Medicare Care Coordination Improvement Act of 2019

II 116TH CONGRESS 1ST SESSION S. 966 To amend title XVIII of the Social Security Act to modernize the physician self-referral prohibitions to promote care coordination in the merit-based incentive payment system and to facilitate physician practice participation in alternative payment models under the Medicare program, and for other purposes. IN THE SENATE OF THE UNITED STATES APRIL 1, 2019 Mr. PORTMAN (for himself and Mr. BENNET) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend title XVIII of the Social Security Act to modernize the physician self-referral prohibitions to promote care coordination in the merit-based incentive payment system and to facilitate physician practice participation in alter- native payment models under the Medicare program, 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 ‘‘Medicare Care Coordi- 4 nation Improvement Act of 2019’’. 5 VerDate Sep 11 2014 22:59 Apr 05, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S966.IS S966 kjohnson on DSK79L0C42 with BILLS 2 •S 966 IS SEC. 2. MODERNIZATION OF LIMITATIONS ON PHYSICIAN 1 SELF-REFERRAL. 2 (a) FACILITATION OF PARTICIPATION IN ALTER- 3 NATIVE PAYMENT MODELS.— 4 (1) IN GENERAL.—Section 1833 of the Social 5 Security Act (42 U.S.C. 1395l) is amended— 6 (A) in subsection (z), as added by section 7 101(e)(2) of the Medicare Access and CHIP 8 Reauthorization Act of 2015 (Public Law 114– 9 10), by adding at the end the following para- 10 graph: 11 ‘‘(5) WAIVER AUTHORITY.— 12 ‘‘(A) IN GENERAL.—The provisions of sub- 13 section (f) of section 1899 shall apply with re- 14 spect to covered APM entities to the same ex- 15 tent and in the same manner as such provisions 16 apply with respect to accountable care organiza- 17 tions under such section. 18 ‘‘(B) COVERED APM ENTITIES.— 19 ‘‘(i) IN GENERAL.—For purposes of 20 subparagraph (A), the term ‘covered APM 21 entity’ means, subject to clause (ii) of this 22 subparagraph and subparagraph (C), each 23 of the following: 24 VerDate Sep 11 2014 22:59 Apr 05, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S966.IS S966 kjohnson on DSK79L0C42 with BILLS 3 •S 966 IS ‘‘(I) An eligible alternative pay- 1 ment entity as defined in paragraph 2 (3)(D). 3 ‘‘(II) An entity participating in 4 an alternative payment model as de- 5 fined in paragraph (3)(C), including 6 such participation that qualifies as a 7 clinical practice improvement activity 8 under section 1848(q)(2)(B)(iii)(VI). 9 ‘‘(III) An entity participating in 10 a physician-focused payment model 11 for which comments and recommenda- 12 tions have, under subparagraph (C) of 13 section 1868(c)(2), been submitted in- 14 dicating that such model meets the 15 criteria described in subparagraph (A) 16 of such section. 17 ‘‘(IV) An entity participating in 18 any other model that the Secretary 19 determines is a covered APM entity 20 for purposes of subparagraph (A), in- 21 cluding such a determination made 22 pursuant to one or more physicians 23 submitting a proposal to the Secretary 24 for an alternative payment model. 25 VerDate Sep 11 2014 22:59 Apr 05, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S966.IS S966 kjohnson on DSK79L0C42 with BILLS 4 •S 966 IS ‘‘(ii) INCLUSION OF CERTAIN ENTI- 1 TIES.—Such term may include an entity 2 engaging in activities that the Secretary 3 has determined constitute significant 4 progress toward establishing a model re- 5 ferred to in any of subclauses (I) through 6 (IV). Any waiver under this paragraph 7 with respect to an entity described in the 8 preceding sentence may only be approved 9 for three years. 10 ‘‘(C) CERTAIN REQUIREMENTS.—A model 11 referred to in any of subclauses (I) through 12 (IV) of subparagraph (B)(i) may not be consid- 13 ered a covered APM entity for purposes of sub- 14 paragraph (A) unless the model meets the re- 15 quirements described in section 16 1877(b)(6)(B).’’; and 17 (B) by redesignating subsection (z), as 18 added by section 514(a) of the Medicare Access 19 and CHIP Reauthorization Act of 2015 (Public 20 Law 114–10), as subsection (aa). 21 (2) CONFORMING AMENDMENT.—Section 22 514(c)(1) of the Medicare Access and CHIP Reau- 23 thorization Act of 2015 (Public Law 114–10) is 24 VerDate Sep 11 2014 22:59 Apr 05, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S966.IS S966 kjohnson on DSK79L0C42 with BILLS 5 •S 966 IS amended by striking ‘‘subsection (z)’’ and inserting 1 ‘‘subsection (aa)’’. 2 (b) EXCEPTION FACILITATING THE DEVELOPMENT 3 AND OPERATION OF ALTERNATIVE PAYMENT MODELS.— 4 Section 1877(b) of the Social Security Act (42 U.S.C. 5 1395nn(b)) is amended by adding at the end the following 6 new paragraph: 7 ‘‘(6) DEVELOPMENT AND OPERATION OF AL- 8 TERNATIVE PAYMENT MODELS.— 9 ‘‘(A) IN GENERAL.—In the case of items 10 and services furnished pursuant to an arrange- 11 ment that meets the requirements described in 12 subparagraph (B) entered into for the purpose 13 of developing or operating a covered APM enti- 14 ty (as defined in section 1833(z)(5)(B)), includ- 15 ing— 16 ‘‘(i) an advanced alternative payment 17 model described in section 1833(z) (includ- 18 ing a physician-focused payment model re- 19 ferred to in section 1868(c)); 20 ‘‘(ii) a MIPS APM (as defined by the 21 Secretary); and 22 ‘‘(iii) any other alternative payment 23 model that the Secretary may, by regula- 24 tion, specify. 25 VerDate Sep 11 2014 22:59 Apr 05, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S966.IS S966 kjohnson on DSK79L0C42 with BILLS 6 •S 966 IS ‘‘(B) REQUIREMENTS.— 1 ‘‘(i) IN GENERAL.—Subject to clause 2 (ii), the requirements described in this sub- 3 paragraph with respect to an arrangement 4 relating to an alternative payment model 5 are as follows: 6 ‘‘(I) The arrangement is in writ- 7 ing, identifies the services, items, or 8 actions subject to the arrangement 9 and is signed by the parties to the ar- 10 rangement. 11 ‘‘(II) The arrangement includes a 12 description of the alternative payment 13 model. 14 ‘‘(III) Under the arrangement 15 written reports are submitted to the 16 Secretary on a semi-annual basis on 17 the progress achieved in the develop- 18 ment and operation of the alternative 19 payment model. 20 ‘‘(IV) The arrangement meets 21 such other requirements as the Sec- 22 retary may impose by regulation as 23 needed to protect against a significant 24 risk of program or patient abuse. 25 VerDate Sep 11 2014 22:59 Apr 05, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S966.IS S966 kjohnson on DSK79L0C42 with BILLS 7 •S 966 IS ‘‘(ii) CLARIFICATION.—The Secretary 1 shall not prohibit or restrict an arrange- 2 ment from meeting the requirements de- 3 scribed in this subparagraph on the basis 4 that the arrangement takes into account 5 the volume or value of referrals if such ar- 6 rangement otherwise meets the require- 7 ments described in clause (i).’’. 8 Æ VerDate Sep 11 2014 22:59 Apr 05, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6301 E:\BILLS\S966.IS S966 kjohnson on DSK79L0C42 with BILLS