[113th Congress Public Law 93]
[From the U.S. Government Publishing Office]
[[Page 1039]]
PROTECTING ACCESS TO MEDICARE ACT
OF 2014
[[Page 128 STAT. 1040]]
Public Law 113-93
113th Congress
An Act
To amend the Social Security Act to extend Medicare payments to
physicians and other provisions of the Medicare and Medicaid programs,
and for other purposes. <<NOTE: Apr. 1, 2014 - [H.R. 4302]>>
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled, <<NOTE: Protecting
Access to Medicare Act of 2014.>>
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short <<NOTE: 42 USC 1305 note.>> Title.--This Act may be cited
as the ``Protecting Access to Medicare Act of 2014''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--MEDICARE EXTENDERS
Sec. 101. Physician payment update.
Sec. 102. Extension of work GPCI floor.
Sec. 103. Extension of therapy cap exceptions process.
Sec. 104. Extension of ambulance add-ons.
Sec. 105. Extension of increased inpatient hospital payment adjustment
for certain low-volume hospitals.
Sec. 106. Extension of the Medicare-dependent hospital (MDH) program.
Sec. 107. Extension for specialized Medicare Advantage plans for special
needs individuals.
Sec. 108. Extension of Medicare reasonable cost contracts.
Sec. 109. Extension of funding for quality measure endorsement, input,
and selection.
Sec. 110. Extension of funding outreach and assistance for low-income
programs.
Sec. 111. Extension of two-midnight rule.
Sec. 112. Technical changes to Medicare LTCH amendments.
TITLE II--OTHER HEALTH PROVISIONS
Sec. 201. Extension of the qualifying individual (QI) program.
Sec. 202. Temporary extension of transitional medical assistance (TMA).
Sec. 203. Extension of Medicaid and CHIP express lane option.
Sec. 204. Extension of special diabetes program for type I diabetes and
for Indians.
Sec. 205. Extension of abstinence education.
Sec. 206. Extension of personal responsibility education program (PREP).
Sec. 207. Extension of funding for family-to-family health information
centers.
Sec. 208. Extension of health workforce demonstration project for low-
income individuals.
Sec. 209. Extension of maternal, infant, and early childhood home
visiting programs.
Sec. 210. Pediatric quality measures.
Sec. 211. Delay of effective date for Medicaid amendments relating to
beneficiary liability settlements.
Sec. 212. Delay in transition from ICD-9 to ICD-10 code sets.
Sec. 213. Elimination of limitation on deductibles for employer-
sponsored health plans.
Sec. 214. GAO report on the Children's Hospital Graduate Medical
Education Program.
Sec. 215. Skilled nursing facility value-based purchasing.
Sec. 216. Improving Medicare policies for clinical diagnostic laboratory
tests.
[[Page 128 STAT. 1041]]
Sec. 217. Revisions under the Medicare ESRD prospective payment system.
Sec. 218. Quality incentives for computed tomography diagnostic imaging
and promoting evidence-based care.
Sec. 219. Using funding from Transitional Fund for Sustainable Growth
Rate (SGR) Reform.
Sec. 220. Ensuring accurate valuation of services under the physician
fee schedule.
Sec. 221. Medicaid DSH.
Sec. 222. Realignment of the Medicare sequester for fiscal year 2024.
Sec. 223. Demonstration programs to improve community mental health
services.
Sec. 224. Assisted outpatient treatment grant program for individuals
with serious mental illness.
Sec. 225. Exclusion from PAYGO scorecards.
TITLE I--MEDICARE EXTENDERS
SEC. 101. PHYSICIAN PAYMENT UPDATE.
Section 1848(d) of the Social Security Act (42 U.S.C. 1395w-4(d)) is
amended--
(1) in paragraph (15)--
(A) in the heading, by striking ``January through
march of'';
(B) in subparagraph (A), by striking ``for the
period beginning on January 1, 2014, and ending on March
31, 2014''; and
(C) in subparagraph (B)--
(i) in the heading, by striking ``remaining
portion of 2014 and''; and
(ii) by striking ``the period beginning on
April 1, 2014, and ending on December 31, 2014,
and for''; and
(2) by adding at the end the following new paragraph:
``(16) <<NOTE: Time periods.>> Update for january through
march of 2015.--
``(A) In general.--Subject to paragraphs (7)(B),
(8)(B), (9)(B), (10)(B), (11)(B), (12)(B), (13)(B),
(14)(B), and (15)(B), in lieu of the update to the
single conversion factor established in paragraph (1)(C)
that would otherwise apply for 2015 for the period
beginning on January 1, 2015, and ending on March 31,
2015, the update to the single conversion factor shall
be 0.0 percent.
``(B) No effect on computation of conversion factor
for remaining portion of 2015 and subsequent years.--The
conversion factor under this subsection shall be
computed under paragraph (1)(A) for the period beginning
on April 1, 2015, and ending on December 31, 2015, and
for 2016 and subsequent years as if subparagraph (A) had
never applied.''.
SEC. 102. EXTENSION OF WORK GPCI FLOOR.
Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)(E)) is amended by striking ``April 1, 2014'' and inserting
``April 1, 2015''.
SEC. 103. EXTENSION OF THERAPY CAP EXCEPTIONS PROCESS.
Section 1833(g) of the Social Security Act (42 U.S.C. 1395l(g)) is
amended--
(1) in paragraph (5)(A), in the first sentence, by striking
``March 31, 2014'' and inserting ``March 31, 2015''; and
(2) in paragraph (6)(A)--
(A) by striking ``March 31, 2014'' and inserting
``March 31, 2015''; and
[[Page 128 STAT. 1042]]
(B) by striking ``2012, 2013, or the first three
months of 2014'' and inserting ``2012, 2013, 2014, or
the first three months of 2015''.
SEC. 104. EXTENSION OF AMBULANCE ADD-ONS.
(a) Ground Ambulance.--Section 1834(l)(13)(A) of the Social Security
Act (42 U.S.C. 1395m(l)(13)(A)) is amended by striking ``April 1, 2014''
and inserting ``April 1, 2015'' each place it appears.
(b) Super Rural Ground Ambulance.--Section 1834(l)(12)(A) of the
Social Security Act (42 U.S.C. 1395m(l)(12)(A)) is amended, in the first
sentence, by striking ``April 1, 2014'' and inserting ``April 1, 2015''.
SEC. 105. EXTENSION OF INCREASED INPATIENT HOSPITAL PAYMENT
ADJUSTMENT FOR CERTAIN LOW-VOLUME
HOSPITALS.
Section 1886(d)(12) of the Social Security Act (42 U.S.C.
1395ww(d)(12)) is amended--
(1) in subparagraph (B), in the matter preceding clause (i),
by striking ``in the portion of fiscal year 2014 beginning on
April 1, 2014, fiscal year 2015, and subsequent fiscal years''
and inserting ``in fiscal year 2015 (beginning on April 1,
2015), fiscal year 2016, and subsequent fiscal years'';
(2) in subparagraph (C)(i), by striking ``fiscal years 2011,
2012, and 2013, and the portion of fiscal year 2014 before'' and
inserting ``fiscal years 2011 through 2014 and fiscal year 2015
(before April 1, 2015),'' each place it appears; and
(3) in subparagraph (D), by striking ``fiscal years 2011,
2012, and 2013, and the portion of fiscal year 2014 before April
1, 2014,'' and inserting ``fiscal years 2011 through 2014 and
fiscal year 2015 (before April 1, 2015),''.
SEC. 106. EXTENSION OF THE MEDICARE-DEPENDENT HOSPITAL (MDH)
PROGRAM.
(a) In General.--Section 1886(d)(5)(G) of the Social Security Act
(42 U.S.C. 1395ww(d)(5)(G)) is amended--
(1) in clause (i), by striking ``April 1, 2014'' and
inserting ``April 1, 2015''; and
(2) in clause (ii)(II), by striking ``April 1, 2014'' and
inserting ``April 1, 2015''.
(b) Conforming Amendments.--
(1) Extension of target amount.--Section 1886(b)(3)(D) of
the Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is amended--
(A) in the matter preceding clause (i), by striking
``April 1, 2014'' and inserting ``April 1, 2015''; and
(B) in clause (iv), by striking ``through fiscal
year 2013 and the portion of fiscal year 2014 before
April 1, 2014'' and inserting ``through fiscal year 2014
and the portion of fiscal year 2015 before April 1,
2015''.
(2) Permitting hospitals to decline reclassification.--
Section 13501(e)(2) of the Omnibus Budget Reconciliation Act of
1993 (42 U.S.C. 1395ww note) is amended by striking ``through
the first 2 quarters of fiscal year 2014'' and inserting
``through the first 2 quarters of fiscal year 2015''.
[[Page 128 STAT. 1043]]
SEC. 107. EXTENSION FOR SPECIALIZED MEDICARE ADVANTAGE PLANS FOR
SPECIAL NEEDS INDIVIDUALS.
Section 1859(f)(1) of the Social Security Act (42 U.S.C. 1395w-
28(f)(1)) is amended by striking ``2016'' and inserting ``2017''.
SEC. 108. EXTENSION OF MEDICARE REASONABLE COST CONTRACTS.
Section 1876(h)(5)(C)(ii) of the Social Security Act (42 U.S.C.
1395mm(h)(5)(C)(ii)) is amended, in the matter preceding subclause (I),
by striking ``January 1, 2015'' and inserting ``January 1, 2016''.
SEC. 109. EXTENSION OF FUNDING FOR QUALITY MEASURE ENDORSEMENT,
INPUT, AND SELECTION.
Section 1890(d) of the Social Security Act (42 U.S.C. 1395aaa(d)) is
amended--
(1) by inserting ``(1)'' before ``For purposes''; and
(2) by adding at the end the following new paragraph:
``(2) For purposes of carrying out this section and section 1890A
(other than subsections (e) and (f)), the Secretary shall provide for
the transfer, from the Federal Hospital Insurance Trust Fund under
section 1817 and the Federal Supplementary Medical Insurance Trust Fund
under section 1841, in such proportion as the Secretary determines
appropriate, to the Centers for Medicare & Medicaid Services Program
Management Account of $5,000,000 for fiscal year 2014 and $15,000,000
for the first 6 months of fiscal year 2015. Amounts transferred under
the preceding sentence shall remain available until expended.''.
SEC. 110. EXTENSION OF FUNDING OUTREACH AND ASSISTANCE FOR LOW-
INCOME PROGRAMS.
(a) Additional Funding for State Health Insurance Programs.--
Subsection (a)(1)(B) of section 119 of the Medicare Improvements for
Patients and Providers Act of 2008 (42 U.S.C. 1395b-3 note), as amended
by section 3306 of the Patient Protection and Affordable Care Act Public
Law 111-148), section 610 of the American Taxpayer Relief Act of 2012
(Public Law 112-240), and section 1110 of the Pathway for SGR Reform Act
of 2013 (Public Law 113-67), is amended--
(1) in clause (iii), by striking ``and'' at the end;
(2) by striking clause (iv); and
(3) by adding at the end the following new clauses:
``(iv) for fiscal year 2014, of $7,500,000;
and
``(v) for the portion of fiscal year 2015
before April 1, 2015, of $3,750,000.''.
(b) Additional Funding for Area Agencies on Aging.--Subsection
(b)(1)(B) of such section 119, as so amended, is amended--
(1) in clause (iii), by striking ``and'' at the end;
(2) by striking clause (iv); and
(3) by inserting after clause (iii) the following new
clauses:
``(iv) for fiscal year 2014, of $7,500,000;
and
``(v) for the portion of fiscal year 2015
before April 1, 2015, of $3,750,000.''.
(c) Additional Funding for Aging and Disability Resource Centers.--
Subsection (c)(1)(B) of such section 119, as so amended, is amended--
(1) in clause (iii), by striking ``and'' at the end;
(2) by striking clause (iv); and
(3) by inserting after clause (iii) the following new
clauses:
[[Page 128 STAT. 1044]]
``(iv) for fiscal year 2014, of $5,000,000;
and
``(v) for the portion of fiscal year 2015
before April 1, 2015, of $2,500,000.''.
(d) Additional Funding for Contract With the National Center for
Benefits and Outreach Enrollment.--Subsection (d)(2) of such section
119, as so amended, is amended--
(1) in clause (iii), by striking ``and'' at the end;
(2) by striking clause (iv); and
(3) by inserting after clause (iii) the following new
clauses:
``(iv) for fiscal year 2014, of $5,000,000;
and
``(v) for the portion of fiscal year 2015
before April 1, 2015, of $2,500,000.''.
SEC. 111. <<NOTE: 42 USC 1395ddd note.>> EXTENSION OF TWO-
MIDNIGHT RULE.
(a) Continuation of Certain Medical Review Activities.--The
Secretary of Health and Human Services may continue medical review
activities described in the notice entitled ``Selecting Hospital Claims
for Patient Status Reviews: Admissions On or After October 1, 2013'',
posted on the Internet website of the Centers for Medicare & Medicaid
Services, through the first 6 months of fiscal year 2015 for such
additional hospital claims as the Secretary determines appropriate.
(b) <<NOTE: Time period.>> Limitation.--The Secretary of Health and
Human Services shall not conduct patient status reviews (as described in
such notice) on a post-payment review basis through recovery audit
contractors under section 1893(h) of the Social Security Act (42 U.S.C.
1395ddd(h)) for inpatient claims with dates of admission October 1,
2013, through March 31, 2015, unless there is evidence of systematic
gaming, fraud, abuse, or delays in the provision of care by a provider
of services (as defined in section 1861(u) of such Act (42 U.S.C.
1395x(u))).
SEC. 112. TECHNICAL CHANGES TO MEDICARE LTCH AMENDMENTS.
(a) In General.--Subclauses (I) and (II) of section
1886(m)(6)(C)(iv) of the Social Security Act (42 U.S.C.
1395ww(m)(6)(C)(iv)) are each amended by striking ``discharges'' and
inserting ``Medicare fee-for-service discharges''.
