Medicare Payment Reform for People with ALS Act of 2022
Bill: H.R.9638 | Sponsor: Rep. Schakowsky, Janice D. (D-IL)
Policy area: Health

Summary:
Medicare Payment Reform for People with ALS Act of 2022
This bill provides for specific Medicare coverage and payment of services for individuals with amyotrophic lateral sclerosis (ALS).

To amend title XVIII of the Social Security Act to provide coverage of 
    ALS-related services under the Medicare program for individuals 
 diagnosed with amyotrophic lateral sclerosis, and for other purposes.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medicare Payment Reform for People 
with ALS Act of 2022''.

SEC. 2. PROVIDING FOR COVERAGE OF ALS-RELATED SERVICES UNDER THE 
              MEDICARE PROGRAM FOR INDIVIDUALS DIAGNOSED WITH 
              AMYOTROPHIC LATERAL SCLEROSIS.

    (a) In General.--Subtitle E of title XVIII of the Social Security 
Act (42 U.S.C. 1395 et. seq.) is amended by inserting after section 
1881A the following new section:

``SEC. 1881B. MEDICARE COVERAGE OF ALS-RELATED SERVICES FOR INDIVIDUALS 
              DIAGNOSED WITH AMYOTROPHIC LATERAL SCLEROSIS.

