Ensuring Access to Quality Complex Rehabilitation Technology Act of 2019

I 116TH CONGRESS 1ST SESSION H. R. 2408 To amend title XVIII of the Social Security Act to update and clarify the classification of and applicable payment methodology for complex rehabilitation technology items under the Medicare program, and for other purposes. IN THE HOUSE OF REPRESENTATIVES APRIL 30, 2019 Mr. SENSENBRENNER (for himself and Mr. HIGGINS of New York) introduced 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 com- mittee concerned A BILL To amend title XVIII of the Social Security Act to update and clarify the classification of and applicable payment methodology for complex rehabilitation technology items 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 ‘‘Ensuring Access to 4 Quality Complex Rehabilitation Technology Act of 2019’’. 5 VerDate Sep 11 2014 21:29 May 02, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H2408.IH H2408 pbinns on DSK79D2C42PROD with BILLS 2 •HR 2408 IH SEC. 2. FINDINGS. 1 Congress finds the following: 2 (1) There is a small and specific population of 3 Medicare beneficiaries who have significant disabil- 4 ities and medical conditions who require complex 5 and individually configured medical equipment, 6 items, and technologies. These items and tech- 7 nologies are referred to as complex rehabilitation 8 technology (or ‘‘CRT’’) and include specialized 9 wheelchairs, specialized seating and positioning, and 10 other types of adaptive equipment and items that 11 are uniquely configured and fitted to the specific in- 12 dividual. Individuals in this population often qualify 13 for Medicare based on their disability (rather than 14 their age) and have significant disabilities and med- 15 ical conditions that may include, but are not limited 16 to, cerebral palsy, muscular dystrophy, multiple scle- 17 rosis, spinal cord injury, amyotrophic lateral scle- 18 rosis (ALS), traumatic brain injury, and spina 19 bifida. This small population comprises less than 15 20 percent of the Medicare beneficiaries who receive 21 wheelchairs. 22 (2) Current provisions addressing Medicare 23 benefit categories and related definitions do not suf- 24 ficiently define certain complex rehabilitation tech- 25 nology items and do not adequately describe and dis- 26 VerDate Sep 11 2014 21:29 May 02, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H2408.IH H2408 pbinns on DSK79D2C42PROD with BILLS 3 •HR 2408 IH tinguish these items as compared to other types of 1 Medicare-covered medical items and equipment. 2 (3) This current lack of definitional clarity for 3 complex rehabilitation technology items results in ac- 4 cess challenges for beneficiaries with significant dis- 5 abilities and medical conditions, as these items are 6 often grouped with standardized, nonspecialized 7 products that significantly differ with respect to the 8 complexity and the individualized configuration in- 9 volved, as well as certain evaluation requirements, 10 clinical coverage criteria, and other considerations. 11 (4) To provide adequate access for the small 12 population of Medicare beneficiaries with significant 13 disabilities and medical conditions who require these 14 complex, specialized, and individually configured 15 items a distinct Medicare benefit category for com- 16 plex rehabilitative technology items is needed. This 17 will allow for related improvements to clarify appli- 18 cable coding, coverage, payment, and supplier stand- 19 ards for such items. A separate benefit category is 20 needed to ensure appropriate access to these items 21 for individuals with significant disabilities and med- 22 ical conditions, and will help prevent potential over- 23 utilization of CRT by individuals for whom such 24 items are not medically necessary. 25 VerDate Sep 11 2014 21:29 May 02, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H2408.IH H2408 pbinns on DSK79D2C42PROD with BILLS 4 •HR 2408 IH SEC. 3. ESTABLISHING SEPARATE BENEFIT CATEGORY FOR 1 COMPLEX REHABILITATION TECHNOLOGIES 2 WITHIN MEDICARE. 