H. R. 133—1819 
in the medical insurance program established under this part for 
purposes of coverage of immunosuppressive drugs.’’. 
(c) COVERAGE PERIOD
FOR INDIVIDUALS ONLY ELIGIBLE
FOR 
COVERAGE OF IMMUNOSUPPRESSIVE DRUGS.— 
(1) IN GENERAL.—Section 1838 of the Social Security Act 
(42 U.S.C. 1395q), as amended by section 120, is further 
amended by adding at the end the following new subsection: 
‘‘(h) In the case of an individual described in section 1836(b)(1), 
the following rules shall apply: 
‘‘(1) In the case of such an individual who is deemed to 
have enrolled in part B for coverage of immunosuppressive 
drugs under section 1837(n)(3), such individual’s coverage 
period shall begin on the first day of the month in which 
the individual first satisfies section 1836(b). 
‘‘(2) In the case of such an individual who enrolls (or 
reenrolls, if applicable) in part B for coverage of immuno-
suppressive drugs under paragraph (2) or (4) of section 1837(n), 
such individual’s coverage period shall begin on January 1, 
2023, or the month following the month in which the individual 
so enrolls (or reenrolls), whichever is later. 
‘‘(3) The provisions of subsections (b) and (d) shall apply 
with respect to an individual described in paragraph (1) or 
(2). 
‘‘(4) In addition to the reasons for termination under sub-
section (b), the coverage period of an individual described in 
paragraph (1) or (2) shall end when the individual becomes 
entitled to benefits under this title under subsection (a) or 
(b) of section 226, or under section 226A, or is no longer eligible 
for such coverage as a result of the application of section 
1836(b)(2). 
‘‘(5) The Secretary may conduct public education activities 
to raise awareness of the availability of more comprehensive, 
individual health insurance coverage (as defined in section 
2791 of the Public Health Service Act) for individuals eligible 
under section 1836(b) to enroll or to be deemed enrolled in 
the medical insurance program established under this part 
for purposes of coverage of immunosuppressive drugs.’’. 
(2) CONFORMING
AMENDMENTS.—Section 1838(b) of the 
Social Security Act (42 U.S.C. 1395q(b)) is amended, in the 
matter following paragraph (2), by inserting ‘‘or section 
1837(n)(3)’’ after ‘‘section 1837(f)’’ each place it appears. 
(d) PREMIUMS FOR INDIVIDUALS ONLY ELIGIBLE FOR COVERAGE 
OF IMMUNOSUPPRESSIVE DRUGS.— 
(1) IN GENERAL.—Section 1839 of the Social Security Act 
(42 U.S.C. 1395r), as amended by section 120, is further 
amended— 
(A) in subsection (b), by adding at the end the following 
new sentence: ‘‘No increase in the premium shall be effected 
for individuals who are enrolled pursuant to section 1836(b) 
for coverage only of immunosuppressive drugs.’’; and 
(B) by adding at the end the following new subsection: 
‘‘(j) DETERMINATION
OF
PREMIUM
FOR
INDIVIDUALS
ONLY 
ELIGIBLE FOR COVERAGE OF IMMUNOSUPPRESSIVE DRUGS.—The Sec-
retary shall, during September of each year (beginning with 2022), 
determine and promulgate a monthly premium rate for the suc-
ceeding calendar year for individuals enrolled only for the purpose 
of coverage of immunosuppressive drugs under section 1836(b).
H. R. 133—1820 
Such premium shall be equal to 15 percent of the monthly actuarial 
rate for enrollees age 65 and over (as would be determined in 
accordance with subsection (a)(1) if the reference to ‘one-half’ in 
such subsection were a reference to ‘100 percent’) for that succeeding 
calendar year. The monthly premium of each individual enrolled 
for coverage of immunosuppressive drugs under section 1836(b) 
for each month shall be the amount promulgated in this subsection. 
In the case of such individual not otherwise enrolled under this 
part, such premium shall be in lieu of any other monthly premium 
applicable under this section. Such amount shall be adjusted in 
accordance with subsections (c), (f), and (i), but shall not be adjusted 
under subsection (b).’’. 
(2) SPECIAL
RULE
FOR
APPLICATION
OF
HOLD
HARMLESS 
PROVISIONS TO TRANSITIONING INDIVIDUALS.—Section 1839(f) of 
the Social Security Act (42 U.S.C. 1395r(f)) is amended by 
adding at the end the following new sentence: ‘‘Any increase 
in the premium for an individual who was enrolled under 
section 1836(b) attributable to such individual otherwise 
enrolling under this part shall not be taken into account in 
applying this subsection.’’. 