    ``(a) In General.--In the case of a covered ALS individual, the 
Secretary shall establish a supplemental facility-based payment system 
described in subsection (d) for ALS-related services provided to such 
an individual.
    ``(b) Covered ALS Individual.--For purposes of this section, the 
term `covered ALS individual' means an individual who is medically 
determined to have amyotrophic lateral sclerosis (as described in 
section 226(h)).
    ``(c) ALS-Related Services.--For purposes of this section, the term 
`ALS-related services' means items and services that are ordinarily 
furnished to a covered ALS individual in an outpatient setting by a 
qualified provider (or by others under arrangements with them made by 
the qualified provider) consistent with a multidisciplinary approach 
(as determined by the Secretary) for the care and treatment of such an 
individual with respect to the progression of amyotrophic lateral 
sclerosis.
    ``(d) Payment System.--
            ``(1) Authority.--The Secretary shall establish a facility-
        based payment system under which a single payment determined in 
        accordance with the succeeding paragraphs is made to a 
        qualified provider for ALS-related services furnished to a 
        covered ALS individual during a visit beginning on and after 
        January 1, 2024.
            ``(2) Base payment amount.--
                    ``(A) 2024.--For coverage year 2024, the Secretary 
                shall establish a single payment amount for ALS-related 
                services equal to $800 for such services furnished for 
                each visit during such year.
                    ``(B) 2025.--
                            ``(i) In general.--For coverage year 2025, 
                        the Secretary shall establish a single payment 
                        amount for ALS-related services furnished for 
                        each visit during such year that is the greater 
                        of--
                                    ``(I) taking into account the 
                                payment amount recommended by the 
                                Comptroller General in the report 
                                described in clause (ii), the amount 
                                specified by the Secretary; or
                                    ``(II) the amount specified in 
                                subparagraph (A).
                            ``(ii) Report by the comptroller general.--
                        Not later than January 1, 2024, the Comptroller 
                        General shall, in consultation with qualified 
                        providers submit to the Secretary of Health and 
                        Human Services a report that recommends a 
                        single payment amount for ALS-related services 
                        that takes into account the average amount of 
                        payment for each item or service included in 
                        ALS-related services that the Comptroller 
                        General estimates would have been payable--
                                    ``(I) under this title for such a 
                                service based on per patient 
                                utilization data from whichever single 
                                coverage year from 2020 through 2022 
                                has the highest per patient utilization 
                                of ALS-related services, even if such 
                                service is not payable for a particular 
                                ALS individual because of the 
                                application of section 1862(a)(1)(A) 
                                with respect to an item or service 
                                provided to such individual;
                                    ``(II) in the case an estimate is 
                                unable to be determined pursuant to 
                                subclause (I), by health insurance 
                                issuers and group health plans (as such 
                                terms are defined in section 2791 of 
                                the Public Health Service Act) and MA 
                                plans under part C for such a service, 
                                based on such data from whichever 
                                single coverage year from 2020 through 
                                2022 has the highest per patient 
                                utilization of ALS-related services; 
                                and
                                    ``(III) in the case an estimate is 
                                unable to be determined pursuant to 
                                subclause (II), based on the 
                                recommendation of the Specialty Society 
                                Relative Value Scale Update Committee 
                                of the American Medical Association or 
                                the estimate of the Comptroller General 
                                for such a service.
                    ``(C) 2026 and subsequent years.--For each coverage 
                year beginning with coverage year 2026, the Secretary 
                shall annually increase the payment amount for each 
                visit determined under this paragraph by an ALS 
                services market basket percentage increase (as 
                determined by the Secretary) that reflects changes over 
                time in the prices of an appropriate mix of goods and 
                services that are ALS-related services.
            ``(3) Payment adjustments.--The payment system under this 
        subsection--
                    ``(A) shall include a payment adjustment based on 
                case mix that may take into account comorbidities, 
                length of time from diagnosis, age, race, ethnicity, 
                and other appropriate factors;
                    ``(B) shall include a payment adjustment for high-
                cost outliers due to unusual variations in the type or 
                amount of medically necessary care;
                    ``(C) shall include a payment adjustment that 
                reflects the extent to which costs incurred by low-
                volume facilities (as defined by the Secretary) in 
                furnishing ALS-related services exceed the costs 
                incurred by other facilities in furnishing such 
                services, and such payment adjustment may not be less 
                than 10 percent;
                    ``(D) shall include a payment adjustment for a 
                medical service or technology which is furnished as a 
                part of ALS-related services for which, as determined 
                by the Secretary--
                            ``(i) payment for the service or technology 
                        as part of ALS-related services under this 
                        section was not being made in the preceding 
                        coverage year; and
                            ``(ii) the cost of the service or 
                        technology is not insignificant in relation the 
                        payment amount (as determined under this 
                        subsection) payable for ALS-related services; 
                        and
                    ``(E) may include such other payment adjustments as 
                the Secretary deems appropriate, including a payment 
                adjustment for--
                            ``(i) a geographic index, such as the index 
                        referred to in section 1886(d)(3)(E);
                            ``(ii) the status of the facility as 
                        provider-based or free-standing (as such terms 
                        are defined in section 413.65(a)(2), title 42, 
                        Code of Federal Regulations); and
                            ``(iii) qualified providers located in 
                        rural areas (as defined in section 
                        1886(d)(2)(D)).
            ``(4) Mechanism for payments.--For purposes of making 
        payments for ALS-related services, the Secretary shall 
        establish a mechanism under the payment system under this 
        subsection which makes payment when a qualified provider 
        submits a claim for reimbursement which includes, with respect 
        to a covered ALS individual, an alphanumeric code issued under 
        the International Classification of Diseases, 10th Revision, 
        Clinical Modification (`ICD-10-CM') and its subsequent 
        revisions that is for the treatment of a diagnosis of 
        amyotrophic lateral sclerosis.
            ``(5) No cost sharing.--Payment under this subsection shall 
        be made only on an assignment-related basis without any cost 
        sharing.
            ``(6) Qualified provider defined.--In this section, the 
        term `qualified provider' means a provider of services which 
        meets requirements as the Secretary prescribes by regulation.
    ``(e) Clarification.--Payment under subsection (d) shall be in 
addition to, and shall not supplant, any payment that would be 
otherwise made to a provider of services, physician, practitioner, 
supplier, or laboratory under any other provision of this title for an 
item or service furnished to a covered ALS individual.
    ``(f) Implementation.--
            ``(1) In general.--Except as provided under paragraph (2), 
        the Secretary may implement the provisions of this section by 
        program instruction or otherwise.
            ``(2) Rulemaking.--The Secretary shall implement 
        subsections (c) and (d)(6) through notice and comment 
        rulemaking.
    ``(g) Funding.--For purposes of carrying out this section, subject 
to subsection (e), payment under this section shall be made from the 
Federal Supplementary Medical Insurance Trust Fund under section 1841 
or from the Federal Hospital Insurance Trust Fund under section 
1817.''.
    (b) Conforming Amendments.--
            (1) Section 1833(t) of the Social Security Act (42 U.S.C. 
        1395(t) is amended by adding at the end the following new 
        paragraph:
            ``(23) Ensuring supplemental payments for als-related 
        services.--Any covered OPD service furnished to a covered ALS 
        individual (as defined in section 1881B(b)) that is otherwise 
        payable to a qualified provider (as defined in section 
        1881B(d)(6)) pursuant to paragraph (4) shall be payable under 
        such paragraph notwithstanding any payment made under section 
        1881B(d).''.
            (2) Section 1861(w)(1) of the Social Security Act (42 
        U.S.C. 1395x(w)(1)) is amended by inserting ``qualified 
        provider (as defined in section 1881B(d)(6)(A)) with respect to 
        ALS-related services (as defined in section 1881B(c)),'' before 
        ``or hospice program''.

SEC. 3. EFFECTIVE DATE.

    The amendments made by this Act shall take effect on the date of 
the enactment of this Act.
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