I 114th CONGRESS 2d Session H. R. 6518 IN THE HOUSE OF REPRESENTATIVES December 8, 2016 Mr. Pitts (for himself, Mr. Flores , Mrs. Brooks of Indiana , Mr. Bucshon , Mr. Collins of New York , Mr. Guthrie , Mrs. Blackburn , and Mr. Mullin ) introduced the following bill; which was referred to the Committee on Energy and Commerce A BILL To amend title XIX of the Social Security Act to improve the Medicaid and CHIP Payment and Access Commission (MACPAC).

1. Short title This Act may be cited as the MACPAC Improvement Act of 2016 . 2. Improvement of MACPAC (a) Duties Section 1900(b) of the Social Security Act ( 42 U.S.C. 1396(b) ) is amended— (1) in paragraph (1)— (A) in the heading, by inserting , payment, financing, and program integrity after access ; (B) in subparagraph (A), by inserting , payment, financing, or program integrity after affecting access to covered items and services ; (C) in subparagraph (B), by striking access ; (D) in subparagraph (C), by striking such policies and inserting the following: policies of such programs relating to financing and program integrity, including— (i) the implications of such policies with respect to changes in health care delivery in the United States; and (ii) with respect to the market for health care items and services, the impact of such policies on the cost and spending growth under such programs; ; and (E) in subparagraph (D), by striking containing and all that follows through the period and inserting the following: containing the results of such reviews and MACPAC’s recommendations concerning the policies of such programs relating to access and payment, including— (i) the implications of such policies with respect to changes in health care delivery in the United States; and (ii) with respect to the market for health care items and services, the impact of such policies on access and payment under such programs. ; (2) in paragraph (2)— (A) in subparagraph (A)— (i) in clause (ii), by striking and at the end; (ii) in clause (iii), by striking the period at the end and inserting ; and ; and (iii) by adding at the end the following new clause: (iv) such payment policies that may result in total payments (taking into account additional or supplemental payments or payment adjustments) under this title or title XXI that exceed the cost of providing items and services to Medicaid or CHIP beneficiaries (as applicable) and changes in such payment policies that could improve efficiency without negatively impacting access to care for such beneficiaries. ; and (B) by adding at the end the following new subparagraph: (I) Data National and State-specific Medicaid and CHIP data. ; (3) by amending paragraph (3) to read as follows: (3) Annual policy recommendations Not less frequently than once a year, MACPAC shall make recommendations regarding Federal statutes that could be enacted or policies which the Secretary or States could implement to achieve, with respect to Medicaid and CHIP, the following goals: (A) Federal and state outlays Reducing Federal and State outlays to make such programs more sustainable. (B) Financing Improving the transparency, integrity, and sustainability of financing. (C) State flexibility and efficiency Improving State flexibility, predictability, accountability, integrity, and efficiency in oversight and administration. (D) Program integrity and reduce waste, fraud, and abuse Enhancing program integrity, reducing the amount and rate of improper payments, improving internal administrative and financial controls, and enhancing efforts to curb waste, fraud, and abuse. (E) Prioritizing the most vulnerable Prioritizing benefits, care, and services for the most vulnerable, low-income Medicaid and CHIP beneficiaries, such as children and pregnant women whose family income is at or below the Federal poverty line, the elderly, and individuals with disabilities. (F) Empowering beneficiaries Improving the independence, self-direction, self-sufficiency, and empowerment of beneficiaries. ; (4) in paragraph (4)— (A) in the heading, by striking system and inserting systems ; (B) by striking MACPAC shall create and inserting the following: (A) System related to access MACPAC shall create ; and (C) by adding at the end the following new subparagraph: (B) System related to program growth MACPAC shall create an early-warning system to identify challenges with sustaining Federal and State funding for Medicaid during the mid-term and long-term. MACPAC shall include in the annual report required under paragraph (1)(C) a description of such challenges, including challenges posed by budgetary pressures which could lead to increased Federal or State deficits, crowd out discretionary Federal or State spending, or necessitate increases in revenues, and proposed recommendations for addressing such challenges. ; (5) in paragraph (5)— (A) in the heading, by striking and regulations and inserting , regulations, and guidance ; (B) in subparagraph (B), by inserting financing, after quality, ; and (C) by adding at the end the following new subparagraph: (C) CMS guidance MACPAC shall review guidance issued to States by the Centers for Medicare & Medicaid Services with respect to Medicaid or CHIP and shall, not later than the date that is 90 days after the date of such issuance, submit a report to the appropriate committees of Congress and the Secretary on the degree to which such guidance is projected to change Federal or State outlays for Medicaid or CHIP. ; (6) in paragraph (7)— (A) in the heading by inserting and working documents after reports ; (B) by striking MACPAC shall transmit and inserting the following: (A) Reports MACPAC shall submit ; and (C) by adding at the end the following new subparagraph: (B) Working documents MACPAC shall make available to the appropriate committees of Congress copies of draft report chapters, white papers, and other materials distributed among members of MACPAC. ; (7) in paragraph (8), by striking of the House of Representatives and the Committee on Finance of the Senate and inserting , the Committee on Appropriations, and the Committee on Oversight and Government Reform of the House of Representatives and the Committee on Finance, the Committee on Homeland Security and Governmental Affairs, and the Committee on Appropriations of the Senate ; (8) in paragraph (10), by adding at the end the following: For each recommendation that MACPAC determines would increase Federal or State outlays for Medicaid or CHIP, MACPAC shall make a recommendation regarding changes in Federal or State policy to offset such increased outlays. ; and (9) by adding at the end the following new paragraph: (15) Annual report Not later than three months after the end of a fiscal year, MACPAC shall prepare and make available on the MACPAC website a report with respect to such fiscal year on its activities that includes— (A) information related to MACPAC’s expenses, contracts, accomplishments, and activities for such fiscal year; and (B) the status of MACPAC’s recommendations, including updates on Federal statutes that have been enacted or policies which the