(b) MMSEA Correction.--Section 114(d) of the Medicare, Medicaid, and
SCHIP Extension Act of 2007 (42 U.S.C. 1395ww note), as amended by
sections 3106(b) and 10312(b) of Public Law 111-148 and by section
1206(b)(2) of the Pathway for SGR Reform Act of 2013 (division B of
Public Law 113-67), is amended--
(1) in paragraph (1), in the matter preceding subparagraph
(A), by striking ``January 1, 2015,'' and inserting ``on the
date of the enactment of paragraph (7) of this subsection'';
(2) in paragraph (6), by striking ``January 1, 2015,'' and
inserting ``on the date of the enactment of paragraph (7) of
this subsection''; and
(3) by adding at the end the following new paragraph:
``(7) Additional exception for certain long-term care
hospitals.--The moratorium under paragraph (1)(A) shall not
apply to a long-term care hospital that--
``(A) began its qualifying period for payment as a
long-term care hospital under section 412.23(e) of title
42, Code of Federal Regulations, on or before the date
of enactment of this paragraph;
[[Page 128 STAT. 1045]]
``(B) has a binding written agreement as of the date
of the enactment of this paragraph with an outside,
unrelated party for the actual construction, renovation,
lease, or demolition for a long-term care hospital, and
has expended, before such date of enactment, at least 10
percent of the estimated cost of the project (or, if
less, $2,500,000); or
``(C) has obtained an approved certificate of need
in a State where one is required on or before such date
of enactment.''.
(c) Additional Amendments.--Section 1206(a) of the Pathway for SGR
Reform Act of 2013 (division B of Public Law 113-67) is amended--
(1) in paragraph (2)(A), by striking ``Assessment'' and
inserting ``Advisory''; and
(2) <<NOTE: 42 USC 1395ww note.>> in paragraph (3)(B), by
striking ``shall not apply to a hospital that is classified as
of December 10, 2013, as a subsection (d) hospital (as defined
in section 1886(d)(1)(B) of the Social Security Act, 42 U.S.C.
1395ww(d)(1)(B))'' and inserting ``shall only apply to a
hospital that is classified as of December 10, 2013, as a long-
term care hospital (as defined in section 1861(ccc) of the
Social Security Act, 42 U.S.C. 1395x(ccc))''.
(d) <<NOTE: 42 USC 1395ww note.>> Effective Date.--The amendments
made by this section are effective as of the date of the enactment of
this Act.
TITLE II--OTHER HEALTH PROVISIONS
SEC. 201. EXTENSION OF THE QUALIFYING INDIVIDUAL (QI) PROGRAM.
(a) Extension.--Section 1902(a)(10)(E)(iv) of the Social Security
Act (42 U.S.C. 1396a(a)(10)(E)(iv)) is amended by striking ``March
2014'' and inserting ``March 2015''.
(b) Extending Total Amount Available for Allocation.--Section
1933(g) of the Social Security Act (42 U.S.C. 1396u-3(g)) is amended--
(1) in paragraph (2)--
(A) in subparagraph (T), by striking ``and'' at the
end;
(B) in subparagraph (U)--
(i) by striking ``March 31, 2014'' and
inserting ``September 30, 2014''; and
(ii) by striking ``$200,000,000.'' and
inserting ``$485,000,000;''; and
(C) <<NOTE: Time periods.>> by adding at the end
the following new subparagraphs:
``(V) for the period that begins on October 1, 2014,
and ends on December 31, 2014, the total allocation
amount is $300,000,000; and
``(W) for the period that begins on January 1, 2015,
and ends on March 31, 2015, the total allocation amount
is $250,000,000.''; and
(2) in paragraph (3), in the matter preceding subparagraph
(A), by striking ``or (T)'' and inserting ``(T), or (V)''.
[[Page 128 STAT. 1046]]
SEC. 202. TEMPORARY EXTENSION OF TRANSITIONAL MEDICAL ASSISTANCE
(TMA).
Sections 1902(e)(1)(B) and 1925(f) of the Social Security Act (42
U.S.C. 1396a(e)(1)(B), 1396r-6(f)) are each amended by striking ``March
31, 2014'' and inserting ``March 31, 2015''.
SEC. 203. EXTENSION OF MEDICAID AND CHIP EXPRESS LANE OPTION.
Section 1902(e)(13)(I) of the Social Security Act (42 U.S.C.
1396a(e)(13)(I)) is amended by striking ``September 30, 2014'' and
inserting ``September 30, 2015''.
SEC. 204. EXTENSION OF SPECIAL DIABETES PROGRAM FOR TYPE I
DIABETES AND FOR INDIANS.
(a) Special Diabetes Programs for Type I Diabetes.--Section
330B(b)(2)(C) of the Public Health Service Act (42 U.S.C. 254c-
2(b)(2)(C)) is amended by striking ``2014'' and inserting ``2015''.
(b) Special Diabetes Programs for Indians.--Section 330C(c)(2)(C) of
the Public Health Service Act (42 U.S.C. 254c-3(c)(2)(C)) is amended by
striking ``2014'' and inserting ``2015''.
SEC. 205. EXTENSION OF ABSTINENCE EDUCATION.
Subsections (a) and (d) of section 510 of the Social Security Act
(42 U.S.C. 710) are each amended by striking ``2014'' and inserting
``2015''.
SEC. 206. EXTENSION OF PERSONAL RESPONSIBILITY EDUCATION PROGRAM
(PREP).
Section 513 of the Social Security Act (42 U.S.C. 713) is amended--
(1) in paragraphs (1)(A) and (4)(A) of subsection (a), by
striking ``2014'' and inserting ``2015'' each place it appears;
(2) in subsection (a)(4)(B)(i), by striking ``and 2014'' and
inserting ``2014, and 2015''; and
(3) in subsection (f), by striking ``2014'' and inserting
``2015''.
SEC. 207. EXTENSION OF FUNDING FOR FAMILY-TO-FAMILY HEALTH
INFORMATION CENTERS.
Section 501(c)(1)(A) of the Social Security Act (42 U.S.C.
701(c)(1)(A)) is amended--
(1) in clause (iii), by striking at the end ``and'';
(2) in clause (iv), by striking the period at the end and
inserting a semicolon and by moving the margin to align with the
margin for clause (iii); and
(3) by adding at the end the following new clauses:
``(v) $2,500,000 for the portion of fiscal year 2014 on or
after April 1, 2014; and
``(vi) $2,500,000 for the portion of fiscal year 2015 before
April 1, 2015.''.
SEC. 208. EXTENSION OF HEALTH WORKFORCE DEMONSTRATION PROJECT FOR
LOW-INCOME INDIVIDUALS.
Section 2008(c)(1) of the Social Security Act (42 U.S.C.
1397g(c)(1)) is amended by striking ``2014'' and inserting ``2015''.
SEC. 209. EXTENSION OF MATERNAL, INFANT, AND EARLY CHILDHOOD HOME
VISITING PROGRAMS.
Section 511(j) of the Social Security Act (42 U.S.C. 711(j)) is
amended--
(1) in paragraph (1)--
[[Page 128 STAT. 1047]]
(A) by striking ``and'' at the end of subparagraph
(D);
(B) by striking the period at the end of
subparagraph (E) and inserting ``; and''; and
(C) by adding at the end the following new
subparagraph:
``(F) <<NOTE: Time period.>> for the period
beginning on October 1, 2014, and ending on March 31,
2015, an amount equal to the amount provided in
subparagraph (E).''; and
(2) in paragraphs (2) and (3), by inserting ``(or portion of
a fiscal year)'' after ``for a fiscal year'' each place it
appears.
SEC. 210. PEDIATRIC QUALITY MEASURES.
(a) Continuation of Funding for Pediatric Quality Measures for
Improving the Quality of Children's Health Care.--Section 1139B(e) of
the Social Security Act (42 U.S.C. 1320b-9b(e)) is amended by adding at
the end the following: ``Of the funds appropriated under this
subsection, not less than $15,000,000 shall be used to carry out section
1139A(b).''.
(b) Elimination of Restriction on Medicaid Quality Measurement
Program.--Section 1139B(b)(5)(A) of the Social Security Act (42 U.S.C.
1320b-9b(b)(5)(A)) is amended by striking ``The aggregate amount awarded
by the Secretary for grants and contracts for the development, testing,
and validation of emerging and innovative evidence-based measures under
such program shall equal the aggregate amount awarded by the Secretary
for grants under section 1139A(b)(4)(A)''.
SEC. 211. DELAY OF EFFECTIVE DATE FOR MEDICAID AMENDMENTS RELATING
TO BENEFICIARY LIABILITY SETTLEMENTS.
Effective as if included in the enactment of the Bipartisan Budget
Act of 2013 (Public Law 113-67), section 202(c) of such Act <<NOTE: 42
USC 1396a note.>> is amended by striking ``October 1, 2014'' and
inserting ``October 1, 2016''.
SEC. 212. DELAY IN TRANSITION FROM ICD-9 TO ICD-10 CODE SETS.
The Secretary of Health and Human Services may not, prior to October
1, 2015, adopt ICD-10 code sets as the standard for code sets under
section 1173(c) of the Social Security Act (42 U.S.C. 1320d-2(c)) and
section 162.1002 of title 45, Code of Federal Regulations.
SEC. 213. ELIMINATION OF LIMITATION ON DEDUCTIBLES FOR EMPLOYER-
SPONSORED HEALTH PLANS.
(a) In General.--Section 1302(c) of the Patient Protection and
Affordable Care Act (Public Law 111-148; 42 U.S.C. 18022(c)) is
amended--
(1) by striking paragraph (2); and
(2) in paragraph (4)(A), by striking ``paragraphs (1)(B)(i)
and (2)(B)(i)'' and inserting ``paragraph (1)(B)(i)''.
(b) Conforming Amendment.--Section 2707(b) of the Public Health
Service Act (42 U.S.C. 300gg-6(b)) is amended by striking ``paragraphs
(1) and (2)'' and inserting ``paragraph (1)''.
(c) <<NOTE: 42 USC 300gg-6 note.>> Effective Date.--The amendments
made by this Act shall be effective as if included in the enactment of
the Patient Protection and Affordable Care Act (Public Law 111-148).
[[Page 128 STAT. 1048]]
SEC. 214. GAO REPORT ON THE CHILDREN'S HOSPITAL GRADUATE MEDICAL
EDUCATION PROGRAM.
(a) <<NOTE: Evaluation.>> In General.--In the case that the
Children's Hospital GME Support Reauthorization Act of 2013 is enacted
into law, the Comptroller General of the United States shall, not later
than November 30, 2017, conduct an independent evaluation, and submit to
the appropriate committees of Congress a report, concerning the
implementation of section 340E(h) of the Public Health Service Act, as
added by section 3 of the Children's Hospital GME Support
Reauthorization Act of 2013.
(b) Content.--The report described in subsection (a) shall review
and assess each of the following, with respect to hospitals receiving
payments under such section 340E(h) during the period of fiscal years
2015 through 2017:
(1) The number and type of such hospitals that applied for
such payments.
(2) The number and type of such hospitals receiving such
payments.
(3) The amount of such payments awarded to such hospitals.
(4) How such hospitals used such payments.
(5) The impact of such payments on--
(A) the number of pediatric providers; and
(B) health care needs of children.
SEC. 215. SKILLED NURSING FACILITY VALUE-BASED PURCHASING.
(a) In General.--Section 1888 of the Social Security Act (42 U.S.C.
1395yy) is amended by adding at the end the following new subsection:
``(g) Skilled Nursing Facility Readmission Measure.--
``(1) <<NOTE: Deadline.>> Readmission measure.--Not later
than October 1, 2015, the Secretary shall specify a skilled
nursing facility all-cause all-condition hospital readmission
measure (or any successor to such a measure).
``(2) <<NOTE: Deadline.>> Resource use measure.--Not later
than October 1, 2016, the Secretary shall specify a measure to
reflect an all-condition risk-adjusted potentially preventable
hospital readmission rate for skilled nursing facilities.
``(3) Measure adjustments.--When specifying the measures
under paragraphs (1) and (2), the Secretary shall devise a
methodology to achieve a high level of reliability and validity,
especially for skilled nursing facilities with a low volume of
readmissions.
``(4) Pre-rulemaking process (measure application
partnership process).--The application of the provisions of
section 1890A shall be optional in the case of a measure
specified under paragraph (1) and a measure specified under
paragraph (2).
``(5) Feedback reports to skilled nursing facilities.--
Beginning <<NOTE: Effective date.>> October 1, 2016, and every
quarter thereafter, the Secretary shall provide confidential
feedback reports to skilled nursing facilities on the
performance of such facilities with respect to a measure
specified under paragraph (1) or (2).
``(6) Public reporting of skilled nursing facilities.--
``(A) <<NOTE: Procedures. Web posting.>> In
general.--Subject to subparagraphs (B) and (C), the
Secretary shall establish procedures for making
available to the public by posting on the Nursing Home
[[Page 128 STAT. 1049]]
Compare Medicare website (or a successor website)
described in section 1819(i) information on the
performance of skilled nursing facilities with respect
to a measure specified under paragraph (1) and a measure
specified under paragraph (2).
``(B) Opportunity to review.--The procedures under
subparagraph (A) shall ensure that a skilled nursing
facility has the opportunity to review and submit
corrections to the information that is to be made public
with respect to the facility prior to such information
being made public.
``(C) Timing.--Such procedures shall provide that
the information described in subparagraph (A) is made
publicly available beginning not later than October 1,
2017.
``(7) Non-application of paperwork reduction act.--Chapter
35 of title 44, United States Code (commonly referred to as the
`Paperwork Reduction Act of 1995') shall not apply to this
subsection.''.
(b) Value-Based Purchasing Program for Skilled Nursing Facilities.--
Section 1888 of the Social Security Act (42 U.S.C. 1395yy), as amended
by subsection (a), is further amended by adding at the end the following
new subsection:
``(h) Skilled Nursing Facility Value-Based Purchasing Program.--
``(1) Establishment.--
``(A) In general.--Subject to the succeeding
provisions of this subsection, the Secretary shall
establish a skilled nursing facility value-based
purchasing program (in this subsection referred to as
the `SNF VBP Program') under which value-based incentive
payments are made in a fiscal year to skilled nursing
facilities.
