Expanding Access to DSMT Act of 2019

I 116TH CONGRESS 1ST SESSION H. R. 1840 To amend title XVIII of the Social Security Act to improve access to diabetes outpatient self-management training services, and for other purposes. IN THE HOUSE OF REPRESENTATIVES MARCH 21, 2019 Mr. REED (for himself, Ms. DEGETTE, Mr. RUIZ, Ms. DELBENE, Mrs. BROOKS of Indiana, and Mr. KELLY of Pennsylvania) introduced the fol- lowing bill; which was referred to the Committee on Energy and Com- merce, and in addition to the Committee on Ways and Means, for a pe- riod to be subsequently determined by the Speaker, in each case for con- sideration of such provisions as fall within the jurisdiction of the com- mittee concerned A BILL To amend title XVIII of the Social Security Act to improve access to diabetes outpatient self-management training services, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘Expanding Access to 4 Diabetes Self-Management Training Act of 2019’’ or the 5 ‘‘Expanding Access to DSMT Act of 2019’’. 6 VerDate Sep 11 2014 22:31 Apr 01, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H1840.IH H1840 kjohnson on DSK79L0C42 with BILLS 2 •HR 1840 IH SEC. 2. IMPROVING ACCESS TO DIABETES OUTPATIENT 1 SELF-MANAGEMENT TRAINING SERVICES. 2 (a) IN GENERAL.—Section 1861(qq) of the Social Se- 3 curity Act (42 U.S.C. 1395x(qq)) is amended— 4 (1) in paragraph (1)— 5 (A) by striking ‘‘the Secretary determines 6 appropriate’’ and inserting ‘‘specified in para- 7 graph (3)’’; 8 (B) by inserting ‘‘or qualified nonphysician 9 practitioner’’ after ‘‘only if the physician’’; and 10 (C) by inserting ‘‘(or other physician or 11 qualified nonphysician practitioner furnishing 12 items or services to such individual, in coordina- 13 tion with the physician or qualified nonphysi- 14 cian practitioner managing such individual’s di- 15 abetic condition)’’ after ‘‘managing the individ- 16 ual’s diabetic condition’’; 17 (2) in paragraph (2)(B), by striking ‘‘para- 18 graph’’ and inserting ‘‘subparagraph’’; and 19 (3) by adding at the end the following new 20 paragraphs: 21 ‘‘(3) For purposes of paragraph (1), the times speci- 22 fied in this paragraph are the following: 23 ‘‘(A) An initial 10 hours of educational and 24 training services described in paragraph (1), to re- 25 main available until used. 26 VerDate Sep 11 2014 22:31 Apr 01, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H1840.IH H1840 kjohnson on DSK79L0C42 with BILLS 3 •HR 1840 IH ‘‘(B) Six additional hours (or a greater number 1 of hours if determined appropriate by the Secretary) 2 of such services during the year in which the indi- 3 vidual exhausts the initial hours described in sub- 4 paragraph (A), provided that the physician or quali- 5 fied nonphysician practitioner who is managing the 6 individual’s diabetic condition (or other physician or 7 qualified nonphysician practitioner furnishing items 8 or services to such individual, in coordination with 9 the physician or qualified nonphysician practitioner 10 managing such individual’s diabetic condition) cer- 11 tifies the medical necessity of such additional hours. 12 ‘‘(C) Six additional hours (or a greater number 13 of hours if determined appropriate by the Secretary) 14 of such services per year for each year beginning 15 after the year in which the individual exhausts the 16 initial hours described in subparagraph (A), provided 17 that the physician or qualified nonphysician practi- 18 tioner who is managing the individual’s diabetic con- 19 dition (or other physician or qualified nonphysician 20 practitioner furnishing items or services to such in- 21 dividual, in coordination with the physician or quali- 22 fied nonphysician practitioner managing such indi- 23 vidual’s diabetic condition) certifies the medical ne- 24 cessity of such additional hours. 25 VerDate Sep 11 2014 22:31 Apr 01, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H1840.IH H1840 kjohnson on DSK79L0C42 with BILLS 4 •HR 1840 IH ‘‘(D) For a year in which the individual has re- 1 ceived additional hours described in subparagraph 2 (B) or (C) and exhausted such hours, an additional 3 number of hours determined appropriate by the phy- 4 sician or qualified nonphysician practitioner who is 5 managing the individual’s diabetic condition (or 6 other physician or qualified nonphysician practi- 7 tioner furnishing items or services to such indi- 8 vidual, in coordination with the physician or quali- 9 fied nonphysician practitioner managing such indi- 10 vidual’s diabetic condition), provided that the physi- 11 cian or qualified nonphysician practitioner who is 12 managing the