Strengthening Innovation in Medicare and Medicaid Act
Bill: H.R.5125 | Sponsor: Rep. Smith, Adrian (R-NE)
Policy area: Health

Summary:
Strengthening Innovation in Medicare and Medicaid Act
This bill makes a series of changes to requirements for the Center for Medicare and Medicaid Innovation, including additional testing parameters, procedural steps, and reporting requirements for models.

To amend title XI of the Social Security Act to clarify parameters for 
   model testing and add accountability to model expansion under the 
  Center for Medicare and Medicaid Innovation, 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 ``Strengthening Innovation in Medicare 
and Medicaid Act''.

SEC. 2. SENSE OF CONGRESS.

    It is the sense of Congress that:
            (1) The Center for Medicare and Medicaid Innovation (CMI) 
        represents a valuable tool for testing innovative health care 
        payment and service delivery models which can improve the 
        coordination, quality, and efficiency of health care services.
            (2) The model testing process is intended to test concepts 
        on a limited scale first in Phase I, then assess initial 
        results, and, if results merit, expand the model to a larger 
        test in Phase II to confirm the initial results.
            (3) Starting model testing on a limited scale, assessing 
        results, and then expanding the model to confirm initial 
        results protects the integrity of the Medicare program by 
        minimizing unintentional losses or negative impacts to the 
        patients or providers participating in Phase I model testing.
            (4) CMI should focus its attention on models most likely to 
        succeed and should continually assess models and terminate 
        those which are not generating results in keeping with its 
        purpose--lowering costs while maintaining or preserving patient 
        outcomes.
            (5) Mandatory models may be necessary to test certain 
        payment models but should be used judiciously and be as limited 
        in scope as possible to minimize accidental adverse impacts.
            (6) As CMI may waive certain provisions of Medicare 
        regulations, Congress may block models which functionally alter 
        or change the underlying existing statutes.

SEC. 3. DEFINING CMI MODEL TESTING PARAMETERS.

    (a) Scope and Duration of Models.--Section 1115A(a) of the Social 
Security Act (42 U.S.C. 1315a(a)) is amended by adding at the end the 
following new paragraph:
            ``(6) Scope and duration of models tested.--beginning on or 
        after the date of the enactment of the Strengthening Innovation 
        In Medicare and Medicaid Act, for purposes of testing new 
        payment and service delivery models, the Secretary shall limit 
        testing of a Phase 1 model to--
                    ``(A) a period not to exceed 5 years; and
                    ``(B) to the lesser of ten percent of applicable 
                individuals or 500,000 beneficiaries.''.
    (b) Cap on Phase 1 Model Testing.--Section 1115A(a) of the Social 
Security Act (42 U.S.C. 1315a(a)), as amended by subsection (a), is 
further amended by adding at the end the following new paragraph:
            ``(7) Phase 1 model limitations.--During each fiscal year 
        starting with Fiscal Year 2023, CMI shall initiate Phase 1 
        testing of no more than six new models each fiscal year. 
        Additionally, CMI shall not concurrently test more than five 
        Phase 1 models which involve mandatory, involuntary, or 
        compulsory participation.''.
    (c) Required Waivers for Hardship.--Section 1115A(a) of the Social 
Security Act (42 U.S.C. 1315a(a)), as amended by subsection (a), is 
further amended by adding at the end the following new paragraph:
            ``(8) Hardship waivers.--Not later than 60 days after the 
        enactment of the Strengthening Innovation in Medicare and 
        Medicaid Act, the Secretary shall develop and implement a plan 
        to allow applicable providers of services or supplies to 
        request a waiver from any requirement of a model if the 
        Secretary determines that such requirement would result in 
        undue economic hardship to such provider or supplier or loss of 
        access to such healthcare services or supplies for vulnerable 
        populations.''.
    (d) Monitoring Impact.--Section 1115A(a) of the Social Security Act 
(42 U.S.C. 1315a(a)), as amended by subsections (a) and (b), is further 
amended by adding at the end the following new paragraph:
            ``(9) Monitoring impact.--Not later than 60 days after the 
        enactment of the Strengthening Innovation in Medicare and 
        Medicaid Act, the Secretary shall develop and implement a plan 
        to--
                    ``(A) monitor continuously and on a real-time basis 
                the effect of a model under subsection (b) on 
                applicable individuals, and mitigate any adverse 
                impact, such as inappropriate reductions in care or 
                reduced access to care;
                    ``(B) assess and track the impact of delivery and 
                payment models on health disparities, using existing 
                measures such as, but not limited to, the National 
                Quality Forum Healthcare Disparities and Cultural 
                Competency Measures; and
                    ``(C) mitigate any adverse impact that the 
                Secretary determines could affect beneficiary 
                health.''.