``(B) <<NOTE: Applicability.>> Program to begin in
fiscal year 2019.--The SNF VBP Program shall apply to
payments for services furnished on or after October 1,
2018.
``(2) Application of measures.--
``(A) In general.--The Secretary shall apply the
measure specified under subsection (g)(1) for purposes
of the SNF VBP Program.
``(B) Replacement.--For purposes of the SNF VBP
Program, the Secretary shall apply the measure specified
under (g)(2) instead of the measure specified under
(g)(1) as soon as practicable.
``(3) Performance standards.--
``(A) Establishment.--The Secretary shall establish
performance standards with respect to the measure
applied under paragraph (2) for a performance period for
a fiscal year.
``(B) Higher of achievement and improvement.--The
performance standards established under subparagraph (A)
shall include levels of achievement and improvement. In
calculating the SNF performance score under paragraph
(4), the Secretary shall use the higher of either
improvement or achievement.
``(C) Timing.--The Secretary shall establish and
announce the performance standards established under
subparagraph (A) not later than 60 days prior to the
beginning of the performance period for the fiscal year
involved.
[[Page 128 STAT. 1050]]
``(4) <<NOTE: Assessment.>> SNF performance score.--
``(A) In general.--The Secretary shall develop a
methodology for assessing the total performance of each
skilled nursing facility based on performance standards
established under paragraph (3) with respect to the
measure applied under paragraph (2). Using such
methodology, the Secretary shall provide for an
assessment (in this subsection referred to as the `SNF
performance score') for each skilled nursing facility
for each such performance period.
``(B) Ranking of snf performance scores.--The
Secretary shall, for the performance period for each
fiscal year, rank the SNF performance scores determined
under subparagraph (A) from low to high.
``(5) Calculation of value-based incentive payments.--
``(A) In general.--With respect to a skilled nursing
facility, based on the ranking under paragraph (4)(B)
for a performance period for a fiscal year, the
Secretary shall increase the adjusted Federal per diem
rate determined under subsection (e)(4)(G) otherwise
applicable to such skilled nursing facility (and after
application of paragraph (6)) for services furnished by
such facility during such fiscal year by the value-based
incentive payment amount under subparagraph (B).
``(B) Value-based incentive payment amount.--The
value-based incentive payment amount for services
furnished by a skilled nursing facility in a fiscal year
shall be equal to the product of--
``(i) the adjusted Federal per diem rate
determined under subsection (e)(4)(G) otherwise
applicable to such skilled nursing facility for
such services furnished by the skilled nursing
facility during such fiscal year; and
``(ii) the value-based incentive payment
percentage specified under subparagraph (C) for
the skilled nursing facility for such fiscal year.
``(C) Value-based incentive payment percentage.--
``(i) In general.--The Secretary shall specify
a value-based incentive payment percentage for a
skilled nursing facility for a fiscal year which
may include a zero percentage.
``(ii) Requirements.--In specifying the value-
based incentive payment percentage for each
skilled nursing facility for a fiscal year under
clause (i), the Secretary shall ensure that--
``(I) such percentage is based on
the SNF performance score of the skilled
nursing facility provided under
paragraph (4) for the performance period
for such fiscal year;
``(II) the application of all such
percentages in such fiscal year results
in an appropriate distribution of value-
based incentive payments under
subparagraph (B) such that--
``(aa) skilled nursing
facilities with the highest
rankings under paragraph (4)(B)
receive the highest value-based
incentive payment amounts under
subparagraph (B);
[[Page 128 STAT. 1051]]
``(bb) skilled nursing
facilities with the lowest
rankings under paragraph (4)(B)
receive the lowest value-based
incentive payment amounts under
subparagraph (B); and
``(cc) in the case of
skilled nursing facilities in
the lowest 40 percent of the
ranking under paragraph (4)(B),
the payment rate under
subparagraph (A) for services
furnished by such facility
during such fiscal year shall be
less than the payment rate for
such services for such fiscal
year that would otherwise apply
under subsection (e)(4)(G)
without application of this
subsection; and
``(III) the total amount of value-
based incentive payments under this
paragraph for all skilled nursing
facilities in such fiscal year shall be
greater than or equal to 50 percent, but
not greater than 70 percent, of the
total amount of the reductions to
payments for such fiscal year under
paragraph (6), as estimated by the
Secretary.
``(6) Funding for value-based incentive payments.--
``(A) In general.--The Secretary shall reduce the
adjusted Federal per diem rate determined under
subsection (e)(4)(G) otherwise applicable to a skilled
nursing facility for services furnished by such facility
during a fiscal year (beginning with fiscal year 2019)
by the applicable percent (as defined in subparagraph
(B)). The Secretary shall make such reductions for all
skilled nursing facilities in the fiscal year involved,
regardless of whether or not the skilled nursing
facility has been determined by the Secretary to have
earned a value-based incentive payment under paragraph
(5) for such fiscal year.
``(B) Applicable percent.--For purposes of
subparagraph (A), the term `applicable percent' means,
with respect to fiscal year 2019 and succeeding fiscal
years, 2 percent.
``(7) Announcement of net result of adjustments.--
Under <<NOTE: Deadline.>> the SNF VBP Program, the Secretary
shall, not later than 60 days prior to the fiscal year involved,
inform each skilled nursing facility of the adjustments to
payments to the skilled nursing facility for services furnished
by such facility during the fiscal year under paragraphs (5) and
(6).
``(8) <<NOTE: Applicability.>> No effect in subsequent
fiscal years.--The value-based incentive payment under paragraph
(5) and the payment reduction under paragraph (6) shall each
apply only with respect to the fiscal year involved, and the
Secretary shall not take into account such value-based incentive
payment or payment reduction in making payments to a skilled
nursing facility under this section in a subsequent fiscal year.
``(9) <<NOTE: Web posting.>> Public reporting.--
``(A) SNF specific information.--The Secretary shall
make available to the public, by posting on the Nursing
Home Compare Medicare website (or a successor website)
described in section 1819(i) in an easily understandable
format, information regarding the performance of
individual skilled nursing facilities under the SNF VBP
Program, with respect to a fiscal year, including--
[[Page 128 STAT. 1052]]
``(i) the SNF performance score of the skilled
nursing facility for such fiscal year; and
``(ii) the ranking of the skilled nursing
facility under paragraph (4)(B) for the
performance period for such fiscal year.
``(B) Aggregate information.--The Secretary shall
periodically post on the Nursing Home Compare Medicare
website (or a successor website) described in section
1819(i) aggregate information on the SNF VBP Program,
including--
``(i) the range of SNF performance scores
provided under paragraph (4)(A); and
``(ii) the number of skilled nursing
facilities receiving value-based incentive
payments under paragraph (5) and the range and
total amount of such value-based incentive
payments.
``(10) Limitation on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of the following:
``(A) The methodology used to determine the value-
based incentive payment percentage and the amount of the
value-based incentive payment under paragraph (5).
``(B) The determination of the amount of funding
available for such value-based incentive payments under
paragraph (5)(C)(ii)(III) and the payment reduction
under paragraph (6).
``(C) The establishment of the performance standards
under paragraph (3) and the performance period.
``(D) The methodology developed under paragraph (4)
that is used to calculate SNF performance scores and the
calculation of such scores.
``(E) The ranking determinations under paragraph
(4)(B).
``(11) Funding for program management.--The Secretary shall
provide for the one time transfer from the Federal Hospital
Insurance Trust Fund established under section 1817 to the
Centers for Medicare & Medicaid Services Program Management
Account of--
``(A) for purposes of subsection (g)(2), $2,000,000;
and
``(B) for purposes of implementing this subsection,
$10,000,000.
Such funds shall remain available until expended.''.
(c) <<NOTE: Deadline. Reports. Recommenda- tions.>> MedPAC Study.--
Not later than June 30, 2021, the Medicare Payment Advisory Commission
shall submit to Congress a report that reviews the progress of the
skilled nursing facility value-based purchasing program established
under section 1888(h) of the Social Security Act, as added by subsection
(b), and makes recommendations, as appropriate, on any improvements that
should be made to such program. For purposes of the previous sentence,
the Medicare Payment Advisory Commission shall consider any unintended
consequences with respect to such skilled nursing facility value-based
purchasing program and any potential adjustments to the readmission
measure specified under section 1888(g)(1) of such Act, as added by
subsection (a), for purposes of determining the effect of the socio-
economic status of a beneficiary under the Medicare program under title
XVIII of the Social Security Act
[[Page 128 STAT. 1053]]
for the SNF performance score of a skilled nursing facility provided
under section 1888(h)(4) of such Act, as added by subsection (b).
SEC. 216. IMPROVING MEDICARE POLICIES FOR CLINICAL DIAGNOSTIC
LABORATORY TESTS.
(a) In General.--Title XVIII of the Social Security Act is amended
by inserting after section 1834 (42 U.S.C. 1395m) the following new
section:
``SEC. 1834A. <<NOTE: 42 USC 1395m-1.>> IMPROVING POLICIES FOR
CLINICAL DIAGNOSTIC LABORATORY TESTS.
``(a) Reporting of Private Sector Payment Rates for Establishment of
Medicare Payment Rates.--
``(1) <<NOTE: Effective date.>> In general.--Beginning
January 1, 2016, and every 3 years thereafter (or, annually, in
the case of reporting with respect to an advanced diagnostic
laboratory test, as defined in subsection (d)(5)), an applicable
laboratory (as defined in paragraph (2)) shall report to the
Secretary, at a time specified by the Secretary, applicable
information (as defined in paragraph (3)) for a data collection
period (as defined in paragraph (4)) for each clinical
diagnostic laboratory test that the laboratory furnishes during
such period for which payment is made under this part.
``(2) Definition of applicable laboratory.--In this section,
the term `applicable laboratory' means a laboratory that, with
respect to its revenues under this title, a majority of such
revenues are from this section, section 1833(h), or section
1848. The Secretary may establish a low volume or low
expenditure threshold for excluding a laboratory from the
definition of applicable laboratory under this paragraph, as the
Secretary determines appropriate.
``(3) Applicable information defined.--
``(A) In general.--In this section, subject to
subparagraph (B), the term `applicable information'
means, with respect to a laboratory test for a data
collection period, the following:
``(i) The payment rate (as determined in
accordance with paragraph (5)) that was paid by
each private payor for the test during the period.
``(ii) The volume of such tests for each such
payor for the period.
``(B) Exception for certain contractual
arrangements.--Such term shall not include information
with respect to a laboratory test for which payment is
made on a capitated basis or other similar payment basis
during the data collection period.
``(4) Data collection period defined.--In this section, the
term `data collection period' means a period of time, such as a
previous 12 month period, specified by the Secretary.
``(5) Treatment of discounts.--The payment rate reported by
a laboratory under this subsection shall reflect all discounts,
rebates, coupons, and other price concessions, including those
described in section 1847A(c)(3).
``(6) Ensuring complete reporting.--In the case where an
applicable laboratory has more than one payment rate for the
same payor for the same test or more than one payment rate for
different payors for the same test, the applicable laboratory
shall report each such payment rate and the volume for
[[Page 128 STAT. 1054]]
the test at each such rate under this
subsection. <<NOTE: Effective date.>> Beginning with January 1,
2019, the Secretary may establish rules to aggregate reporting
with respect to the situations described in the preceding
sentence.
``(7) Certification.--An officer of the laboratory shall
certify the accuracy and completeness of the information
reported under this subsection.
``(8) Private payor defined.--In this section, the term
`private payor' means the following:
``(A) A health insurance issuer and a group health
plan (as such terms are defined in section 2791 of the
Public Health Service Act).
``(B) A Medicare Advantage plan under part C.
``(C) A medicaid managed care organization (as
defined in section 1903(m)).
``(9) Civil money penalty.--
``(A) <<NOTE: Determination.>> In general.--If the
Secretary determines that an applicable laboratory has
failed to report or made a misrepresentation or omission
in reporting information under this subsection with
respect to a clinical diagnostic laboratory test, the
Secretary may apply a civil money penalty in an amount
of up to $10,000 per day for each failure to report or
each such misrepresentation or omission.
``(B) Application.--The provisions of section 1128A
(other than subsections (a) and (b)) shall apply to a
civil money penalty under this paragraph in the same
manner as they apply to a civil money penalty or
proceeding under section 1128A(a).
``(10) Confidentiality of information.--Notwithstanding any
other provision of law, information disclosed by a laboratory
under this subsection is confidential and shall not be disclosed
by the Secretary or a Medicare contractor in a form that
discloses the identity of a specific payor or laboratory, or
prices charged or payments made to any such laboratory, except--
``(A) as the Secretary determines to be necessary to
carry out this section;
``(B) to permit the Comptroller General to review
the information provided;
``(C) to permit the Director of the Congressional
Budget Office to review the information provided; and
``(D) to permit the Medicare Payment Advisory
Commission to review the information provided.
``(11) Protection from public disclosure.--A payor shall not
be identified on information reported under this subsection. The
name of an applicable laboratory under this subsection shall be
exempt from disclosure under section 552(b)(3) of title 5,
United States Code.
``(12) <<NOTE: Deadline. Notice.>> Regulations.--Not later
than June 30, 2015, the Secretary shall establish through notice
and comment rulemaking parameters for data collection under this
subsection.
``(b) Payment for Clinical Diagnostic Laboratory Tests.--
``(1) Use of private payor rate information to determine
medicare payment rates.--
``(A) In general.--Subject to paragraph (3) and
subsections (c) and (d), in the case of a clinical
diagnostic laboratory test furnished on or after January
1, 2017, the
[[Page 128 STAT. 1055]]
payment amount under this section shall be equal to the
weighted median determined for the test under paragraph
(2) for the most recent data collection period.
``(B) Application of payment amounts to hospital
laboratories.--The payment amounts established under
this section shall apply to a clinical diagnostic
laboratory test furnished by a hospital laboratory if
such test is paid for separately, and not as part of a
bundled payment under section 1833(t).
``(2) Calculation of weighted median.--For each laboratory
test with respect to which information is reported under
subsection (a) for a data collection period, the Secretary shall
calculate a weighted median for the test for the period, by
arraying the distribution of all payment rates reported for the
period for each test weighted by volume for each payor and each
laboratory.