individual’s diabetic condition (or 13 other physician or qualified nonphysician practi- 14 tioner furnishing items or services to such indi- 15 vidual, in coordination with the physician or quali- 16 fied nonphysician practitioner managing such indi- 17 vidual’s diabetic condition) certifies that— 18 ‘‘(i) there has been a change in the individ- 19 ual’s diagnosis, medical condition, or treatment 20 regimen; 21 ‘‘(ii) the individual is not meeting appro- 22 priate clinical outcomes (as determined by such 23 physician or qualified nonphysician practitioner) 24 for such condition; or 25 VerDate Sep 11 2014 22:31 Apr 01, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H1840.IH H1840 kjohnson on DSK79L0C42 with BILLS 5 •HR 1840 IH ‘‘(iii) the individual meets other criteria 1 that necessitates such additional number of 2 hours, as determined by the Secretary. 3 ‘‘(4) For purposes of this section, the term ‘qualified 4 nonphysician practitioner’ means a physician assistant, 5 nurse practitioner, or clinical nurse specialist (as defined 6 in section 1861(aa)(5)).’’. 7 (b) MEDICAL NUTRITION THERAPY SERVICES.—Sec- 8 tion 1861(s)(2)(V) of such Act (42 U.S.C. 9 1395x(s)(2)(V)) is amended— 10 (1) by striking clause (i); 11 (2) by redesignating clauses (ii) and (iii) as 12 clauses (i) and (ii), respectively; and 13 (3) in clause (ii), as so redesignated, by striking 14 ‘‘after consideration of’’ and inserting ‘‘consistent 15 with’’. 16 (c) COST-SHARING.—Section 1833 of such Act (42 17 U.S.C. 1395l) is amended— 18 (1) in subsection (a)(1)— 19 (A) by striking ‘‘and (CC)’’ and inserting 20 ‘‘(CC)’’; and 21 (B) by striking the semicolon at the end 22 and inserting ‘‘, and (DD) with respect to dia- 23 betes outpatient self-management training serv- 24 ices (as defined in section 1861(qq)), the 25 VerDate Sep 11 2014 22:31 Apr 01, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H1840.IH H1840 kjohnson on DSK79L0C42 with BILLS 6 •HR 1840 IH amount paid shall be 100 percent of the lesser 1 of the actual charge for the services or the 2 amount determined under the fee schedule that 3 applies to such services under this part;’’; and 4 (2) in subsection (b)— 5 (A) by striking ‘‘and (10)’’ and inserting 6 ‘‘(10)’’; and 7 (B) by striking ‘‘1861(hhh)(1)).’’ and in- 8 serting ‘‘1861(hhh)(1)), and (11) such deduct- 9 ible shall not apply with respect to diabetes out- 10 patient self-management training services (as 11 defined in section 1861(qq)).’’ 12 (d) REVISION OF MANUAL.—Not later than 180 days 13 after the date of the enactment of this Act, the Secretary 14 of Health and Human Services shall revise the Medicare 15 Benefit Policy Manual to ensure that diabetes outpatient 16 self-management training services (as defined in section 17 1861(qq) of the Social Security Act (42 U.S.C. 18 1395x(qq)), as amended by subsection (a)) may be fur- 19 nished by an entity that is a hospital outpatient depart- 20 ment at alternate, nonhospital sites (including community- 21 based locations). 22 (e) APPLICATION.—The amendments made by this 23 section shall apply with respect to items and services fur- 24 nished on or after January 1, 2020. 25 VerDate Sep 11 2014 22:31 Apr 01, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H1840.IH H1840 kjohnson on DSK79L0C42 with BILLS 7 •HR 1840 IH SEC. 3. VIRTUAL DIABETES OUTPATIENT SELF-MANAGE- 1 MENT TRAINING SERVICES DEMONSTRATION 2 PROGRAM. 3 (a) IN GENERAL.—Beginning not later than January 4 1, 2020, the Secretary of Health and Human Services (in 5 this section referred to as the ‘‘Secretary’’) shall select an 6 appropriate number of applicable beneficiaries to partici- 7 pate in a 2-year demonstration program to test the impact 8 of furnishing diabetes outpatient self-management train- 9 ing services through a qualified online platform with re- 10 spect to cost and clinical outcomes for such applicable 11 beneficiaries. Under such program, diabetes outpatient 12 self-management training services furnished through a 13 qualified online platform to an applicable beneficiary shall 14 be covered under title XVIII of the Social Security Act, 15 and payment for such services shall be made in the same 16 manner as payment is made under such title for such serv- 17 ices furnished in an outpatient setting. 18 (b) DEFINITIONS.—In this section: 19 (1) APPLICABLE BENEFICIARY.—The term ‘‘ap- 20 plicable beneficiary’’ means an individual— 21 (A) who is enrolled under part B of title 22 XVIII of the Social Security Act; 23 (B) who has a diagnosis of diabetes; and 24 (C) who agrees to take part in the dem- 25 onstration program described in subsection (a). 