3 Section 1861 of the Social Security Act (42 U.S.C. 4 1395x) is amended— 5 (1) in subsection (s)(2)— 6 (A) in subparagraph (GG), by striking 7 ‘‘and’’ at the end; 8 (B) in subparagraph (HH), by inserting 9 ‘‘and’’ at the end; and 10 (C) by inserting after subparagraph (HH) 11 the following new paragraph: 12 ‘‘(II) complex rehabilitation technology 13 items (as defined in subsection (kkk));’’; and 14 (2) by adding at the end, the following new sub- 15 sections: 16 ‘‘(kkk) COMPLEX REHABILITATION TECHNOLOGY 17 ITEM.— 18 ‘‘(1) The terms ‘complex rehabilitation tech- 19 nology item’ and ‘CRT item’ mean an item that— 20 ‘‘(A) is designed, manufactured, individ- 21 ually configured, adjusted, or modified for a 22 specific individual to meet the individual’s 23 unique medical, physical, or functional needs 24 and capacities; 25 VerDate Sep 11 2014 21:29 May 02, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H2408.IH H2408 pbinns on DSK79D2C42PROD with BILLS 5 •HR 2408 IH ‘‘(B) is primarily used to serve a medical, 1 physical, or functional purpose and is generally 2 not useful to a person in the absence of dis- 3 ability, illness, injury, or other medical condi- 4 tion; and 5 ‘‘(C) requires certain services to ensure ap- 6 propriate use of such item, including one or 7 more of the following— 8 ‘‘(i) an evaluation of the features and 9 functions of CRT items to the specific indi- 10 vidual who will use such an item, as re- 11 quired under section 1834(x)(2)(B)(ii)(II); 12 or 13 ‘‘(ii) configuring, fitting, program- 14 ming, adjusting, or adapting the particular 15 complex rehabilitation technology item for 16 use by such individual. 17 ‘‘(2)(A) CRT items shall include— 18 ‘‘(i) complex rehabilitation manual and 19 power wheelchairs, options, and accessories; 20 ‘‘(ii) specialized seating and positioning 21 items, options, and accessories; 22 ‘‘(iii) adaptive equipment such as standing 23 frames and gait trainers and options and acces- 24 sories; and 25 VerDate Sep 11 2014 21:29 May 02, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H2408.IH H2408 pbinns on DSK79D2C42PROD with BILLS 6 •HR 2408 IH ‘‘(iv) other items that meet the definition 1 in subparagraph (1), as determined by the Sec- 2 retary. 3 ‘‘(B) In determining which items meet the defi- 4 nition of a CRT item under this subsection, the Sec- 5 retary shall review existing and new technologies on 6 at least a yearly basis, and in a manner that takes 7 into consideration technological differences in avail- 8 able items and equipment, as well as the varying 9 clinical needs of individuals who rely on such items 10 and equipment. 11 ‘‘(3)(A) Not later than six months after the 12 date of enactment of this subsection, the Secretary 13 shall publish a list of HCPCS codes that meet the 14 definition of CRT items under this subsection. In 15 considering and publishing the list of codes that 16 meet such definition, the Secretary must ensure that 17 the HCPCS code set provides adequate and appro- 18 priate access to existing and new technologies that 19 may improve medical, physical, or functional out- 20 comes for beneficiaries with significant disabilities 21 and medical conditions, taking into consideration 22 technological differences, clinical application, and the 23 unique medical, physical, and functional needs of 24 VerDate Sep 11 2014 21:29 May 02, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H2408.IH H2408 pbinns on DSK79D2C42PROD with BILLS 7 •HR 2408 IH beneficiaries who rely on medically necessary CRT 1 items. 2 ‘‘(B) In establishing the list under subpara- 3 graph (A), the Secretary shall— 4 ‘‘(i) identify and include existing HCPCS 5 codes that are exclusively CRT items, including 6 items that, as of January 1, 2019, were classi- 7 fied within the following HCPCS codes: E0637, 8 E0638, E0641, E0642, E0953, E0954, E0986, 9 E1002, E1003, E1004, E1005, E1006, E1007, 10 E1008, E1009, E1010, E1011, E1012, E1014, 11 E1037, E1161, E1220, E1228, E1229, E1231, 12 E1232, E1233, E1234, E1235, E1236, E1237, 13 E1238, E1239, E2209, E2291, E2292, E2293, 14 E2294, E2295, E2300, E2301, E2310, E2311, 15 E2312, E2313, E2321, E2322, E2323, E2324, 16 E2325, E2326, E2327, E2328, E2329, E2330, 