``(3) Phase-in of reductions from private payor rate
implementation.--
``(A) In general.--Payment amounts determined under
this subsection for a clinical diagnostic laboratory
test for each of 2017 through 2022 shall not result in a
reduction in payments for a clinical diagnostic
laboratory test for the year of greater than the
applicable percent (as defined in subparagraph (B)) of
the amount of payment for the test for the preceding
year.
``(B) Applicable percent defined.--In this
paragraph, the term `applicable percent' means--
``(i) for each of 2017 through 2019, 10
percent; and
``(ii) for each of 2020 through 2022, 15
percent.
``(C) No application to new tests.--This paragraph
shall not apply to payment amounts determined under this
section for either of the following.
``(i) A new test under subsection (c).
``(ii) A new advanced diagnostic test (as
defined in subsection (d)(5)) under subsection
(d).
``(4) Application of market rates.--
``(A) In general.--Subject to paragraph (3), once
established for a year following a data collection
period, the payment amounts under this subsection shall
continue to apply until the year following the next data
collection period.
``(B) Other adjustments not applicable.--The payment
amounts under this section shall not be subject to any
adjustment (including any geographic adjustment, budget
neutrality adjustment, annual update, or other
adjustment).
``(5) Sample collection fee.--In the case of a sample
collected from an individual in a skilled nursing facility or by
a laboratory on behalf of a home health agency, the nominal fee
that would otherwise apply under section 1833(h)(3)(A) shall be
increased by $2.
``(c) Payment for New Tests That Are Not Advanced Diagnostic
Laboratory Tests.--
``(1) Payment during initial period.--In the case of a
clinical diagnostic laboratory test that is assigned a new or
[[Page 128 STAT. 1056]]
substantially revised HCPCS code on or after the date of
enactment of this section, and which is not an advanced
diagnostic laboratory test (as defined in subsection (d)(5)),
during an initial period until payment rates under subsection
(b) are established for the test, payment for the test shall be
determined--
``(A) using cross-walking (as described in section
414.508(a) of title 42, Code of Federal Regulations, or
any successor regulation) to the most appropriate
existing test under the fee schedule under this section
during that period; or
``(B) if no existing test is comparable to the new
test, according to the gapfilling process described in
paragraph (2).
``(2) Gapfilling process described.--The gapfilling process
described in this paragraph shall take into account the
following sources of information to determine gapfill amounts,
if available:
``(A) Charges for the test and routine discounts to
charges.
``(B) Resources required to perform the test.
``(C) Payment amounts determined by other payors.
``(D) Charges, payment amounts, and resources
required for other tests that may be comparable or
otherwise relevant.
``(E) Other criteria the Secretary determines
appropriate.
``(3) Additional consideration.--In determining the payment
amount under crosswalking or gapfilling processes under this
subsection, the Secretary shall consider recommendations from
the panel established under subsection (f)(1).
``(4) <<NOTE: Public information.>> Explanation of payment
rates.--In the case of a clinical diagnostic laboratory test for
which payment is made under this subsection, the Secretary shall
make available to the public an explanation of the payment rate
for the test, including an explanation of how the criteria
described in paragraph (2) and paragraph (3) are applied.
``(d) Payment for New Advanced Diagnostic Laboratory Tests.--
``(1) Payment during initial period.--
``(A) In general.--In the case of an advanced
diagnostic laboratory test for which payment has not
been made under the fee schedule under section 1833(h)
prior to the date of enactment of this section, during
an initial period of three quarters, the payment amount
for the test for such period shall be based on the
actual list charge for the laboratory test.
``(B) <<NOTE: Definition.>> Actual list charge.--
For purposes of subparagraph (A), the term `actual list
charge', with respect to a laboratory test furnished
during such period, means the publicly available rate on
the first day at which the test is available for
purchase by a private payor.
``(2) Special rule for timing of initial reporting.--With
respect to an advanced diagnostic laboratory test described in
paragraph (1)(A), an applicable laboratory shall initially be
required to report under subsection (a) not later than the last
day of the second quarter of the initial period under such
paragraph.
[[Page 128 STAT. 1057]]
``(3) Application of market rates after initial period.--
Subject to paragraph (4), data reported under paragraph (2)
shall be used to establish the payment amount for an advanced
diagnostic laboratory test after the initial period under
paragraph (1)(A) using the methodology described in subsection
(b). Such payment amount shall continue to apply until the year
following the next data collection period.
``(4) Recoupment if actual list charge exceeds market
rate.--With <<NOTE: Determination.>> respect to the initial
period described in paragraph (1)(A), if, after such period, the
Secretary determines that the payment amount for an advanced
diagnostic laboratory test under paragraph (1)(A) that was
applicable during the period was greater than 130 percent of the
payment amount for the test established using the methodology
described in subsection (b) that is applicable after such
period, the Secretary shall recoup the difference between such
payment amounts for tests furnished during such period.
``(5) Advanced diagnostic laboratory test defined.--In this
subsection, the term `advanced diagnostic laboratory test' means
a clinical diagnostic laboratory test covered under this part
that is offered and furnished only by a single laboratory and
not sold for use by a laboratory other than the original
developing laboratory (or a successor owner) and meets one of
the following criteria:
``(A) The test is an analysis of multiple biomarkers
of DNA, RNA, or proteins combined with a unique
algorithm to yield a single patient-specific result.
``(B) The test is cleared or approved by the Food
and Drug Administration.
``(C) The test meets other similar criteria
established by the Secretary.
``(e) Coding.--
``(1) Temporary codes for certain new tests.--
``(A) In general.--The Secretary shall adopt
temporary HCPCS codes to identify new advanced
diagnostic laboratory tests (as defined in subsection
(d)(5)) and new laboratory tests that are cleared or
approved by the Food and Drug Administration.
``(B) Duration.--
``(i) In general.--Subject to clause (ii), the
temporary code shall be effective until a
permanent HCPCS code is established (but not to
exceed 2 years).
``(ii) Exception.--The Secretary may extend
the temporary code or establish a permanent HCPCS
code, as the Secretary determines appropriate.
``(2) <<NOTE: Deadline.>> Existing tests.--Not later than
January 1, 2016, for each existing advanced diagnostic
laboratory test (as so defined) and each existing clinical
diagnostic laboratory test that is cleared or approved by the
Food and Drug Administration for which payment is made under
this part as of the date of enactment of this section, if such
test has not already been assigned a unique HCPCS code, the
Secretary shall--
``(A) assign a unique HCPCS code for the test; and
``(B) <<NOTE: Public information.>> publicly report
the payment rate for the test.
``(3) Establishment of unique identifier for certain
tests.--For purposes of tracking and monitoring, if a laboratory
or a manufacturer requests a unique identifier for an advanced
[[Page 128 STAT. 1058]]
diagnostic laboratory test (as so defined) or a laboratory test
that is cleared or approved by the Food and Drug Administration,
the Secretary shall utilize a means to uniquely track such test
through a mechanism such as a HCPCS code or modifier.
``(f) Input From Clinicians and Technical Experts.--
``(1) <<NOTE: Consultation. Establishment. Deadline.>> In
general.--The Secretary shall consult with an expert outside
advisory panel, established by the Secretary not later than July
1, 2015, composed of an appropriate selection of individuals
with expertise, which may include molecular pathologists,
researchers, and individuals with expertise in laboratory
science or health economics, in issues related to clinical
diagnostic laboratory tests, which may include the development,
validation, performance, and application of such tests, to
provide--
``(A) input on--
``(i) the establishment of payment rates under
this section for new clinical diagnostic
laboratory tests, including whether to use
crosswalking or gapfilling processes to determine
payment for a specific new test; and
``(ii) the factors used in determining
coverage and payment processes for new clinical
diagnostic laboratory tests; and
``(B) recommendations to the Secretary under this
section.
``(2) Compliance with faca.--The panel shall be subject to
the Federal Advisory Committee Act (5 U.S.C. App.).
``(3) Continuation of annual meeting.--The Secretary shall
continue to convene the annual meeting described in section
1833(h)(8)(B)(iii) after the implementation of this section for
purposes of receiving comments and recommendations (and data on
which the recommendations are based) as described in such
section on the establishment of payment amounts under this
section.
``(g) Coverage.--
``(1) Issuance of coverage policies.--
``(A) In general.--A medicare administrative
contractor shall only issue a coverage policy with
respect to a clinical diagnostic laboratory test in
accordance with the process for making a local coverage
determination (as defined in section 1869(f)(2)(B)),
including the appeals and review process for local
coverage determinations under part 426 of title 42, Code
of Federal Regulations (or successor regulations).
``(B) No effect on national coverage determination
process.--This paragraph shall not apply to the national
coverage determination process (as defined in section
1869(f)(1)(B)).
``(C) Effective date.--This paragraph shall apply to
coverage policies issued on or after January 1, 2015.
``(2) Designation of one or more medicare administrative
contractors for clinical diagnostic laboratory tests.--The
Secretary may designate one or more (not to exceed 4) medicare
administrative contractors to either establish coverage policies
or establish coverage policies and process claims
[[Page 128 STAT. 1059]]
for payment for clinical diagnostic laboratory tests, as
determined appropriate by the Secretary.
``(h) Implementation.--
``(1) Implementation.--There shall be no administrative or
judicial review under section 1869, section 1878, or otherwise,
of the establishment of payment amounts under this section.
``(2) Administration.--Chapter 35 of title 44, United States
Code, shall not apply to information collected under this
section.
``(3) Funding.--For purposes of implementing this section,
the Secretary shall provide for the transfer, from the Federal
Supplementary Medical Insurance Trust Fund under section 1841,
to the Centers for Medicare & Medicaid Services Program
Management Account, for each of fiscal years 2014 through 2018,
$4,000,000, and for each of fiscal years 2019 through 2023,
$3,000,000. Amounts transferred under the preceding sentence
shall remain available until expended.
``(i) <<NOTE: Time period.>> Transitional Rule.--During the period
beginning on the date of enactment of this section and ending on
December 31, 2016, with respect to advanced diagnostic laboratory tests
under this part, the Secretary shall use the methodologies for pricing,
coding, and coverage in effect on the day before such date of enactment,
which may include cross-walking or gapfilling methods.''.
(b) Conforming Amendments.--
(1) Section 1833(a) of the Social Security Act (42 U.S.C.
1395l(a)) is amended--
(A) in paragraph (1)(D)--
(i) by striking ``(i) on the basis'' and
inserting ``(i)(I) on the basis'';
(ii) in subclause (I), as added by clause (i),
by striking ``subsection (h)(1)'' and inserting
``subsection (h)(1) (for tests furnished before
January 1, 2017)'';
(iii) by striking ``or (ii)'' and inserting
``or (II) under section 1834A (for tests furnished
on or after January 1, 2017), the amount paid
shall be equal to 80 percent (or 100 percent, in
the case of such tests for which payment is made
on an assignment-related basis) of the lesser of
the amount determined under such section or the
amount of the charges billed for the tests, or
(ii)''; and
(iv) in clause (ii), by striking ``on the
basis'' and inserting ``for tests furnished before
January 1, 2017, on the basis'';
(B) in paragraph (2)(D)--
(i) by striking ``(i) on the basis'' and
inserting ``(i)(I) on the basis'';
(ii) in subclause (I), as added by clause (i),
by striking ``subsection (h)(1)'' and inserting
``subsection (h)(1) (for tests furnished before
January 1, 2017)'';
(iii) by striking ``or (ii)'' and inserting
``or (II) under section 1834A (for tests furnished
on or after January 1, 2017), the amount paid
shall be equal to 80 percent (or 100 percent, in
the case of such tests for which payment is made
on an assignment-related basis or to a provider
having an agreement under section 1866) of the
lesser of the amount determined under such
[[Page 128 STAT. 1060]]
section or the amount of the charges billed for
the tests, or (ii)''; and
(iv) in clause (ii), by striking ``on the
basis'' and inserting ``for tests furnished before
January 1, 2017, on the basis'';
(C) in subsection (b)(3)(B), by striking ``on the
basis'' and inserting ``for tests furnished before
January 1, 2017, on the basis'';
(D) in subsection (h)(2)(A)(i), by striking ``and
subject to'' and inserting ``and, for tests furnished
before the date of enactment of section 1834A, subject
to'';
(E) in subsection (h)(3), in the matter preceding
subparagraph (A), by striking ``fee schedules'' and
inserting ``fee schedules (for tests furnished before
January 1, 2017) or under section 1834A (for tests
furnished on or after January 1, 2017), subject to
subsection (b)(5) of such section'';
(F) in subsection (h)(6), by striking ``In the
case'' and inserting ``For tests furnished before
January 1, 2017, in the case''; and
(G) in subsection (h)(7), in the first sentence--
(i) by striking ``and (4)'' and inserting
``and (4) and section 1834A''; and
(ii) by striking ``under this subsection'' and
inserting ``under this part''.
(2) Section 1869(f)(2) of the Social Security Act (42 U.S.C.
1395ff(f)(2)) is amended by adding at the end the following new
subparagraph:
``(C) Local coverage determinations for clinical
diagnostic laboratory tests.--For provisions relating to
local coverage determinations for clinical diagnostic
laboratory tests, see section 1834A(g).''.
(c) GAO Study and Report; Monitoring of Medicare Expenditures and
Implementation of New Payment System for Laboratory Tests.--
(1) GAO study and report on implementation of new payment
rates for clinical diagnostic laboratory tests.--
(A) 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 section 1834A of the Social Security
Act, as added by subsection (a). The study shall include
an analysis of--
(i) payment rates paid by private payors for
laboratory tests furnished in various settings,
including--
(I) how such payment rates compare
across settings;
(II) the trend in payment rates over
time; and
(III) trends by private payors to
move to alternative payment
methodologies for laboratory tests;
(ii) the conversion to the new payment rate
for laboratory tests under such section;
(iii) the impact of such implementation on
beneficiary access under title XVIII of the Social
Security Act;
[[Page 128 STAT. 1061]]
(iv) the impact of the new payment system on
laboratories that furnish a low volume of services
and laboratories that specialize in a small number
of tests;
(v) the number of new Healthcare Common
Procedure Coding System (HCPCS) codes issued for
laboratory tests;
(vi) the spending trend for laboratory tests
under such title;
(vii) whether the information reported by
laboratories and the new payment rates for
laboratory tests under such section accurately
reflect market prices;
(viii) the initial list price for new
laboratory tests and the subsequent reported rates
for such tests under such section;
(ix) changes in the number of advanced
diagnostic laboratory tests and laboratory tests
cleared or approved by the Food and Drug
Administration for which payment is made under
such section; and
(x) healthcare economic information on
downstream cost impacts for such tests and
decision making based on accepted methodologies.