26 VerDate Sep 11 2014 22:31 Apr 01, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H1840.IH H1840 kjohnson on DSK79L0C42 with BILLS 8 •HR 1840 IH (2) QUALIFIED ONLINE PLATFORM.—The term 1 ‘‘qualified online platform’’ means an online-based 2 platform— 3 (A) designed to furnish educational and 4 training services to an individual with diabetes 5 to ensure therapy compliance with respect to 6 the individual’s diabetic condition or to provide 7 the individual with necessary skills and knowl- 8 edge (including skills related to the self-admin- 9 istration of injectable drugs) to participate in 10 the individual’s management of such condition; 11 and 12 (B) that meets the National Standards for 13 Diabetes Self-Management Education and Sup- 14 port, as jointly published by the American Asso- 15 ciation of Diabetes Educators and the American 16 Diabetes Association. 17 (3) DIABETES SELF-MANAGEMENT TRAINING 18 SERVICES.—The term ‘‘diabetes outpatient self-man- 19 agement training services’’ has the meaning given 20 such term in section 1861(qq) of the Social Security 21 Act (42 U.S.C. 1395x(qq)) except that the require- 22 ment in paragraph (1) of such section with respect 23 to such services being furnished in an outpatient set- 24 ting shall not apply. 25 VerDate Sep 11 2014 22:31 Apr 01, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H1840.IH H1840 kjohnson on DSK79L0C42 with BILLS 9 •HR 1840 IH (c) EVALUATION.—The Secretary shall evaluate the 1 demonstration program described in subsection (a) based 2 on the following criteria: 3 (1) The improvement, if any, in health out- 4 comes with respect to the diabetic conditions of ap- 5 plicable beneficiaries participating in such program 6 as evidenced by— 7 (A) any improvement attributable to such 8 program in the knowledge of such beneficiaries 9 with respect to such conditions; 10 (B) any behavioral changes attributable to 11 such program; 12 (C) any clinical outcome improvements at- 13 tributable to such program; 14 (D) any quality of life improvements at- 15 tributable to such program; and 16 (E) the overall satisfaction of such bene- 17 ficiaries with such program. 18 (2) Reductions, if any, in expenditures under 19 title XVIII of the Social Security Act attributable to 20 such program. 21 (3) Other criteria determined appropriate by 22 the Secretary. 23 (d) REPORT.—Not later than 18 months after the 24 date of the completion of the demonstration program de- 25 VerDate Sep 11 2014 22:31 Apr 01, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H1840.IH H1840 kjohnson on DSK79L0C42 with BILLS 10 •HR 1840 IH scribed in subsection (a), the Secretary shall submit to 1 Congress a report containing— 2 (1) the results of the evaluation described in 3 subsection (c); 4 (2) an analysis of the demographic characteris- 5 tics of applicable beneficiaries who participated in 6 such program; and 7 (3) a recommendation on whether such program 8 should be continued or expanded. 9 (e) WAIVER AUTHORITY.—The Secretary may waive 10 such requirements of titles XI and XVIII of the Social 11 Security Act (42 U.S.C. 1301 et seq., 1395 et seq.) as 12 may be necessary to carry out the provisions of this sec- 13 tion. 14 (f) AUTHORITY TO EXPAND DEMONSTRATION PRO- 15 GRAM.—Notwithstanding subsection (a), taking into ac- 16 count the evaluation described in subsection (c), the Sec- 17 retary may, through rulemaking, expand the duration and 18 the scope of the demonstration program described in sub- 19 section (a), to the extent determined appropriate by the 20 Secretary, if— 21 (1) the Secretary determines that such expan- 22 sion is expected to— 23 VerDate Sep 11 2014 22:31 Apr 01, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H1840.IH H1840 kjohnson on DSK79L0C42 with BILLS 11 •HR 1840 IH (A) reduce spending under title XVIII of 1 the Social Security Act without reducing quality 2 of care; or 3 (B) improve the quality of care for individ- 4 uals enrolled under part B of such title without 5 increasing spending under such title; 6 (2) the Chief Actuary of the Centers for Medi- 7 care & Medicaid Services certifies that such expan- 8 sion would reduce (or would not result in any in- 9 crease in) net program spending under such title; 10 and 11 (3) the Secretary determines that such expan- 12 sion would not deny or limit the coverage or provi- 13 sion of benefits under such title for individuals en- 14 rolled under part B of such title. 15 Æ VerDate Sep 11 2014 22:31 Apr 01, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6301 E:\BILLS\H1840.IH H1840 kjohnson on DSK79L0C42 with BILLS