(3) SPECIAL RULE FOR APPLICATION OF PREMIUM SUBSIDY 
REDUCTION
PROVISIONS.—Section 1839(i)(3)(A)(ii)(II) of the 
Social Security Act (42 U.S.C. 1395r(i)(3)(A)(ii)(II)) is amended 
by inserting ‘‘(or, with respect to an individual enrolled under 
section 1836(b) and not otherwise enrolled under this part, 
0 times the amount of such increase)’’ after ‘‘in the year’’. 
(e) GOVERNMENT CONTRIBUTION.—Section 1844(a) of the Social 
Security Act (42 U.S.C. 1395w(a)) is amended— 
(1) in paragraph (3), by striking the period at the end 
and inserting ‘‘; plus’’; 
(2) by inserting after paragraph (3) the following new para-
graph: 
‘‘(4) a Government contribution equal to the estimated 
aggregate reduction in premiums payable under part B that 
results from establishing the premium at 15 percent of the 
actuarial rate (as would be determined in accordance with 
section 1839(a)(1) if the reference to ‘one-half’ in such section 
were a reference to ‘100 percent’) under section 1839(j) instead 
of 25 percent of such rate (as so determined) for individuals 
enrolled only for the purpose of coverage of immunosuppressive 
drugs under section 1836(b).’’; and 
(3) by adding the following sentence at the end of the 
flush matter following paragraph (4), as added by paragraph 
(2) of this subsection: 
‘‘The Government contribution under paragraph (4) shall be 
treated as premiums payable and deposited for purposes of 
subparagraphs (A) and (B) of paragraph (1).’’. 
(f) ENSURING COVERAGE UNDER THE MEDICARE SAVINGS PRO-
GRAM.— 
(1) IN GENERAL.—Section 1905(p)(1)(A) of the Social Secu-
rity Act (42 U.S.C. 1396d(p)(1)(A)) is amended by inserting 
‘‘or who is enrolled under part B for the purpose of coverage 
of immunosuppressive drugs under section 1836(b)’’ after 
‘‘under section 1818A)’’. 
(2) CONFORMING AMENDMENTS.—Section 1902(a)(10)(E) of 
the Social Security Act (42 U.S.C. 1396a(a)(10)(E)) is amended 
in each of clauses (iii) and (iv) by inserting ‘‘(including such
H. R. 133—1821 
individuals enrolled under section 1836(b))’’ after ‘‘section 
1905(p)(1)’’. 
(g) PART D.—Section 1860D–1(a)(3)(A) of the Social Security 
Act (42 U.S.C. 1395w–101(a)(3)(A)) is amended by inserting ‘‘(but 
not including an individual enrolled solely for coverage of immuno-
suppressive drugs under section 1836(b))’’ before the period at the 
end. 
(h) GAO STUDY AND REPORT.— 
(1) STUDY.—The Comptroller General of the United States 
(in this subsection referred to as the ‘‘Comptroller General’’) 
shall conduct a study on the implementation of coverage of 
immunosuppressive drugs for kidney transplant patients under 
the Medicare program pursuant to the provisions of, and 
amendments made by, this section. 
(2) REPORT.—Not later than January 1, 2025, the Comp-
troller General shall submit to Congress a report on the study 
conducted under paragraph (1), together with recommendations 
as the Comptroller General determines appropriate. 
SEC. 403. PERMITTING DIRECT PAYMENT TO PHYSICIAN ASSISTANTS 
UNDER MEDICARE. 
Section 1842(b)(6)(C) of the Social Security Act (42 U.S.C. 
1395u(b)(6)(C)) is amended, in the matter preceding clause (i), by 
inserting ‘‘for such services furnished before January 1, 2022,’’ 
after ‘‘1861(s)(2)(K),’’. 
SEC. 404. ADJUSTING CALCULATION OF HOSPICE CAP AMOUNT UNDER 
MEDICARE. 
Section 1814(i)(2)(B) of the Social Security Act (42 U.S.C. 
1395f(i)(2)(B)) is amended— 
(1) in clause (ii), by striking ‘‘2025’’ and inserting ‘‘2030’’; 
and 
(2) in clause (iii), by striking ‘‘2025’’ and inserting ‘‘2030’’. 