(B) Report.--Not later than October 1, 2018, the
Comptroller General shall submit to the Committee on
Ways and Means and the Committee on Energy and Commerce
of the House of Representatives and the Committee on
Finance of the Senate a report on the study under
subparagraph (A), including recommendations for such
legislation and administrative action as the Comptroller
General determines appropriate.
(2) <<NOTE: Analysis. 42 USC 1395m-1 note.>> Monitoring of
medicare expenditures and implementation of new payment system
for laboratory tests.--The Inspector General of the Department
of Health and Human Services shall--
(A) <<NOTE: Public information. Deadline.>>
publicly release an annual analysis of the top 25
laboratory tests by expenditures under title XVIII of
the Social Security Act; and
(B) conduct analyses the Inspector General
determines appropriate with respect to the
implementation and effect of the new payment system for
laboratory tests under section 1834A of the Social
Security Act, as added by subsection (a).
SEC. 217. REVISIONS UNDER THE MEDICARE ESRD PROSPECTIVE PAYMENT
SYSTEM.
(a) Delay of Implementation of Oral-Only Policy.--Section 632(b)(1)
of the American Taxpayer Relief Act of 2012 (42 U.S.C. 1395rr note) is
amended--
(1) by striking ``2016'' and inserting ``2024''; and
(2) by adding at the end the following new sentence:
``Notwithstanding section 1881(b)(14)(A)(ii) of the Social
Security Act (42 U.S.C. 1395rr(b)(14)(A)(ii)), implementation of
the policy described in the previous sentence shall be based on
data from the most recent year available.''.
(b) Mitigation of the Application of Adjustment to ESRD Bundled
Payment Rate To Account for Changes in the Utilization of Certain Drugs
and Biologicals.--
[[Page 128 STAT. 1062]]
(1) In general.--Section 1881(b)(14)(I) of the Social
Security Act (42 U.S.C. 1395rr(b)(14)(I)) is amended by
inserting ``and before January 1, 2015,'' after ``January 1,
2014,''.
(2) Market basket.--Section 1881(b)(14)(F)(i) of the Social
Security Act (42 U.S.C. 1395rr(b)(14)(F)(i)) is amended--
(A) in subclause (I)--
(i) by striking ``subclause (II)'' and
inserting ``subclauses (II) and (III)''; and
(ii) by adding at the end the following new
sentence: ``In order to accomplish the purposes of
subparagraph (I) with respect to 2016, 2017, and
2018, after determining the increase factor
described in the preceding sentence for each of
2016, 2017, and 2018, the Secretary shall reduce
such increase factor by 1.25 percentage points for
each of 2016 and 2017 and by 1 percentage point
for 2018.'';
(B) in subclause (II), by striking ``For 2012'' and
inserting ``Subject to subclause (III), for 2012''; and
(C) by adding at the end the following new
subclause:
``(III) Notwithstanding subclauses (I) and (II), in order to
accomplish the purposes of subparagraph (I) with respect to
2015, the increase factor described in subclause (I) for 2015
shall be 0.0 percent pursuant to the regulation issued by the
Secretary on December 2, 2013, entitled `Medicare Program; End-
Stage Renal Disease Prospective Payment System, Quality
Incentive Program, and Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies; Final Rule' (78 Fed. Reg. 72156).''.
(c) <<NOTE: Process. 42 USC 1395rr note.>> Drug Designations.--As
part of the promulgation of annual rule for the Medicare end stage renal
disease prospective payment system under section 1881(b)(14) of the
Social Security Act (42 U.S.C. 1395rr(b)(14)) for calendar year 2016,
the Secretary of Health and Human Services (in this subsection referred
to as the ``Secretary'') shall establish a process for--
(1) determining when a product is no longer an oral-only
drug; and
(2) including new injectable and intravenous products into
the bundled payment under such system.
(d) Quality Measures Related to Conditions Treated by Oral-Only
Drugs Under the ESRD Quality Incentive Program.--Section 1881(h)(2) of
the Social Security Act (42 U.S.C. 1395rr(h)(2)) is amended--
(1) in subparagraph (A)--
(A) in clause (ii), by striking ``and'' at the end;
(B) by redesignating clause (iii) as clause (iv);
and
(C) by inserting after clause (ii) the following new
clause:
``(iii) for 2016 and subsequent years,
measures described in subparagraph (E)(i); and'';
(2) in subparagraph (B)(i), by striking ``(A)(iii)'' and
inserting ``(A)(iv)''; and
(3) by adding at the end the following new subparagraph:
``(E) Measures specific to the conditions treated
with oral-only drugs.--
``(i) In general.--The measures described in
this subparagraph are measures specified by the
Secretary that are specific to the conditions
treated with oral-
[[Page 128 STAT. 1063]]
only drugs. To the extent feasible, such measures
shall be outcomes-based measures.
``(ii) Consultation.--In specifying the
measures under clause (i), the Secretary shall
consult with interested stakeholders.
``(iii) Use of endorsed measures.--
``(I) In general.--Subject to
subclause (I), any measures specified
under clause (i) must have been endorsed
by the entity with a contract under
section 1890(a).
``(II) Exception.--If the entity
with a contract under section 1890(a)
has not endorsed a measure for a
specified area or topic related to
measures described in clause (i) that
the Secretary determines appropriate,
the Secretary may specify a measure that
is endorsed or adopted by a consensus
organization recognized by the Secretary
that has expertise in clinical
guidelines for kidney disease.''.
(e) <<NOTE: 42 USC 1395rr note.>> Audits of Cost Reports of ESRD
Providers as Recommended by MedPAC.--
(1) In general.--The Secretary of Health and Human Services
shall conduct audits of Medicare cost reports beginning during
2012 for a representative sample of providers of services and
renal dialysis facilities furnishing renal dialysis services.
(2) Funding.--For purposes of carrying out paragraph (1),
the Secretary of Health and Human Services shall provide for the
transfer from the Federal Supplementary Medical Insurance Trust
Fund established under section 1841 of the Social Security Act
(42 U.S.C. 1395t) to the Centers for Medicare & Medicaid
Services Program Management Account of $18,000,000 for fiscal
year 2014. Amounts transferred under this paragraph for a fiscal
year shall be available until expended.
SEC. 218. QUALITY INCENTIVES FOR COMPUTED TOMOGRAPHY DIAGNOSTIC
IMAGING AND PROMOTING EVIDENCE-BASED CARE.
(a) Quality Incentives To Promote Patient Safety and Public Health
in Computed Tomography Diagnostic Imaging.--
(1) In general.--Section 1834 of the Social Security Act (42
U.S.C. 1395m) is amended by adding at the end the following new
subsection:
``(p) Quality Incentives To Promote Patient Safety and Public Health
in Computed Tomography.--
``(1) Quality incentives.--In the case of an applicable
computed tomography service (as defined in paragraph (2)) for
which payment is made under an applicable payment system (as
defined in paragraph (3)) and that is furnished on or after
January 1, 2016, using equipment that is not consistent with the
CT equipment standard (described in paragraph (4)), the payment
amount for such service shall be reduced by the applicable
percentage (as defined in paragraph (5)).
``(2) Applicable computed tomography services defined.--In
this subsection, the term `applicable computed tomography
service' means a service billed using diagnostic radiological
imaging codes for computed tomography (identified
[[Page 128 STAT. 1064]]
as of January 1, 2014, by HCPCS codes 70450-70498, 71250-71275,
72125-72133, 72191-72194, 73200-73206, 73700-73706, 74150-74178,
74261-74263, and 75571-75574 (and any succeeding codes).
``(3) Applicable payment system defined.--In this
subsection, the term `applicable payment system' means the
following:
``(A) The technical component and the technical
component of the global fee under the fee schedule
established under section 1848(b).
``(B) The prospective payment system for hospital
outpatient department services under section 1833(t).
``(4) <<NOTE: Definition.>> Consistency with ct equipment
standard.--In this subsection, the term `not consistent with the
CT equipment standard' means, with respect to an applicable
computed tomography service, that the service was furnished
using equipment that does not meet each of the attributes of the
National Electrical Manufacturers Association (NEMA) Standard
XR-29-2013, entitled `Standard Attributes on CT Equipment
Related to Dose Optimization and Management'. Through
rulemaking, the Secretary may apply successor standards.
``(5) Applicable percentage defined.--In this subsection,
the term `applicable percentage' means--
``(A) for 2016, 5 percent; and
``(B) for 2017 and subsequent years, 15 percent.
``(6) Implementation.--
``(A) Information.--The Secretary shall require that
information be provided and attested to by a supplier
and a hospital outpatient department that indicates
whether an applicable computed tomography service was
furnished that was not consistent with the CT equipment
standard (described in paragraph (4)). Such information
may be included on a claim and may be
a <<NOTE: Verification.>> modifier. Such information
shall be verified, as appropriate, as part of the
periodic accreditation of suppliers under section
1834(e) and hospitals under section 1865(a).
``(B) Administration.--Chapter 35 of title 44,
United States Code, shall not apply to information
described in subparagraph (A).''.
(2) Conforming amendments.--
(A) Prospective payment system for hospital
outpatient department services.--Section 1833(t) of the
Social Security Act (42 1395l(t)) is amended by adding
at the end the following new paragraph:
``(20) Not budget neutral application of reduced
expenditures resulting from quality incentives for computed
tomography.--The Secretary shall not take into account the
reduced expenditures that result from the application of section
1834(p) in making any budget neutrality adjustments this
subsection.''.
(B) Physician fee schedule.--Section
1848(c)(2)(B)(v) of the Social Security Act (42 U.S.C.
1395w-4(c)(2)(B)(v)) is amended by adding at the end the
following new subclause:
``(VIII) Reduced expenditures
attributable to application of quality
incentives for computed tomography.--
Effective <<NOTE: Effective date.>> for
fee schedules
[[Page 128 STAT. 1065]]
established beginning with 2016, reduced
expenditures attributable to the
application of the quality incentives
for computed tomography under section
1834(p)''.
(b) Promoting Evidence-Based Care.--
(1) In general.--Section 1834 of the Social Security Act (42
U.S.C. 1395m), as amended by subsection (a), is amended by
adding at the end the following new subsection:
``(q) Recognizing Appropriate Use Criteria for Certain Imaging
Services.--
``(1) Program established.--
``(A) In general.--The Secretary shall establish a
program to promote the use of appropriate use criteria
(as defined in subparagraph (B)) for applicable imaging
services (as defined in subparagraph (C)) furnished in
an applicable setting (as defined in subparagraph (D))
by ordering professionals and furnishing professionals
(as defined in subparagraphs (E) and (F), respectively).
``(B) Appropriate use criteria defined.--In this
subsection, the term `appropriate use criteria' means
criteria, only developed or endorsed by national
professional medical specialty societies or other
provider-led entities, to assist ordering professionals
and furnishing professionals in making the most
appropriate treatment decision for a specific clinical
condition for an individual. To the extent feasible,
such criteria shall be evidence-based.
``(C) Applicable imaging service defined.--In this
subsection, the term `applicable imaging service' means
an advanced diagnostic imaging service (as defined in
subsection (e)(1)(B)) for which the Secretary
determines--
``(i) one or more applicable appropriate use
criteria specified under paragraph (2) apply;
``(ii) there are one or more qualified
clinical decision support mechanisms listed under
paragraph (3)(C); and
``(iii) one or more of such mechanisms is
available free of charge.
``(D) Applicable setting defined.--In this
subsection, the term `applicable setting' means a
physician's office, a hospital outpatient department
(including an emergency department), an ambulatory
surgical center, and any other provider-led outpatient
setting determined appropriate by the Secretary.
``(E) Ordering professional defined.--In this
subsection, the term `ordering professional' means a
physician (as defined in section 1861(r)) or a
practitioner described in section 1842(b)(18)(C) who
orders an applicable imaging service.
``(F) Furnishing professional defined.--In this
subsection, the term `furnishing professional' means a
physician (as defined in section 1861(r)) or a
practitioner described in section 1842(b)(18)(C) who
furnishes an applicable imaging service.
``(2) Establishment of applicable appropriate use
criteria.--
[[Page 128 STAT. 1066]]
``(A) <<NOTE: Deadline. Regulations. Consultation.>> In
general.--Not later than November 15, 2015, the
Secretary shall through rulemaking, and in consultation
with physicians, practitioners, and other stakeholders,
specify applicable appropriate use criteria for
applicable imaging services only from among appropriate
use criteria developed or endorsed by national
professional medical specialty societies or other
provider-led entities.
``(B) Considerations.--In specifying applicable
appropriate use criteria under subparagraph (A), the
Secretary shall take into account whether the criteria--
``(i) have stakeholder consensus;
``(ii) are scientifically valid and evidence
based; and
``(iii) are based on studies that are
published and reviewable by stakeholders.
``(C) <<NOTE: Review. Deadline.>> Revisions.--The
Secretary shall review, on an annual basis, the
specified applicable appropriate use criteria to
determine if there is a need to update or revise (as
appropriate) such specification of applicable
appropriate use criteria and make such updates or
revisions through rulemaking.
``(D) Treatment of multiple applicable appropriate
use criteria.--In the case where the Secretary
determines that more than one appropriate use criterion
applies with respect to an applicable imaging service,
the Secretary shall apply one or more applicable
appropriate use criteria under this paragraph for the
service.
``(3) Mechanisms for consultation with applicable
appropriate use criteria.--
``(A) Identification of mechanisms to consult with
applicable appropriate use criteria.--
``(i) In general.--The Secretary shall specify
qualified clinical decision support mechanisms
that could be used by ordering professionals to
consult with applicable appropriate use criteria
for applicable imaging services.
