESRD.—In addition 
to the data required to be collected, ana-
lyzed, and reported under clause (i) and 
notwithstanding the limitations under sub-
paragraph (B), as part of the quality im-
provement program under paragraph (1), 
each MA organization shall provide for the 
collection, analysis, and reporting of data, 
determined in consultation with the kidney 
care community, that permits the measure-
ment of health outcomes and other indices 
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of quality with respect to individuals deter-
mined to have end stage renal disease.’’. 
(b) PERMANENT EXTENSION OF MEDICARE ADVAN-
TAGE ESRD SPECIAL NEEDS PLANS AUTHORITY.—Sec-
tion 1859(f)(1) of the Social Security Act (42 U.S.C. 
1395w–28(f)(1)) is amended by inserting ‘‘, in the case 
of a specialized MA plan for special needs individuals who 
have not been determined to have end stage renal dis-
ease,’’ before ‘‘for periods before January 1, 2017’’. 
(c) 
VOLUNTARY
ESRD 
COORDINATED
CARE 
GAINSHARING PROGRAM.— 
(1) IN GENERAL.—Section 1881(b) of the So-
cial Security Act (42 U.S.C. 1395rr(b)) is amended 
by adding at the end the following new paragraph: 
‘‘(15)(A) Not later than January 1, 2016, the Sec-
retary shall, in accordance with this paragraph, establish 
an ESRD Care Coordination gainsharing program for 
nephrologists, renal dialysis facilities, and providers of 
services that develop coordinated care organizations to 
provide a full range of clinical and supportive services (as 
described in subparagraph (D)) to individuals determined 
to have end stage renal disease. 
‘‘(B) Under such program, subject to subparagraph 
(C), the payment amounts renal dialysis facilities and pro-
viders of services described in subparagraph (A) would 
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otherwise receive under paragraph (14) and nephrologists 
described in subparagraph (A) would otherwise receive 
under section 1848 with respect to dialysis services fur-
nished by such a facility, provider, or nephrologist during 
a year, shall be increased by a portion of the amount (as 
determined by the Secretary) of actual reductions in ex-
penditure under this title attributable to the coordinated 
care organization developed by such facility, provider, or 
nephrologist involved, taking into account non-dialysis ex-
penditures under parts A and B, during the preceding cal-
endar year. The payment amount under this subparagraph 
shall be provided to a nephrologist, renal dialysis facility, 
and provider of services that developed the coordinated 
care organization no later than March 31 of the year after 
the year during which such services are provided by such 
nephrologist, facility, or provider. 
‘‘(C) The aggregate incentive payment amounts pro-
vided under such program for a year may not exceed the 
amount equal to 2 percent less than the estimated total 
amount of non-dialysis expenditures under parts A and 
B for 2016 for items and services that are not related 
to dialysis or transplant services. 
‘‘(D) For purposes of subparagraph (A), the full 
range of clinical and supportive services includes at least 
the following: 
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