[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4302 Enrolled Bill (ENR)]
H.R.4302
One Hundred Thirteenth Congress
of the
United States of America
AT THE SECOND SESSION
Begun and held at the City of Washington on Friday,
the third day of January, two thousand and fourteen
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.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,

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(a) Short 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:

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TITLE I

-MEDICARE EXTENDERS

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TITLE II

-OTHER HEALTH PROVISIONS

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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) 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.''.

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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''.

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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
(B) by striking ``2012, 2013, or the first three months of
2014'' and inserting ``2012, 2013, 2014, or the first three
months of 2015''.

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(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''.

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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),''.

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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''.

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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''.

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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''.

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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.''.

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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:
``(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.''.

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(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) 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))).

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(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;
``(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) 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) Effective Date.--The amendments made by this section are
effective as of the date of the enactment of this Act.

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(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) 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)''.

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(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''.

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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''.

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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''.

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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''.

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(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''.

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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.''.

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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''.

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VISITING PROGRAMS.
Section 511(j) of the Social Security Act (42 U.S.C. 711(j)) is
amended--
(1) in paragraph (1)--
(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) 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.

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(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)''.

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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 is amended
by striking ``October 1, 2014'' and inserting ``October 1, 2016''.

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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.

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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) 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).

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EDUCATION PROGRAM.
(a) 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.

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(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) 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) 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 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) 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 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) 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.
``(4) 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);
``(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 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) 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) 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--
``(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) 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 for the SNF performance score of a skilled nursing
facility provided under section 1888(h)(4) of such Act, as added by
subsection (b).

a279f16087d6252ca9c90bdca5fe30ef51cecab0bdb162a4b3e9a6d719f8437f

b7fc29d0f5a19e87c06d8b9d87d710a30682194f26a01eb61ea3166c934ae076

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.--
(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) 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-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) 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.

857b8261067b8474c254da91745d266d90af751458d3c3d54db0de3d24b6903b

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 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) 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 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 for fee schedules 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.--
``(A) 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) 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.--
``(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) List of mechanisms for consultation with applicable
appropriate use criteria.--
``(i) 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
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
``(ii) provide to the furnishing professional the
information described in clauses (i) through (iii) of
subparagraph (B).
``(B) 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) 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 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) 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 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.

056683a1d7698feda4763f4f383eb8f07f741a2a71acaae1d1340744a04241ad

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''.

8cacdf35e117643720c1eb9998530fa4c0043924acfec7c4df18d55d89fcf6c3

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.
``(IV) Any other mechanism determined appropriate
by the Secretary.
``(v) Transparency of use of information.--
``(I) 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).''.
(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.
``(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 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:
``(VIII) Reductions for misvalued services if
target not met.--Effective for 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 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.--
``(A) 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) 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) 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.
``(E) 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) 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).

310be56cd9f1207f83ac320e5fa270f5e2ca2458195d8d2a37d9e88fa9bf459e

(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:
``(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.''.

2a032e8101b7ac5d843a3a23dbd3f9088c50f7f170bf2874bd381b61e694eeee

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) 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.''.

6d84f6c98c98cd0f0c1d03a8673887fa456e7ee442d786520522f3bbfca0cb51

SERVICES.
(a) Criteria for Certified Community Behavioral Health Clinics To
Participate in Demonstration Programs.--
(1) 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.
(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) 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) 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).
(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) 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) 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
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-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.--
(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.

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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
such report shall include an evaluation of the following:
(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) 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.

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(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).
Speaker of the House of Representatives.
Vice President of the United States and
President of the Senate.

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Protecting Access to Medicare Act of 2014 — HR. 4302

Other Sections

TITLE I

TITLE II

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