SEC. 4. IMPLEMENTATION OF TESTING AND EXPANSION OF MODELS WITH 
              CONGRESSIONAL INACTION.

    Section 1115A(d) of the Social Security Act (42 U.S.C. 1315a(d)) is 
amended by adding at the end the following new paragraph:
            ``(4) Implementation of testing and expansion of models 
        with congressional inaction.--
                    ``(A) The Secretary shall transmit a proposal for 
                the testing, expansion, or modification of a model 
                under subsections (b) and (c), including a proposed 
                effective date and a summary of the determinations and 
                certification made under paragraphs (1) through (3) of 
                subsection (c), if applicable, to the Committee on Ways 
                and Means and the Committee on Energy and Commerce of 
                the House of Representatives and to the Committee on 
                Finance and the Committee on Health, Education, Labor, 
                and Pensions of the Senate.
                    ``(B) The testing, expansion, or modification of a 
                model proposed in a report submitted under subparagraph 
                (A) shall be carried out by the Secretary if Congress 
                does not, within 45 days of receiving such report, pass 
                a joint resolution disapproving of the proposed testing 
                or expansion in accordance with the following 
                procedure:
                            ``(i) The succeeding subparagraphs of this 
                        paragraph are enacted by Congress as an 
                        exercise of the rulemaking power of the Senate 
                        and the House of Representatives, respectively, 
                        and as such they shall be deemed a part of the 
                        rules of each House, respectively, but 
                        applicable only with the respect to the 
                        procedure to be followed in that House in the 
                        case of resolutions described in subparagraph 
                        (B). They shall supersede other rules only to 
                        the extent that they are inconsistent 
                        therewith. They are enacted with full 
                        recognition of the constitutional right of 
                        either House to change the rules (so far as 
                        relating to the procedure of that House) at any 
                        time, in the same manner and to the same extent 
                        as in the case of any ruse of that House.
                            ``(ii) For the purpose of the succeeding 
                        paragraphs of this subsection, `resolution' 
                        means only a joint resolution, the matter after 
                        the resolving clause of which is as follows: 
                        `That Congress disapproves the model expansion 
                        requested pursuant to section 1115A(c) of the 
                        Social Security Act transmitted by the 
                        Secretary on _____, and such an expansion shall 
                        not proceed.', the blank space therein being 
                        filled with the date on which the Secretary's 
                        message proposing such expansion was delivered.
                            ``(iii) Upon receipt of a report submitted 
                        to Congress under subparagraph (c)(4), each 
                        House shall provide copies of the report to the 
                        chairman and ranking member of the Committee on 
                        Ways and Means and the Committee on Energy and 
                        Commerce of the House of Representatives and to 
                        the Committee on Finance and the Committee on 
                        Health, Education, Labor, and Pensions of the 
                        Senate.
                            ``(iv) A resolution shall be referred to 
                        the Committee on Ways and Means and the 
                        Committee on Energy and Commerce of the House 
                        of Representatives and to the Committee on 
                        Finance and the Committee on Health, Education, 
                        Labor, and Pensions of the Senate.
                            ``(v) If a committee to which has been 
                        referred a resolution has not reported it 
                        before the expiration of 10 legislative days 
                        after its introduction, it shall then (but not 
                        before) be in order to move to discharge the 
                        committee from further consideration of that 
                        resolution, or to discharge the committee from 
                        further consideration of any other resolution 
                        with respect to the proposed expansion which 
                        has been referred to the committee. The motion 
                        to discharge may be made only by a person 
                        favoring the resolution, shall be highly 
                        privileged (except that it may not be made 
                        after the committee has reported a resolution 
                        with respect to the same proposed expansion), 
                        and debate thereon shall be limited to not more 
                        than 1 hour, to be divided equally between 
                        those favoring and those opposing the 
                        resolution. An amendment to the motion is not 
                        in order, and it is not in order to move to 
