I 117th CONGRESS 2d Session H. R. 9638 IN THE HOUSE OF REPRESENTATIVES December 20, 2022 Ms. Schakowsky (for herself, Mr. Quigley , Mr. Fitzpatrick , and Mr. Crow ) introduced the following bill; which was referred to the Committee on Ways and Means , and in addition to the Committee on Energy and Commerce , for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL 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.

1. Short title This Act may be cited as the Medicare Payment Reform for People with ALS Act of 2022 . 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: 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 . 3. Effective date The amendments made by this Act shall take effect on the date of the enactment of this Act.