``(ii) Consultation.--The Secretary shall
consult with physicians, practitioners, health
care technology experts, and other stakeholders in
specifying mechanisms under this paragraph.
``(iii) Inclusion of certain mechanisms.--
Mechanisms specified under this paragraph may
include any or all of the following that meet the
requirements described in subparagraph (B)(ii):
``(I) Use of clinical decision
support modules in certified EHR
technology (as defined in section
1848(o)(4)).
``(II) Use of private sector
clinical decision support mechanisms
that are independent from certified EHR
technology, which may include use of
clinical decision support mechanisms
available from medical specialty
organizations.
``(III) Use of a clinical decision
support mechanism established by the
Secretary.
``(B) Qualified clinical decision support
mechanisms.--
[[Page 128 STAT. 1067]]
``(i) In general.--For purposes of this
subsection, a qualified clinical decision support
mechanism is a mechanism that the Secretary
determines meets the requirements described in
clause (ii).
``(ii) Requirements.--The requirements
described in this clause are the following:
``(I) The mechanism makes available
to the ordering professional applicable
appropriate use criteria specified under
paragraph (2) and the supporting
documentation for the applicable imaging
service ordered.
``(II) In the case where there is
more than one applicable appropriate use
criterion specified under such paragraph
for an applicable imaging service, the
mechanism indicates the criteria that it
uses for the service.
``(III) The mechanism determines the
extent to which an applicable imaging
service ordered is consistent with the
applicable appropriate use criteria so
specified.
``(IV) The mechanism generates and
provides to the ordering professional a
certification or documentation that
documents that the qualified clinical
decision support mechanism was consulted
by the ordering professional.
``(V) The mechanism is updated on a
timely basis to reflect revisions to the
specification of applicable appropriate
use criteria under such paragraph.
``(VI) The mechanism meets privacy
and security standards under applicable
provisions of law.
``(VII) The mechanism performs such
other functions as specified by the
Secretary, which may include a
requirement to provide aggregate
feedback to the ordering professional.
``(C) <<NOTE: Deadlines.>> List of mechanisms for
consultation with applicable appropriate use criteria.--
``(i) <<NOTE: Publication.>> Initial list.--
Not later than April 1, 2016, the Secretary shall
publish a list of mechanisms specified under this
paragraph.
``(ii) Periodic updating of list.--The
Secretary shall identify on an annual basis the
list of qualified clinical decision support
mechanisms specified under this paragraph.
``(4) Consultation with applicable appropriate use
criteria.--
``(A) Consultation by ordering professional.--
Beginning <<NOTE: Effective date.>> with January 1,
2017, subject to subparagraph (C), with respect to an
applicable imaging service ordered by an ordering
professional that would be furnished in an applicable
setting and paid for under an applicable payment system
(as defined in subparagraph (D)), an ordering
professional shall--
``(i) consult with a qualified decision
support mechanism listed under paragraph (3)(C);
and
[[Page 128 STAT. 1068]]
``(ii) provide to the furnishing professional
the information described in clauses (i) through
(iii) of subparagraph (B).
``(B) <<NOTE: Effective date.>> Reporting by
furnishing professional.--Beginning with January 1,
2017, subject to subparagraph (C), with respect to an
applicable imaging service furnished in an applicable
setting and paid for under an applicable payment system
(as defined in subparagraph (D)), payment for such
service may only be made if the claim for the service
includes the following:
``(i) Information about which qualified
clinical decision support mechanism was consulted
by the ordering professional for the service.
``(ii) Information regarding--
``(I) whether the service ordered
would adhere to the applicable
appropriate use criteria specified under
paragraph (2);
``(II) whether the service ordered
would not adhere to such criteria; or
``(III) whether such criteria was
not applicable to the service ordered.
``(iii) The national provider identifier of
the ordering professional (if different from the
furnishing professional).
``(C) Exceptions.--The provisions of subparagraphs
(A) and (B) and paragraph (6)(A) shall not apply to the
following:
``(i) Emergency services.--An applicable
imaging service ordered for an individual with an
emergency medical condition (as defined in section
1867(e)(1)).
``(ii) Inpatient services.--An applicable
imaging service ordered for an inpatient and for
which payment is made under part A.
``(iii) Significant hardship.--An applicable
imaging service ordered by an ordering
professional who the Secretary may, on a case-by-
case basis, exempt from the application of such
provisions if the Secretary determines, subject to
annual renewal, that consultation with applicable
appropriate use criteria would result in a
significant hardship, such as in the case of a
professional who practices in a rural area without
sufficient Internet access.
``(D) Applicable payment system defined.--In this
subsection, the term `applicable payment system' means
the following:
``(i) The physician fee schedule established
under section 1848(b).
``(ii) The prospective payment system for
hospital outpatient department services under
section 1833(t).
``(iii) The ambulatory surgical center payment
systems under section 1833(i).
``(5) Identification of outlier ordering professionals.--
``(A) <<NOTE: Effective date. Determination.>> In
general.--With respect to applicable imaging services
furnished beginning with 2017, the Secretary shall
determine, on an annual basis, no more than five percent
[[Page 128 STAT. 1069]]
of the total number of ordering professionals who are
outlier ordering professionals.
``(B) Outlier ordering professionals.--The
determination of an outlier ordering professional
shall--
``(i) be based on low adherence to applicable
appropriate use criteria specified under paragraph
(2), which may be based on comparison to other
ordering professionals; and
``(ii) include data for ordering professionals
for whom prior authorization under paragraph
(6)(A) applies.
``(C) Use of two years of data.--The Secretary shall
use two years of data to identify outlier ordering
professionals under this paragraph.
``(D) Process.--The Secretary shall establish a
process for determining when an outlier ordering
professional is no longer an outlier ordering
professional.
``(E) Consultation with stakeholders.--The Secretary
shall consult with physicians, practitioners and other
stakeholders in developing methods to identify outlier
ordering professionals under this paragraph.
``(6) Prior authorization for ordering professionals who are
outliers.--
``(A) <<NOTE: Effective date.>> In general.--
Beginning January 1, 2020, subject to paragraph (4)(C),
with respect to services furnished during a year, the
Secretary shall, for a period determined appropriate by
the Secretary, apply prior authorization for applicable
imaging services that are ordered by an outlier ordering
professional identified under paragraph (5).
``(B) Appropriate use criteria in prior
authorization.--In applying prior authorization under
subparagraph (A), the Secretary shall utilize only the
applicable appropriate use criteria specified under this
subsection.
``(C) Funding.--For purposes of carrying out this
paragraph, the Secretary shall provide for the transfer,
from the Federal Supplementary Medical Insurance Trust
Fund under section 1841, of $5,000,000 to the Centers
for Medicare & Medicaid Services Program Management
Account for each of fiscal years 2019 through 2021.
Amounts transferred under the preceding sentence shall
remain available until expended.
``(7) Construction.--Nothing in this subsection shall be
construed as granting the Secretary the authority to develop or
initiate the development of clinical practice guidelines or
appropriate use criteria.''.
(2) Conforming amendment.--Section 1833(t)(16) of the Social
Security Act (42 U.S.C. 1395l(t)(16)) is amended by adding at
the end the following new subparagraph:
``(E) Application of appropriate use criteria for
certain imaging services.--For provisions relating to
the application of appropriate use criteria for certain
imaging services, see section 1834(q).''.
(3) Report on experience of imaging appropriate use criteria
program.--Not later than 18 months after the date of the
enactment of this Act, the Comptroller General of the United
States shall submit to Congress a report that includes
[[Page 128 STAT. 1070]]
a description of the extent to which appropriate use criteria
could be used for other services under part B of title XVIII of
the Social Security Act (42 U.S.C. 1395j et seq.), such as
radiation therapy and clinical diagnostic laboratory services.
SEC. 219. USING FUNDING FROM TRANSITIONAL FUND FOR SUSTAINABLE
GROWTH RATE (SGR) REFORM.
Section 1898(b)(1) of the Social Security Act (42 U.S.C.
1395iii(b)(1)) is amended by striking ``$2,300,000,000'' and inserting
``$0''.
SEC. 220. ENSURING ACCURATE VALUATION OF SERVICES UNDER THE
PHYSICIAN FEE SCHEDULE.
(a) Authority To Collect and Use Information on Physicians' Services
in the Determination of Relative Values.--
(1) In general.--Section 1848(c)(2) of the Social Security
Act (42 U.S.C. 1395w-4(c)(2)) is amended by adding at the end
the following new subparagraph:
``(M) Authority to collect and use information on
physicians' services in the determination of relative
values.--
``(i) Collection of information.--
Notwithstanding any other provision of law, the
Secretary may collect or obtain information on the
resources directly or indirectly related to
furnishing services for which payment is made
under the fee schedule established under
subsection (b). Such information may be collected
or obtained from any eligible professional or any
other source.
``(ii) Use of information.--Notwithstanding
any other provision of law, subject to clause (v),
the Secretary may (as the Secretary determines
appropriate) use information collected or obtained
pursuant to clause (i) in the determination of
relative values for services under this section.
``(iii) Types of information.--The types of
information described in clauses (i) and (ii) may,
at the Secretary's discretion, include any or all
of the following:
``(I) Time involved in furnishing
services.
``(II) Amounts and types of practice
expense inputs involved with furnishing
services.
``(III) Prices (net of any
discounts) for practice expense inputs,
which may include paid invoice prices or
other documentation or records.
``(IV) Overhead and accounting
information for practices of physicians
and other suppliers.
``(V) Any other element that would
improve the valuation of services under
this section.
``(iv) Information collection mechanisms.--
Information may be collected or obtained pursuant
to this subparagraph from any or all of the
following:
``(I) Surveys of physicians, other
suppliers, providers of services,
manufacturers, and vendors.
``(II) Surgical logs, billing
systems, or other practice or facility
records.
``(III) Electronic health records.
[[Page 128 STAT. 1071]]
``(IV) Any other mechanism
determined appropriate by the Secretary.
``(v) Transparency of use of information.--
``(I) <<NOTE: Notice. Comments.>>
In general.--Subject to subclauses (II)
and (III), if the Secretary uses
information collected or obtained under
this subparagraph in the determination
of relative values under this
subsection, the Secretary shall disclose
the information source and discuss the
use of such information in such
determination of relative values through
notice and comment rulemaking.
``(II) Thresholds for use.--The
Secretary may establish thresholds in
order to use such information, including
the exclusion of information collected
or obtained from eligible professionals
who use very high resources (as
determined by the Secretary) in
furnishing a service.
``(III) Disclosure of information.--
The Secretary shall make aggregate
information available under this
subparagraph but shall not disclose
information in a form or manner that
identifies an eligible professional or a
group practice, or information collected
or obtained pursuant to a nondisclosure
agreement.
``(vi) Incentive to participate.--The
Secretary may provide for such payments under this
part to an eligible professional that submits such
solicited information under this subparagraph as
the Secretary determines appropriate in order to
compensate such eligible professional for such
submission. Such payments shall be provided in a
form and manner specified by the Secretary.
``(vii) Administration.--Chapter 35 of title
44, United States Code, shall not apply to
information collected or obtained under this
subparagraph.
``(viii) Definition of eligible
professional.--In this subparagraph, the term
`eligible professional' has the meaning given such
term in subsection (k)(3)(B).
``(ix) Funding.--For purposes of carrying out
this subparagraph, in addition to funds otherwise
appropriated, the Secretary shall provide for the
transfer, from the Federal Supplementary Medical
Insurance Trust Fund under section 1841, of
$2,000,000 to the Centers for Medicare & Medicaid
Services Program Management Account for each
fiscal year beginning with fiscal year 2014.
Amounts transferred under the preceding sentence
for a fiscal year shall be available until
expended.''.
(2) Limitation on review.--Section 1848(i)(1) of the Social
Security Act (42 U.S.C. 1395w-4(i)(1)) is amended--
(A) in subparagraph (D), by striking ``and'' at the
end;
(B) in subparagraph (E), by striking the period at
the end and inserting ``, and''; and
(C) by adding at the end the following new
subparagraph:
``(F) the collection and use of information in the
determination of relative values under subsection
(c)(2)(M).''.
[[Page 128 STAT. 1072]]
(b) Authority for Alternative Approaches To Establishing Practice
Expense Relative Values.--Section 1848(c)(2) of the Social Security Act
(42 U.S.C. 1395w-4(c)(2)), as amended by subsection (a), is amended by
adding at the end the following new subparagraph:
``(N) Authority for alternative approaches to
establishing practice expense relative values.--The
Secretary may establish or adjust practice expense
relative values under this subsection using cost,
charge, or other data from suppliers or providers of
services, including information collected or obtained
under subparagraph (M).''.
(c) Revised and Expanded Identification of Potentially Misvalued
Codes.--Section 1848(c)(2)(K)(ii) of the Social Security Act (42 U.S.C.
1395w-4(c)(2)(K)(ii)) is amended to read as follows:
``(ii) Identification of potentially misvalued
codes.--For purposes of identifying potentially
misvalued codes pursuant to clause (i)(I), the
Secretary shall examine codes (and families of
codes as appropriate) based on any or all of the
following criteria:
``(I) Codes that have experienced
the fastest growth.
``(II) Codes that have experienced
substantial changes in practice
expenses.
``(III) Codes that describe new
technologies or services within an
appropriate time period (such as 3
years) after the relative values are
initially established for such codes.
``(IV) Codes which are multiple
codes that are frequently billed in
conjunction with furnishing a single
service.
``(V) Codes with low relative
values, particularly those that are
often billed multiple times for a single
treatment.
``(VI) Codes that have not been
subject to review since implementation
of the fee schedule.
``(VII) Codes that account for the
majority of spending under the physician
fee schedule.
``(VIII) Codes for services that
have experienced a substantial change in
the hospital length of stay or procedure
time.
``(IX) Codes for which there may be
a change in the typical site of service
since the code was last valued.
``(X) Codes for which there is a
significant difference in payment for
the same service between different sites
of service.
``(XI) Codes for which there may be
anomalies in relative values within a
family of codes.