Secretary or States have implemented to effect such recommendations. . (b) Membership Section 1900(c) of the Social Security Act ( 42 U.S.C. 1396(c) ) is amended— (1) by amending paragraph (2) to read as follows: (2) Qualifications (A) In general The membership of MACPAC shall include the following: (i) At least three individuals representing health care providers, such as physicians, nurses, or dentists. (ii) At least two individuals representing health plans that enroll Medicaid or CHIP beneficiaries, including one or more individuals representing a Medicaid managed care plan. (iii) At least one individual who is an actuary with expertise in health care. (iv) At least two individuals who are or have been directors of Medicaid for a State, including at least one individual who is such a director at the time of appointment to MACPAC. (v) At least one individual who is or has been a director of CHIP for a State. (vi) At least one individual with expertise in health care finance and health economics. (vii) At least two individuals who are representatives of Medicaid and CHIP beneficiaries, such as children, pregnant women, the elderly, and individuals with disabilities. (viii) At least one individual with expertise in long-term services and supports, such as in the financing or delivery of long-term services and supports or managed long-term care services, including care delivered in nursing homes or home and community-based settings. (B) Inclusion The membership of MACPAC shall include individuals with expertise in— (i) Federal safety net health programs; (ii) developing, negotiating, or implementing a Medicaid waiver based on experience working for a State; (iii) health care payment and financing reforms; (iv) integrated health care delivery systems, coordinated care models, and value-based contracting; (v) public health; (vi) program integrity and fraud prevention; (vii) health information technology and telehealth; (viii) prescription drug pricing or payment; and (ix) operating a Medicaid program, health plan, hospital, or health care delivery system. (C) Diversity The membership of MACPAC shall also provide representation from a variety of different professions and geographic areas and provide for a balanced representation among urban, suburban, and rural areas. (D) Balance of perspectives The Comptroller General of the United States shall ensure members appointed for initial or subsequent terms to MACPAC reflect an appropriate balance of political perspectives, including by taking into account political party registration and contributions made to political candidates and parties. (E) Majority nonproviders (i) In general Individuals who are directly involved in the provision, or management of the delivery, of items and services covered under Medicaid or CHIP shall not constitute a majority of the membership of MACPAC. (ii) Medicaid and CHIP directors For purposes of this subparagraph, Medicaid and CHIP directors shall not be considered to be directly involved in the provision, or management of the delivery, of items and services covered under Medicaid or CHIP. (F) Ethical disclosure (i) In general The Comptroller General of the United States shall establish a system for the public disclosure of financial, professional, political, advocacy, or other activities of members of MACPAC that may result in, or be perceived to result in, conflicts of interest relating to such members’ service on MACPAC. (ii) Timing of disclosures The Comptroller General shall require that each member of MACPAC make— (I) the disclosure described in clause (i) on an annual basis; and (II) in the case of a significant change in any of the activities of the member described in such clause, a supplemental disclosure at the time of such significant change. (iii) Treatment as employees of Congress Members of MACPAC shall be treated as employees of Congress for purposes of applying title I of the Ethics in Government Act of 1978 ( Public Law 95–521 ). ; and (2) in paragraph (5), by adding at the end the following: Such designation shall be based on previous management experience. The Comptroller General may not exclude a member from consideration for such designation based on the fact that such member is an individual employed by a State or by an entity that receives Medicaid or CHIP payments, including a local government, a health plan that enrolls Medicaid or CHIP beneficiaries, or a health care provider. . (c) Conflicts of interest Section 1900 of the Social Security Act ( 42 U.S.C. 1396 ) is amended by adding at the end the following new subsection: (g) Conflict of interest policy MACPAC shall maintain and make available on the MACPAC website a conflict of interest policy outlining requirements for members and personnel of MACPAC. Such policy shall include the following: (1) Disclosure Requirements for initially disclosing, and periodically updating, any substantial political activity or significant financial interests that might influence, or that might reasonably appear to influence, perspectives on issues that could come before MACPAC. (2) Legal involvement With respect to any matter under adjudication before a court, administrative law judge, or other judicial entities: (A) A requirement of disclosure of any direct or indirect involvement in any such matter related to a Federal or State health care program (as such terms are defined in sections 1128(h) and 1128B(f), respectively), including filing an amicus brief. (B) A prohibition on direct or indirect involvement in any such matter that involves the Congress as a party, including filing an amicus brief. (3) Recusal The criteria and circumstances under which a member of MACPAC shall suspend participation in MACPAC or otherwise seek recusal from MACPAC votes, including the process by which MACPAC discloses recommendations for such a recusal. . (d) Application (1) Duties The amendments made by subsection (a) shall apply with respect to reports (and recommendations included in reports) submitted on or after the date that is more than one year after the date of the enactment of this Act. (2) Guidance The amendments made by subsection (b)(5) shall apply with respect to guidance issued on or after the date of the enactment of this Act. (3) Membership (A) Appointment of new members The Comptroller General of the United States shall apply the changes to the membership of the Medicaid and CHIP Payment and Access Commission required by amendments made by subsection (b) as soon as is practicable, consistent with subparagraph (B), and in no event later than the date that is three years after the date of the enactment of this Act. (B) Retention of current members An individual who is a member of the Medicaid and CHIP Payment and Access Commission as of the date of the enactment of this Act may continue to serve until the end of the individual’s term as of such date without regard to the amendments made by subsection (b). (4) Conflicts of interest The amendment made by subsection (c) shall apply beginning on the date that is 90 days after the date of the enactment of this Act.