                        reconsider the vote by which the motion is 
                        agreed to or disagreed to. If the motion to 
                        discharge is agreed to or disagreed to, the 
                        motion may not be renewed, nor may another 
                        motion to discharge the committee be made with 
                        respect to any other resolution with respect to 
                        the same proposed expansion.
                            ``(vi) When the committee has reported, or 
                        has been discharged from further consideration 
                        of a resolution, it is at any time thereafter 
                        in order (even though a previous motion to the 
                        same effect has been disagreed to) to move to 
                        proceed to the consideration of the resolution. 
                        The motion is highly privileged and is not 
                        debatable. An amendment to the motion is not in 
                        order, and it is not in order to move to 
                        reconsider the vote by which the motion is 
                        agreed to or disagreed to. Debate on the 
                        resolution shall be limited to not more than 2 
                        hours, which shall be divided equally between 
                        those favoring and those opposing the 
                        resolution. A motion further to limit debate is 
                        not debatable. An amendment to, or motion to 
                        recommit, the resolution is not in order, and 
                        it is not in order to move to reconsider the 
                        vote by which the resolution is agreed to or 
                        disagreed to.
                            ``(vii) Motions to postpone, made with 
                        respect to the discharge from committee, or the 
                        consideration of, a resolution and motions to 
                        proceed to the consideration of other business 
                        shall be decided without debate. Appeals from 
                        the decision of the Chair relating to the 
                        application of the rules of the Senate or the 
                        House of Representatives, as the case may be, 
                        to the procedure relating to a resolution shall 
                        be decided without debate.
                            ``(viii) Coordination with action by the 
                        other house.--If, before the passage by one 
                        House of a joint resolution of that House, that 
                        House receives from the other House a joint 
                        resolution, then the following procedures shall 
                        apply:
                                    ``(I) The joint resolution of the 
                                other House shall not be referred to a 
                                committee.
                                    ``(II) With respect to a joint 
                                resolution of the House receiving the 
                                resolution, the procedure in that House 
                                shall be the same as if no joint 
                                resolution had been received from the 
                                other House; but the vote on passage 
                                shall be on the joint resolution of the 
                                other House.
                            ``(ix) If one House fails to introduce or 
                        consider a joint resolution under this section, 
                        the joint resolution of the other House shall 
                        be entitled to expedited floor procedures under 
                        this section.
                            ``(x) If, following passage of the joint 
                        resolution in the Senate, the Senate then 
                        receives the companion measure from the House 
                        of Representatives, the companion measure shall 
                        not be debatable.
                            ``(xi) If Congress passes a joint 
                        resolution, the period beginning on the date 
                        the President is presented with the joint 
                        resolution and ending on the date the President 
                        takes action with respect to the joint 
                        resolution shall be disregarded in computing 
                        the 45-calendar day period described in 
                        subsection (c)(4).
                            ``(xii) If the President vetoes the joint 
                        resolution--
                                    ``(I) the period beginning on the 
                                date the President vetoes the joint 
                                resolution and ending on the date the 
                                Congress receives the veto message with 
                                respect to the joint resolution shall 
                                be disregarded in computing the 45-
                                calendar day period described in 
                                subsection (c)(4), and
                                    ``(II) debate on a veto message in 
                                the Senate under this section shall be 
                                1 hour equally divided between the 
                                majority and minority leaders or their 
                                designees.''.