``(XII) Codes for services where
there may be efficiencies when a service
is furnished at the same time as other
services.
``(XIII) Codes with high intra-
service work per unit of time.
``(XIV) Codes with high practice
expense relative value units.
``(XV) Codes with high cost
supplies.
[[Page 128 STAT. 1073]]
``(XVI) Codes as determined
appropriate by the Secretary.''.
(d) Target for Relative Value Adjustments for Misvalued Services.--
(1) In general.--Section 1848(c)(2) of the Social Security
Act (42 U.S.C. 1395w-4(c)(2)), as amended by subsections (a) and
(b), is amended by adding at the end the following new
subparagraph:
``(O) Target for relative value adjustments for
misvalued services.--With respect
to <<NOTE: Applicability.>> fee schedules established
for each of 2017 through 2020, the following shall
apply:
``(i) Determination of net reduction in
expenditures.--For each year, the Secretary shall
determine the estimated net reduction in
expenditures under the fee schedule under this
section with respect to the year as a result of
adjustments to the relative values established
under this paragraph for misvalued codes.
``(ii) Budget neutral redistribution of funds
if target met and counting overages towards the
target for the succeeding year.--If the estimated
net reduction in expenditures determined under
clause (i) for the year is equal to or greater
than the target for the year--
``(I) reduced expenditures
attributable to such adjustments shall
be redistributed for the year in a
budget neutral manner in accordance with
subparagraph (B)(ii)(II); and
``(II) the amount by which such
reduced expenditures exceeds the target
for the year shall be treated as a
reduction in expenditures described in
clause (i) for the succeeding year, for
purposes of determining whether the
target has or has not been met under
this subparagraph with respect to that
year.
``(iii) Exemption from budget neutrality if
target not met.--If the estimated net reduction in
expenditures determined under clause (i) for the
year is less than the target for the year, reduced
expenditures in an amount equal to the target
recapture amount shall not be taken into account
in applying subparagraph (B)(ii)(II) with respect
to fee schedules beginning with 2017.
``(iv) Target recapture amount.--For purposes
of clause (iii), the target recapture amount is,
with respect to a year, an amount equal to the
difference between--
``(I) the target for the year; and
``(II) the estimated net reduction
in expenditures determined under clause
(i) for the year.
``(v) Target.--For purposes of this
subparagraph, with respect to a year, the target
is calculated as 0.5 percent of the estimated
amount of expenditures under the fee schedule
under this section for the year.''.
(2) Conforming amendment.--Section 1848(c)(2)(B)(v) of the
Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)(v)) is amended
by adding at the end the following new subclause:
[[Page 128 STAT. 1074]]
``(VIII) Reductions for misvalued
services if target not met.--Effective
for <<NOTE: Effective date. Time
period.>> fee schedules beginning with
2017, reduced expenditures attributable
to the application of the target
recapture amount described in
subparagraph (O)(iii).''.
(e) Phase-In of Significant Relative Value Unit (RVU) Reductions.--
(1) In general.--Section 1848(c) of the Social Security Act
(42 U.S.C. 1395w-4(c)) is amended by adding at the end the
following new paragraph:
``(7) Phase-in of significant relative value unit (rvu)
reductions.--Effective for <<NOTE: Effective date.>> fee
schedules established beginning with 2017, for services that are
not new or revised codes, if the total relative value units for
a service for a year would otherwise be decreased by an
estimated amount equal to or greater than 20 percent as compared
to the total relative value units for the previous year, the
applicable adjustments in work, practice expense, and
malpractice relative value units shall be phased-in over a 2-
year period.''.
(2) Conforming amendments.--Section 1848(c)(2) of the Social
Security Act (42 U.S.C. 1395w-4(c)(2)) is amended--
(A) in subparagraph (B)(ii)(I), by striking
``subclause (II)'' and inserting ``subclause (II) and
paragraph (7)''; and
(B) in subparagraph (K)(iii)(VI)--
(i) by striking ``provisions of subparagraph
(B)(ii)(II)'' and inserting ``provisions of
subparagraph (B)(ii)(II) and paragraph (7)''; and
(ii) by striking ``under subparagraph
(B)(ii)(II)'' and inserting ``under subparagraph
(B)(ii)(I)''.
(f) Authority To Smooth Relative Values Within Groups of Services.--
Section 1848(c)(2)(C) of the Social Security Act (42 U.S.C. 1395w-
4(c)(2)(C)) is amended--
(1) in each of clauses (i) and (iii), by striking ``the
service'' and inserting ``the service or group of services''
each place it appears; and
(2) in the first sentence of clause (ii), by inserting ``or
group of services'' before the period.
(g) GAO Study and Report on Relative Value Scale Update Committee.--
(1) Study.--The Comptroller General of the United States (in
this subsection referred to as the ``Comptroller General'')
shall conduct a study of the processes used by the Relative
Value Scale Update Committee (RUC) to provide recommendations to
the Secretary of Health and Human Services regarding relative
values for specific services under the Medicare physician fee
schedule under section 1848 of the Social Security Act (42
U.S.C. 1395w-4).
(2) Report.--Not later than 1 year after the date of the
enactment of this Act, the Comptroller General shall submit to
Congress a report containing the results of the study conducted
under paragraph (1).
(h) Adjustment to Medicare Payment Localities.--
(1) In general.--Section 1848(e) of the Social Security Act
(42 U.S.C. 1395w-4(e)) is amended by adding at the end the
following new paragraph:
``(6) Use of msas as fee schedule areas in california.--
[[Page 128 STAT. 1075]]
``(A) <<NOTE: Applicability.>> In general.--Subject
to the succeeding provisions of this paragraph and
notwithstanding the previous provisions of this
subsection, for services furnished on or after January
1, 2017, the fee schedule areas used for payment under
this section applicable to California shall be the
following:
``(i) Each Metropolitan Statistical Area (each
in this paragraph referred to as an `MSA'), as
defined by the Director of the Office of
Management and Budget as of December 31 of the
previous year, shall be a fee schedule area.
``(ii) All areas not included in an MSA shall
be treated as a single rest-of-State fee schedule
area.
``(B) Transition for msas previously in rest-of-
state payment locality or in locality 3.--
``(i) <<NOTE: Time period.>> In general.--For
services furnished in California during a year
beginning with 2017 and ending with 2021 in an MSA
in a transition area (as defined in subparagraph
(D)), subject to subparagraph (C), the geographic
index values to be applied under this subsection
for such year shall be equal to the sum of the
following:
``(I) Current law component.--The
old weighting factor (described in
clause (ii)) for such year multiplied by
the geographic index values under this
subsection for the fee schedule area
that included such MSA that would have
applied in such area (as estimated by
the Secretary) if this paragraph did not
apply.
``(II) MSA-based component.--The
MSA-based weighting factor (described in
clause (iii)) for such year multiplied
by the geographic index values computed
for the fee schedule area under
subparagraph (A) for the year
(determined without regard to this
subparagraph).
``(ii) Old weighting factor.--The old
weighting factor described in this clause--
``(I) for 2017, is \5/6\; and
``(II) for each succeeding year, is
the old weighting factor described in
this clause for the previous year minus
\1/6\.
``(iii) MSA-based weighting factor.--The MSA-
based weighting factor described in this clause
for a year is 1 minus the old weighting factor
under clause (ii) for that year.
``(C) <<NOTE: Applicability.>> Hold harmless.--For
services furnished in a transition area in California
during a year beginning with 2017, the geographic index
values to be applied under this subsection for such year
shall not be less than the corresponding geographic
index values that would have applied in such transition
area (as estimated by the Secretary) if this paragraph
did not apply.
``(D) Transition area defined.--In this paragraph,
the term `transition area' means each of the following
fee schedule areas for 2013:
``(i) The rest-of-State payment locality.
``(ii) Payment locality 3.
[[Page 128 STAT. 1076]]
``(E) <<NOTE: Effective date.>> References to fee
schedule areas.--Effective for services furnished on or
after January 1, 2017, for California, any reference in
this section to a fee schedule area shall be deemed a
reference to a fee schedule area established in
accordance with this paragraph.''.
(2) Conforming amendment to definition of fee schedule
area.--Section 1848(j)(2) of the Social Security Act (42 U.S.C.
1395w-4(j)(2)) is amended by striking ``The term'' and inserting
``Except as provided in subsection (e)(6)(D), the term''.
(i) <<NOTE: 42 USC 1395w-4 note. Public information.>> Disclosure
of Data Used To Establish Multiple Procedure Payment Reduction Policy.--
The Secretary of Health and Human Services shall make publicly available
the information used to establish the multiple procedure payment
reduction policy to the professional component of imaging services in
the final rule published in the Federal Register, v. 77, n. 222,
November 16, 2012, pages 68891-69380 under the physician fee schedule
under section 1848 of the Social Security Act (42 U.S.C. 1395w-4).
SEC. 221. MEDICAID DSH.
(a) Modifications of Reductions to Allotments.--Section 1923(f) of
the Social Security Act (42 U.S.C. 1396r-4(f)) is amended--
(1) in paragraph (7)(A)--
(A) in clause (i), by striking ``2016 through 2020''
and inserting ``2017 through 2024''; and
(B) in clause (ii), by striking subclauses (I)
through (IV), and inserting the following:
``(I) $1,800,000,000 for fiscal year
2017;
``(II) $4,700,000,000 for fiscal
year 2018;
``(III) $4,700,000,000 for fiscal
year 2019;
``(IV) $4,700,000,000 for fiscal
year 2020;
``(V) $4,800,000,000 for fiscal year
2021;
``(VI) $5,000,000,000 for fiscal
year 2022;
``(VII) $5,000,000,000 for fiscal
year 2023; and
``(VIII) $4,400,000,000 for fiscal
year 2024.''; and
(2) by striking paragraph (8) and inserting the following:
``(8) Calculation of DSH allotments after reductions
period.--The DSH allotment for a State for fiscal years after
fiscal year 2024 shall be calculated under paragraph (3) without
regard to paragraph (7).''.
(b) MACPAC Review and Report.--Section 1900(b)(6) of the Social
Security Act (42 U.S.C. 1396(b)(6)) is amended--
(1) by striking ``MACPAC shall consult'' and inserting the
following:
``(A) In general.--MACPAC shall consult''; and
(2) by adding at the end the following:
``(B) Review and reports regarding medicaid dsh.--
``(i) In general.--MACPAC shall review and
submit an annual report to Congress on
disproportionate share hospital payments under
section 1923. Each report shall include the
information specified in clause (ii).
``(ii) Required report information.--Each
report required under this subparagraph shall
include the following:
[[Page 128 STAT. 1077]]
``(I) Data relating to changes in
the number of uninsured individuals.
``(II) Data relating to the amount
and sources of hospitals' uncompensated
care costs, including the amount of such
costs that are the result of providing
unreimbursed or under-reimbursed
services, charity care, or bad debt.
``(III) Data identifying hospitals
with high levels of uncompensated care
that also provide access to essential
community services for low-income,
uninsured, and vulnerable populations,
such as graduate medical education, and
the continuum of primary through
quarternary care, including the
provision of trauma care and public
health services.
``(IV) State-specific analyses
regarding the relationship between the
most recent State DSH allotment and the
projected State DSH allotment for the
succeeding year and the data reported
under subclauses (I), (II), and (III)
for the State.
``(iii) Data.--Notwithstanding any other
provision of law, the Secretary regularly shall
provide MACPAC with the most recent State reports
and most recent independent certified audits
submitted under section 1923(j), cost reports
submitted under title XVIII, and such other data
as MACPAC may request for purposes of conducting
the reviews and preparing and submitting the
annual reports required under this subparagraph.
``(iv) Submission deadlines.--The first report
required under this subparagraph shall be
submitted to Congress not later than February 1,
2016. Subsequent reports shall be submitted as
part of, or with, each annual report required
under paragraph (1)(C) during the period of fiscal
years 2017 through 2024.''.
SEC. 222. REALIGNMENT OF THE MEDICARE SEQUESTER FOR FISCAL YEAR
2024.
Paragraph (6) (relating to implementing direct spending reductions)
of section 251A of the Balanced Budget and Emergency Deficit Control Act
of 1985 (2 U.S.C. 901a) is amended by adding at the end the following
new subparagraph:
``(D) <<NOTE: Applicability.>> Notwithstanding the 2
percent limit specified in subparagraph (A) for payments for the
Medicare programs specified in section 256(d), the sequestration
order of the President under such subparagraph for fiscal year
2024 shall be applied to such payments so that--
``(i) with respect to the first 6 months in which
such order is effective for such fiscal year, the
payment reduction shall be 4.0 percent; and
``(ii) with respect to the second 6 months in which
such order is so effective for such fiscal year, the
payment reduction shall be 0.0 percent.''.
SEC. 223. <<NOTE: 42 USC 1396a note.>> DEMONSTRATION PROGRAMS TO
IMPROVE COMMUNITY MENTAL HEALTH SERVICES.
(a) Criteria for Certified Community Behavioral Health Clinics To
Participate in Demonstration Programs.--
[[Page 128 STAT. 1078]]
(1) <<NOTE: Deadline.>> Publication.--Not later than
September 1, 2015, the Secretary shall publish criteria for a
clinic to be certified by a State as a certified community
behavioral health clinic for purposes of participating in a
demonstration program conducted under subsection (d).
(2) Requirements.--The criteria published under this
subsection shall include criteria with respect to the following:
(A) Staffing.--Staffing requirements, including
criteria that staff have diverse disciplinary
backgrounds, have necessary State-required license and
accreditation, and are culturally and linguistically
trained to serve the needs of the clinic's patient
population.
(B) Availability and accessibility of services.--
Availability and accessibility of services, including
crisis management services that are available and
accessible 24 hours a day, the use of a sliding scale
for payment, and no rejection for services or limiting
of services on the basis of a patient's ability to pay
or a place of residence.
(C) Care coordination.--Care coordination, including
requirements to coordinate care across settings and
providers to ensure seamless transitions for patients
across the full spectrum of health services including
acute, chronic, and behavioral health needs. Care
coordination requirements shall include partnerships or
formal contracts with the following:
(i) Federally-qualified health centers (and as
applicable, rural health clinics) to provide
Federally-qualified health center services (and as
applicable, rural health clinic services) to the
extent such services are not provided directly
through the certified community behavioral health
clinic.