SEC. 405. SPECIAL RULE FOR DETERMINATION OF ASP IN CASES OF 
CERTAIN 
NONCOVERED 
SELF-ADMINISTERED 
DRUG 
PRODUCTS. 
Section 1847A of the Social Security Act (42 U.S.C. 1395w– 
3a) is amended by redesignating subsection (g) as subsection (h) 
and by inserting after subsection (f) the following: 
‘‘(g) PAYMENT ADJUSTMENT FOR CERTAIN DRUGS FOR WHICH 
THERE IS A SELF-ADMINISTERED NDC.— 
‘‘(1) OIG STUDIES.—The Inspector General of the Depart-
ment of Health and Human Services shall conduct periodic 
studies to identify National Drug Codes for drug or biological 
products that are self-administered for which payment may 
not be made under this part because such products are not 
covered pursuant to section 1861(s)(2) and which the Inspector 
General determines (based on the same or similar methodolo-
gies to the methodologies used in the final recommendation 
followup report of the Inspector General described in paragraph 
(3) or in the November 2017 final report of the Inspector 
General entitled ‘Excluding Noncovered Versions When Setting 
Payment for Two Part B Drugs Would Have Resulted in Lower 
Drug Costs for Medicare and its Beneficiaries’) should be 
excluded from the determination of the payment amount under 
this section.
H. R. 133—1822 
‘‘(2) PAYMENT
ADJUSTMENT.—If the Inspector General 
identifies a National Drug Code for a drug or biological product 
under paragraph (1), the Inspector General shall inform the 
Secretary (at such times as the Secretary may specify to carry 
out this paragraph) and the Secretary shall, to the extent 
the Secretary deems appropriate, apply as the amount of pay-
ment under this section for the applicable billing and payment 
code the lesser of— 
‘‘(A) the amount of payment that would be determined 
under this section for such billing and payment code if 
such National Drug Code for such product so identified 
under paragraph (1) were excluded from such determina-
tion; or 
‘‘(B) the amount of payment otherwise determined 
under this section for such billing and payment code with-
out application of this subsection. 
‘‘(3) APPLICATION
TO
CERTAIN
IDENTIFIED
PRODUCTS.—In 
the case of a National Drug Code for a drug or biological 
product that is self-administered for which payment is not 
made under this part because such product is not covered 
pursuant to section 1861(s)(2) that was identified by the 
Inspector General of the Department of Health and Human 
Services in the final recommendation followup report of the 
Inspector General published July 2020, entitled Loophole in 
Drug Payment Rule Continues To Cost Medicare and Bene-
ficiaries Hundreds of Millions of Dollars, beginning July 1, 
2021, the amount of payment under this section for the 
applicable billing and payment code shall be the lesser of— 
‘‘(A) the amount of payment that would be determined 
under this section for such billing and payment code if 
such National Drug Code for such drug or biological prod-
ucts so identified were excluded from such determination; 
or 
‘‘(B) the amount of payment otherwise determined 
under this section for such billing and payment code with-
out application of this subsection.’’. 
SEC. 406. MEDICAID IMPROVEMENT FUND. 
Section 1941(b)(3)(A) of the Social Security Act (42 U.S.C 
1396w–1(b)(3)(A)), as amended by section 1303 of the Further Con-
tinuing Appropriations Act, 2021, and Other Extensions Act, is 
amended by striking ‘‘ $3,464,000,000’’ and inserting ‘‘ $0’’. 
SEC. 407. ESTABLISHING HOSPICE PROGRAM SURVEY AND ENFORCE-
MENT PROCEDURES UNDER THE MEDICARE PROGRAM. 
(a) SURVEY AND ENFORCEMENT PROCEDURES.— 
(1) IN GENERAL.—Part A of title XVIII of the Social Security 
Act (42 U.S.C. 1395c et seq.) is amended by adding at the 
end the following new section: 
‘‘SEC. 1822. HOSPICE PROGRAM SURVEY AND ENFORCEMENT PROCE-
DURES. 
‘‘(a) SURVEYS.— 
‘‘(1) FREQUENCY.—Any entity that is certified as a hospice 
program (as defined in section 1861(dd)(2)) shall be subject 
to a standard survey by an appropriate State or local survey 
agency, or an approved accreditation agency, as determined 
by the Secretary, not less frequently than once every 36 months.