SEC. 5. PUBLIC INPUT.

    Section 115A(d) of the Social Security Act (42 U.S.C. 1315a(d)) is 
amended by Section 3, is further amended by adding at the end of the 
following new paragraphs:
            ``(5) Public input.--The Secretary shall use a process 
        involving advance public notice and an opportunity for 
        stakeholder input and public comments to ensure transparency 
        and accountability regarding the establishment, testing, 
        implementation, evaluation, and expansion of a model under 
        section 1115A(b) and (c). Such public notice shall describe and 
        define the standards, criteria, and processes that the 
        Secretary will use for selecting and evaluating--
                    ``(A) during initial stages of model development;
                    ``(B) prior to testing under subsection (b)(1);
                    ``(C) prior to modification of non-contractual 
                models under subsection (b)(3)(B); and
                    ``(D) following evaluation of a model under 
                subsection (b)(4) and prior to rulemaking under 
                subsection (c).
        Such notice shall explain the basis for the Secretary's 
        determination that the conditions set forth in section 115A(c) 
        of the Social Security Act (42 U.S.C. 1315a(c)) have been met. 
        Additionally, the notice shall explain the basis for selection 
        and the standards established by the Secretary under the 
        regulations issued under paragraph (1), and any additional 
        factors that will be used to test the model's impact on quality 
        of care, patient-centeredness, and innovation. The notice shall 
        provide a minimum 45-day period for public comment. The 
        Secretary shall take stakeholder comments into consideration 
        when determining whether or how to refine the model or whether 
        to proceed with testing under subsection (b)(1).
            ``(6) Consultation.--In carrying out the duties under this 
        subsection, the CMI shall consult representatives of relevant 
        Federal agencies, and clinical and analytical experts with 
        expertise in medicine and health care management, specifically 
        such experts with expertise in--
                    ``(A) the health care needs of minority, rural and 
                underserved populations; and
                    ``(B) the financial needs of safety net, community-
                based, rural, and critical access providers, including 
                federally qualified health centers.
        The CMI shall use open door forums or other mechanisms to seek 
        external feedback from interested parties and incorporate that 
        feedback into the development of models.''.

SEC. 6. REESTABLISHING JUDICIAL REVIEW.

    Section 1115A(g) of the Social Security Act (42 U.S.C. 1315a(g)) is 
amended--
            (1) in the matter preceding subparagraph (A) by inserting 
        after ``or otherwise'' the following: ``(except as may be 
        necessary to enforce requirements of this section or other laws 
        or constitutional provisions intended to protect beneficiaries 
        of affected programs)'';
            (2) by striking subparagraph (C);
            (3) in subparagraph (D), by adding at the end ``; and'';
            (4) by redesignating subparagraph (D) as subparagraph (C);
            (5) in subparagraph (E), at the end, by striking ``; and'';
            (6) by redesignating subparagraph (E) as subparagraph (D); 
        and
            (7) by striking subparagraph (F).

SEC. 7. REVISION OF REPORTING REQUIREMENT.

    Section 1115A(g) of the Social Security Act (42 U.S.C. 1315a(g)) is 
amended--
            (1) by striking ``and not less than once every other year 
        thereafter'' and inserting ``and, for years before 2020, not 
        less than once biennially (and, for years beginning with 2020, 
        not less than annually) thereafter''; and
            (2) by adding at the end the following new sentence: ``With 
        respect to 2020 and each subsequent year, the Secretary shall 
        submit each such report by not later than December 15 of such 
        year.''.

SEC. 8. ADDRESSING OVERLAP IN VALUE-BASED CARE PROGRAMS.