(ii) Inpatient psychiatric facilities and
substance use detoxification, post-detoxification
step-down services, and residential programs.
(iii) Other community or regional services,
supports, and providers, including schools, child
welfare agencies, juvenile and criminal justice
agencies and facilities, Indian Health Service
youth regional treatment centers, State licensed
and nationally accredited child placing agencies
for therapeutic foster care service, and other
social and human services.
(iv) Department of Veterans Affairs medical
centers, independent outpatient clinics, drop-in
centers, and other facilities of the Department as
defined in section 1801 of title 38, United States
Code.
(v) Inpatient acute care hospitals and
hospital outpatient clinics.
(D) Scope of services.--Provision (in a manner
reflecting person-centered care) of the following
services which, if not available directly through the
certified community behavioral health clinic, are
provided or referred through formal relationships with
other providers:
(i) Crisis mental health services, including
24-hour mobile crisis teams, emergency crisis
intervention services, and crisis stabilization.
(ii) Screening, assessment, and diagnosis,
including risk assessment.
[[Page 128 STAT. 1079]]
(iii) Patient-centered treatment planning or
similar processes, including risk assessment and
crisis planning.
(iv) Outpatient mental health and substance
use services.
(v) Outpatient clinic primary care screening
and monitoring of key health indicators and health
risk.
(vi) Targeted case management.
(vii) Psychiatric rehabilitation services.
(viii) Peer support and counselor services and
family supports.
(ix) Intensive, community-based mental health
care for members of the armed forces and veterans,
particularly those members and veterans located in
rural areas, provided the care is consistent with
minimum clinical mental health guidelines
promulgated by the Veterans Health Administration
including clinical guidelines contained in the
Uniform Mental Health Services Handbook of such
Administration.
(E) Quality and other reporting.--Reporting of
encounter data, clinical outcomes data, quality data,
and such other data as the Secretary requires.
(F) Organizational authority.--Criteria that a
clinic be a non-profit or part of a local government
behavioral health authority or operated under the
authority of the Indian Health Service, an Indian tribe
or tribal organization pursuant to a contract, grant,
cooperative agreement, or compact with the Indian Health
Service pursuant to the Indian Self-Determination Act
(25 U.S.C. 450 et seq.), or an urban Indian organization
pursuant to a grant or contract with the Indian Health
Service under title V of the Indian Health Care
Improvement Act (25 U.S.C. 1601 et seq.).
(b) Guidance on Development of Prospective Payment System for
Testing Under Demonstration Programs.--
(1) <<NOTE: Deadline. Applicability.>> In general.--Not
later than September 1, 2015, the Secretary, through the
Administrator of the Centers for Medicare & Medicaid Services,
shall issue guidance for the establishment of a prospective
payment system that shall only apply to medical assistance for
mental health services furnished by a certified community
behavioral health clinic participating in a demonstration
program under subsection (d).
(2) Requirements.--The guidance issued by the Secretary
under paragraph (1) shall provide that--
(A) no payment shall be made for inpatient care,
residential treatment, room and board expenses, or any
other non-ambulatory services, as determined by the
Secretary; and
(B) no payment shall be made to satellite facilities
of certified community behavioral health clinics if such
facilities are established after the date of enactment
of this Act.
(c) Planning Grants.--
(1) <<NOTE: Deadline.>> In general.--Not later than January
1, 2016, the Secretary shall award planning grants to States for
the purpose of developing proposals to participate in time-
limited demonstration programs described in subsection (d).
[[Page 128 STAT. 1080]]
(2) Use of funds.--A State awarded a planning grant under
this subsection shall--
(A) solicit input with respect to the development of
such a demonstration program from patients, providers,
and other stakeholders;
(B) <<NOTE: Certification.>> certify clinics as
certified community behavioral health clinics for
purposes of participating in a demonstration program
conducted under subsection (d); and
(C) establish a prospective payment system for
mental health services furnished by a certified
community behavioral health clinic participating in a
demonstration program under subsection (d) in accordance
with the guidance issued under subsection (b).
(d) Demonstration Programs.--
(1) <<NOTE: Deadline.>> In general.--Not later than
September 1, 2017, the Secretary shall select States to
participate in demonstration programs that are developed through
planning grants awarded under subsection (c), meet the
requirements of this subsection, and represent a diverse
selection of geographic areas, including rural and underserved
areas.
(2) Application requirements.--
(A) In general.--The Secretary shall solicit
applications to participate in demonstration programs
under this subsection solely from States awarded
planning grants under subsection (c).
(B) Required information.--An application for a
demonstration program under this subsection shall
include the following:
(i) The target Medicaid population to be
served under the demonstration program.
(ii) A list of participating certified
community behavioral health clinics.
(iii) Verification that the State has
certified a participating clinic as a certified
community behavioral health clinic in accordance
with the requirements of subsection (b).
(iv) A description of the scope of the mental
health services available under the State Medicaid
program that will be paid for under the
prospective payment system tested in the
demonstration program.
(v) Verification that the State has agreed to
pay for such services at the rate established
under the prospective payment system.
(vi) Such other information as the Secretary
may require relating to the demonstration program
including with respect to determining the
soundness of the proposed prospective payment
system.
(3) Number and length of demonstration programs.--Not more
than 8 States shall be selected for 2-year demonstration
programs under this subsection.
(4) Requirements for selecting demonstration programs.--
(A) In general.--The Secretary shall give preference
to selecting demonstration programs where participating
certified community behavioral health clinics--
(i) provide the most complete scope of
services described in subsection (a)(2)(D) to
individuals eligible
[[Page 128 STAT. 1081]]
for medical assistance under the State Medicaid
program;
(ii) will improve availability of, access to,
and participation in, services described in
subsection (a)(2)(D) to individuals eligible for
medical assistance under the State Medicaid
program;
(iii) will improve availability of, access to,
and participation in assisted outpatient mental
health treatment in the State; or
(iv) demonstrate the potential to expand
available mental health services in a
demonstration area and increase the quality of
such services without increasing net Federal
spending.
(5) Payment for medical assistance for mental health
services provided by certified community behavioral health
clinics.--
(A) In general.--The Secretary shall pay a State
participating in a demonstration program under this
subsection the Federal matching percentage specified in
subparagraph (B) for amounts expended by the State to
provide medical assistance for mental health services
described in the demonstration program application in
accordance with paragraph (2)(B)(iv) that are provided
by certified community behavioral health clinics to
individuals who are enrolled in the State Medicaid
program. Payments to States made under this paragraph
shall be considered to have been under, and are subject
to the requirements of, section 1903 of the Social
Security Act (42 U.S.C. 1396b).
(B) Federal matching percentage.--The Federal
matching percentage specified in this subparagraph is
with respect to medical assistance described in
subparagraph (A) that is furnished--
(i) to a newly eligible individual described
in paragraph (2) of section 1905(y) of the Social
Security Act (42 U.S.C. 1396d(y)), the matching
rate applicable under paragraph (1) of that
section; and
(ii) to an individual who is not a newly
eligible individual (as so described) but who is
eligible for medical assistance under the State
Medicaid program, the enhanced FMAP applicable to
the State.
(C) Limitations.--
(i) In general.--Payments shall be made under
this paragraph to a State only for mental health
services--
(I) that are described in the
demonstration program application in
accordance with paragraph (2)(iv);
(II) for which payment is available
under the State Medicaid program; and
(III) that are provided to an
individual who is eligible for medical
assistance under the State Medicaid
program.
(ii) Prohibited payments.--No payment shall be
made under this paragraph--
(I) for inpatient care, residential
treatment, room and board expenses, or
any other non-
[[Page 128 STAT. 1082]]
ambulatory services, as determined by
the Secretary; or
(II) with respect to payments made
to satellite facilities of certified
community behavioral health clinics if
such facilities are established after
the date of enactment of this Act.
(6) Waiver of statewideness requirement.--The Secretary
shall waive section 1902(a)(1) of the Social Security Act (42
U.S.C. 1396a(a)(1)) (relating to statewideness) as may be
necessary to conduct demonstration programs in accordance with
the requirements of this subsection.
(7) Annual reports.--
(A) In general.--Not later than 1 year after the
date on which the first State is selected for a
demonstration program under this subsection, and
annually thereafter, the Secretary shall submit to
Congress an annual report on the use of funds provided
under all demonstration programs conducted under this
subsection. Each such report shall include--
(i) an assessment of access to community-based
mental health services under the Medicaid program
in the area or areas of a State targeted by a
demonstration program compared to other areas of
the State;
(ii) an assessment of the quality and scope of
services provided by certified community
behavioral health clinics compared to community-
based mental health services provided in States
not participating in a demonstration program under
this subsection and in areas of a demonstration
State that are not participating in the
demonstration program; and
(iii) an assessment of the impact of the
demonstration programs on the Federal and State
costs of a full range of mental health services
(including inpatient, emergency and ambulatory
services).
(B) Recommendations.--Not later than December 31,
2021, the Secretary shall submit to Congress
recommendations concerning whether the demonstration
programs under this section should be continued,
expanded, modified, or terminated.
(e) Definitions.--In this section:
(1) Federally-qualified health center services; federally-
qualified health center; rural health clinic services; rural
health clinic.--The terms ``Federally-qualified health center
services'', ``Federally-qualified health center'', ``rural
health clinic services'', and ``rural health clinic'' have the
meanings given those terms in section 1905(l) of the Social
Security Act (42 U.S.C. 1396d(l)).
(2) Enhanced fmap.--The term ``enhanced FMAP'' has the
meaning given that term in section 2105(b) of the Social
Security Act (42 U.S.C. 1397dd(b)) but without regard to the
second and third sentences of that section.
(3) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(4) State.--The term ``State'' has the meaning given such
term for purposes of title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
(f) Funding.--
[[Page 128 STAT. 1083]]
(1) In general.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to the Secretary--
(A) for purposes of carrying out subsections (a),
(b), and (d)(7), $2,000,000 for fiscal year 2014; and
(B) for purposes of awarding planning grants under
subsection (c), $25,000,000 for fiscal year 2016.
(2) Availability.--Funds appropriated under paragraph (1)
shall remain available until expended.
SEC. 224. <<NOTE: 42 USC 290aa note.>> ASSISTED OUTPATIENT
TREATMENT GRANT PROGRAM FOR INDIVIDUALS
WITH SERIOUS MENTAL ILLNESS.
(a) In General.--The Secretary shall establish a 4-year pilot
program to award not more than 50 grants each year to eligible entities
for assisted outpatient treatment programs for individuals with serious
mental illness.
(b) Consultation.--The Secretary shall carry out this section in
consultation with the Director of the National Institute of Mental
Health, the Attorney General of the United States, the Administrator of
the Administration for Community Living, and the Administrator of the
Substance Abuse and Mental Health Services Administration.
(c) Selecting Among Applicants.--The Secretary--
(1) may only award grants under this section to applicants
that have not previously implemented an assisted outpatient
treatment program; and
(2) shall evaluate applicants based on their potential to
reduce hospitalization, homelessness, incarceration, and
interaction with the criminal justice system while improving the
health and social outcomes of the patient.
(d) Use of Grant.--An assisted outpatient treatment program funded
with a grant awarded under this section shall include--
(1) evaluating the medical and social needs of the patients
who are participating in the program;
(2) preparing and executing treatment plans for such
patients that--
(A) include criteria for completion of court-ordered
treatment; and
(B) provide for monitoring of the patient's
compliance with the treatment plan, including compliance
with medication and other treatment regimens;
(3) providing for such patients case management services
that support the treatment plan;
(4) ensuring appropriate referrals to medical and social
service providers;
(5) evaluating the process for implementing the program to
ensure consistency with the patient's needs and State law; and
(6) measuring treatment outcomes, including health and
social outcomes such as rates of incarceration, health care
utilization, and homelessness.
(e) Report.--Not later than the end of each of fiscal years 2016,
2017, and 2018, the Secretary shall submit a report to the appropriate
congressional committees on the grant program under this section.
Each <<NOTE: Evaluation.>> such report shall include an evaluation of
the following:
[[Page 128 STAT. 1084]]
(1) Cost savings and public health outcomes such as
mortality, suicide, substance abuse, hospitalization, and use of
services.
(2) Rates of incarceration by patients.
(3) Rates of homelessness among patients.
(4) Patient and family satisfaction with program
participation.
(f) Definitions.--In this section:
(1) The term ``assisted outpatient treatment'' means
medically prescribed mental health treatment that a patient
receives while living in a community under the terms of a law
authorizing a State or local court to order such treatment.
(2) The term ``eligible entity'' means a county, city,
mental health system, mental health court, or any other entity
with authority under the law of the State in which the grantee
is located to implement, monitor, and oversee assisted
outpatient treatment programs.
(3) The term ``Secretary'' means the Secretary of Health and
Human Services.
(g) Funding.--
(1) <<NOTE: Determination.>> Amount of grants.--A grant
under this section shall be in an amount that is not more than
$1,000,000 for each of fiscal years 2015 through 2018. Subject
to the preceding sentence, the Secretary shall determine the
amount of each grant based on the population of the area,
including estimated patients, to be served under the grant.
(2) Authorization of appropriations.--There is authorized to
be appropriated to carry out this section $15,000,000 for each
of fiscal years 2015 through 2018.
SEC. 225. EXCLUSION FROM PAYGO SCORECARDS.
(a) Statutory Pay-As-You-Go Scorecards.--The budgetary effects of
this Act shall not be entered on either PAYGO scorecard maintained
pursuant to section 4(d) of the Statutory Pay-As-You-Go Act of 2010.
(b) Senate PAYGO Scorecards.--The budgetary effects of this Act
shall not be entered on any PAYGO scorecard maintained for purposes of
section 201 of S. Con. Res. 21 (110th Congress).
Approved April 1, 2014.
LEGISLATIVE HISTORY--H.R. 4302:
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CONGRESSIONAL RECORD, Vol. 160 (2014):
Mar. 27, considered and passed House.
Mar. 31, considered and passed Senate.
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