Medicare Care Coordination Improvement Act of 2019

I 116TH CONGRESS 1ST SESSION H. R. 2282 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 HOUSE OF REPRESENTATIVES APRIL 10, 2019 Mr. RUIZ (for himself, Mr. BUCSHON, Mr. KIND, and Mr. MARCHANT) intro- duced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend title XVIII of the Social Security Act to 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 VerDate Sep 11 2014 00:11 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H2282.IH H2282 pamtmann on DSKBFK8HB2PROD with BILLS 2 •HR 2282 IH SECTION 1. SHORT TITLE. 1 This Act may be cited as the ‘‘Medicare Care Coordi- 2 nation Improvement Act of 2019’’. 3 SEC. 2. MODERNIZATION OF LIMITATIONS ON PHYSICIAN 4 SELF-REFERRAL. 5 (a) FACILITATION OF PARTICIPATION IN ALTER- 6 NATIVE PAYMENT MODELS.— 7 (1) IN GENERAL.—Section 1833 of the Social 8 Security Act (42 U.S.C. 1395l) is amended— 9 (A) in subsection (z), as added by section 10 101(e)(2) of the Medicare Access and CHIP 11 Reauthorization Act of 2015 (Public Law 114– 12 10), by adding at the end the following para- 13 graph: 14 ‘‘(5) WAIVER AUTHORITY.— 15 ‘‘(A) IN GENERAL.—The provisions of sub- 16 section (f) of section 1899 shall apply with re- 17 spect to covered APM entities to the same ex- 18 tent and in the same manner as such provisions 19 apply with respect to accountable care organiza- 20 tions under such section. 21 ‘‘(B) COVERED APM ENTITIES.— 22 ‘‘(i) IN GENERAL.—For purposes of 23 subparagraph (A), the term ‘covered APM 24 entity’ means, subject to clause (ii) of this 25 VerDate Sep 11 2014 00:11 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H2282.IH H2282 pamtmann on DSKBFK8HB2PROD with BILLS 3 •HR 2282 IH subparagraph and subparagraph (C), each 1 of the following: 2 ‘‘(I) An eligible alternative pay- 3 ment entity as defined in paragraph 4 (3)(D). 5 ‘‘(II) An entity participating in 6 an alternative payment model as de- 7 fined in paragraph (3)(C), including 8 such participation that qualifies as a 9 clinical practice improvement activity 10 under section 1848(q)(2)(B)(iii)(VI). 11 ‘‘(III) An entity participating in 12 a physician-focused payment model 13 for which comments and recommenda- 14 tions have, under subparagraph (C) of 15 section 1868(c)(2), been submitted in- 16 dicating that such model meets the 17 criteria described in subparagraph (A) 18 of such section. 19 ‘‘(IV) An entity participating in 20 any other model that the Secretary 21 determines is a covered APM entity 22 for purposes of subparagraph (A), in- 23 cluding such a determination made 24 pursuant to one or more physicians 25 VerDate Sep 11 2014 00:11 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H2282.IH H2282 pamtmann on DSKBFK8HB2PROD with BILLS 4 •HR 2282 IH submitting a proposal to the Secretary 1 for an alternative payment model. 2 ‘‘(ii) INCLUSION OF CERTAIN ENTI- 3 TIES.—Such term may include an entity 4 engaging in activities that the Secretary 5 has determined constitute significant 6 progress toward establishing a model re- 7 ferred to in any of subclauses (I) through 8 (IV). Any waiver under this paragraph 9 with respect to an entity described in the 10 preceding sentence may only be approved 11 for three years. 12 ‘‘(C) CERTAIN REQUIREMENTS.—A model 13 referred to in any of subclauses (I) through 14 (IV) of subparagraph (B)(i) may not be consid- 15 ered a covered APM entity for purposes of sub- 16 paragraph (A) unless the model meets the re- 17 quirements described in section 18 1877(b)(6)(B).’’; and 19 (B) by redesignating subsection (z), as 20 added by section 514(a) of the Medicare Access 21 and CHIP Reauthorization Act of 2015 (Public 22 Law 114–10), as subsection (aa). 23 (2) CONFORMING AMENDMENT.—Section 24 514(c)(1) of the Medicare Access and CHIP Reau- 25 VerDate Sep 11 2014 00:11 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H2282.IH H2282 pamtmann on DSKBFK8HB2PROD with BILLS 5 •HR 2282 IH thorization Act of 2015 (Public Law 114–10) is 1 amended by striking ‘‘subsection (z)’’ and inserting 2 ‘‘subsection (aa)’’. 3 (b) EXCEPTION FACILITATING THE DEVELOPMENT 4 AND OPERATION OF ALTERNATIVE PAYMENT MODELS.— 5 Section 1877(b) of the Social Security Act (42 U.S.C. 6 1395nn(b)) is amended by adding at the end the following 7 new paragraph: 8 ‘‘(6) DEVELOPMENT AND OPERATION OF AL- 9 TERNATIVE PAYMENT MODELS.— 10 ‘‘(A) IN GENERAL.—In the case of items 11 and services furnished pursuant to an arrange- 12 ment that meets the requirements described in 13 subparagraph (B) entered into for the purpose 14 of developing or operating a covered APM enti- 15 ty (as defined in section 1833(z)(5)(B)), includ- 16 ing— 17 ‘‘(i) an advanced alternative payment 18 model described in section 1833(z) (includ- 19 ing a physician-focused payment model re- 20 ferred to in section 1868(c)); 21 ‘‘(ii) a MIPS APM (as defined by the 22 Secretary); and 23 VerDate Sep 11 2014 00:11 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H2282.IH H2282 pamtmann on DSKBFK8HB2PROD with BILLS 6 •HR 2282 IH ‘‘(iii) any other alternative payment 1 model that the Secretary may, by regula- 2 tion, specify. 3 ‘‘(B) REQUIREMENTS.— 4 ‘‘(i) IN GENERAL.—Subject to clause 5 (ii), the requirements described in this sub- 6 paragraph with respect to an arrangement 7 relating to an alternative payment model 8 are as follows: 9 ‘‘(I) The arrangement is in writ- 10 ing, identifies the services, items, or 11 actions subject to the arrangement 12 and is signed by the parties to the ar- 13 rangement. 14 ‘‘(II) The arrangement includes a 15 description of the alternative payment 16 model. 17 ‘‘(III) Under the arrangement 18 written reports are submitted to the 19 Secretary on a semi-annual basis on 20 the progress achieved in the develop- 21 ment and operation of the alternative 22 payment model. 23 ‘‘(IV) The arrangement meets 24 such other requirements as the Sec- 25 VerDate Sep 11 2014 00:11 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H2282.IH H2282 pamtmann on DSKBFK8HB2PROD with BILLS 7 •HR 2282 IH retary may impose by regulation as 1 needed to protect against a significant 2 risk of program or patient abuse. 3 ‘‘(ii) CLARIFICATION.—The Secretary 4 shall not prohibit or restrict an arrange- 5 ment from meeting the requirements de- 6 scribed in this subparagraph on the basis 7 that the arrangement takes into account 8 the volume or value of referrals if such ar- 9 rangement otherwise meets the require- 10 ments described in clause (i).’’. 11 Æ VerDate Sep 11 2014 00:11 Apr 23, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6301 E:\BILLS\H2282.IH H2282 pamtmann on DSKBFK8HB2PROD with BILLS