    (a) In General.--
            (1) CMI.--Section 1115A(a)(5) of the Social Security Act 
        (42 U.S.C. 1315a(a)(5)) is amended by adding at the end the 
        following new sentence: ``In establishing such limits, the 
        Secretary shall take into account payment and service delivery 
        models in progress in such geographic areas.''.
            (2) Repeal of medicare duplication prohibition.--Section 
        1899(b) of the Social Security Act (42 U.S.C. 1395jjj(b)) is 
        amended by striking paragraph (4)(A).
    (b) Report.--Not later than 60 days after the date of the enactment 
of this Act, the Secretary of Health and Human Services shall conduct 
an assessment and submit to Congress a report on alternative payment 
model overlap under the Medicare program under title XVIII of the 
Social Security Act. Such report shall include a description of and 
recommendations relating to--
            (1) appropriate participation in multiple alternative 
        payment models for health care providers;
            (2) feasibility of adequate evaluation of alternative 
        payment models if participants are participating in multiple 
        arrangements; and
            (3) obstacles created by competing incentives with respect 
        to alternative payment models.

SEC. 9. MODEL ELIGIBILITY AND QUALITY OF CARE.

    (a) Clarification of Model Eligibility.--Section 1115A of the 
Social Security Act (42 U.S.C. 1315a) is amended--
            (1) by striking ``also'' before ``improve''; and
            (2) in subsection (b)(2)(A), by inserting after the second 
        sentence the following new sentence:
    ``The Secretary may also focus on models solely aimed at 
implementing practices to demonstrate ways to significantly improve the 
care, patient safety, and health outcomes of individuals receiving 
benefits under the applicable title in anticipation that quality of 
care benefits and potential direct or indirect savings will over time 
accrue to the Medicare or Medicaid program.''.
    (b) Additional Opportunity.--Section 1115A(b)(2)(B) of the Social 
Security Act (42 U.S.C. 1315a(b)(2)(B)) is amended by adding at the end 
the following new clause:
                            ``(xxviii) Implementing newly recognized 
                        and evidence-based, professionally supported 
                        care delivery practices and bundles to improve 
                        the efficient and effective delivery of 
                        hospital-based care and lead to enhanced 
                        patient outcomes, reductions in readmissions, 
                        or avoidance of costly medical errors or 
                        complications.''.
    (c) Inclusion of Indirect Savings.--Section 1115A(b)(3)(A) of the 
Social Security Act (42 U.S.C. 1315a(b)(3)(A)) is amended by inserting 
at the end ``or that savings cannot be made indirectly over time when 
testing quality of care delivery models.''.
    (d) Evaluating Quality of Care.--Section 1115A(b)(4) of the Social 
Security Act (42 U.S.C. 1315a(b)(4)) is amended--
            (1) in subparagraph (A), by amending clause (i) to read as 
        follows:
                            ``(i) the quality of care furnished under 
                        the model, including the measurement of 
                        patient-level outcomes, patient-centeredness, 
                        and any unintended consequences, such as access 
                        to services, using criteria determined 
                        appropriate by the Secretary for each model; 
                        and''; and
            (2) in subparagraph (C), by striking ``and'' before 
        ``patient-centered care'' and inserting ``, are appropriate to 
        issues of quality outcomes related to the medical conditions 
        under study, and are''.

SEC. 10. GAO REPORT.

    Not later than 12 months after the date of enactment of this Act, 
the Comptroller General of the United States shall submit to Congress a 
report on the efforts of the Center for Medicare and Medicaid 
Innovation to attract, retain, and develop emerging experts, including 
underrepresented individuals in medicine, such as women, racial and 
ethnic minorities, and other groups. Such report shall include an 
analysis of the role minority staff play in model development and 
operational decisions on an ongoing bases and of the impact of the 
existing authority provided to the Center for Medicare and Medicaid 
Innovation to address workforce shortages and gaps in priority areas.

SEC. 11. EFFECTIVE DATE.

    Except as otherwise provided in the previous sections of this Act 
(or the amendments made by such sections), such amendments shall apply 
with respect to the testing, expansion, or modification of models on or 
after January 1, 2022.
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