17 E2331, E2351, E2373, E2374, E2376, E2377, 18 E2609, E2610, E2617, E8000, E8001, E8002, 19 K0005, K0835, K0836, K0837, K0838, 20 K0839, K0840, K0841, K0842, K0843, 21 K0848, K0849, K0850, K0851, K0852, 22 K0853, K0854, K0855, K0856, K0857, 23 K0858, K0859, K0860, K0861, K0862, 24 K0863, K0864, K0868, K0869, K0870, 25 VerDate Sep 11 2014 21:29 May 02, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H2408.IH H2408 pbinns on DSK79D2C42PROD with BILLS 8 •HR 2408 IH K0871, K0877, K0878, K0879, K0880, 1 K0884, K0885, K0886, K0890, K0891, and 2 K0898; 3 ‘‘(ii) create and include in the list new 4 HCPCS codes and appropriate code descriptors 5 for CRT items that are currently considered to 6 be included in existing HCPCS codes that in- 7 clude both CRT and non-CRT items, including 8 CRT items that, as of January 1, 2019, were 9 classified within the following HCPCS codes: 10 E0143, E0950, E0951, E0952, E0955, E0956, 11 E0957, E0960, E0967, E0978, E0990, E0995, 12 E1015, E1016, E1028, E1029, E1030, E2205, 13 E2208, E2231, E2368, E2369, E2370, E2605, 14 E2606, E2607, E2608, E2613, E2614, E2615, 15 E2616, E2620, E2621, E2622, E2623, E2624, 16 E2625, K0004, K0009, K0040, K0108, and 17 K0669; and 18 ‘‘(iii) create new HCPCS codes for other 19 miscellaneous, otherwise not classified, or cus- 20 tom CRT items. 21 ‘‘(C) For each year subsequent to the year dur- 22 ing which the Secretary publishes the list under sub- 23 paragraph (A), the Secretary shall publish any nec- 24 essary updates to such list (including additions of 25 VerDate Sep 11 2014 21:29 May 02, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H2408.IH H2408 pbinns on DSK79D2C42PROD with BILLS 9 •HR 2408 IH new CRT items and any changes in applicable 1 HCPCS codes and/or code descriptors) as needed to 2 ensure appropriate access to the full range of medi- 3 cally necessary CRT items and technologies.’’. 4 SEC. 4. PAYMENT RULES. 5 Section 1834 of the Social Security Act (42 U.S.C. 6 1395m) is amended by adding at the end the following: 7 ‘‘(x) PAYMENT FOR CRT ITEMS.— 8 ‘‘(1) GENERAL RULE FOR PAYMENT.— 9 ‘‘(A) IN GENERAL.—Not later than the 10 date that is one year after the date of the en- 11 actment of this subsection, subject to subpara- 12 graph (B), the Secretary shall establish a fee 13 schedule that shall apply to CRT items as de- 14 fined at section 1861(kkk) and shall ensure 15 that such fee schedule considers the potential 16 impact on quality, access, and beneficiary liabil- 17 ity, including the likely effects on assignment 18 rates and participation rates, and facilitates ap- 19 propriate access to medically necessary CRT 20 items and technologies. 21 ‘‘(B) METHODOLOGY.—In establishing the 22 CRT fee schedule payment system under sub- 23 paragraph (A), the Secretary shall include in 24 such fee schedule, at a minimum, the allowance 25 VerDate Sep 11 2014 21:29 May 02, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H2408.IH H2408 pbinns on DSK79D2C42PROD with BILLS 10 •HR 2408 IH of purchase of items identified at section 1 1861(kkk)(3) and— 2 ‘‘(i) shall set the CRT fee schedule 3 payment amounts for CRT items identified 4 by the codes listed in section 5 1861(kkk)(3)(B)(i) at a purchase price de- 6 rived from payment amounts from the 7 January 1, 2015 Medicare fee schedule 8 plus annual Consumer Price Index-Urban 9 All Item updates for each subsequent year 10 to such items, as applicable, under this 11 section; 12 ‘‘(ii) shall calculate the payment 13 amounts for CRT items identified by the 14 codes created pursuant to section 15 1861(kkk)(3)(B)(ii) in accordance with the 16 methodology described in subparagraph 17 (C); 18 ‘‘(iii) shall permit the payment 19 amounts for CRT items identified by codes 20 for miscellaneous, otherwise not classified, 21 or custom items, created pursuant to sec- 22 tion 1861(kkk)(3)(B)(iii), to be calculated 23 based on the methodology described in sub- 24 VerDate Sep 11 2014 21:29 May 02, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H2408.IH H2408 pbinns on DSK79D2C42PROD with BILLS 11 •HR 2408 IH paragraph (C) applied to the specific item 1 billed under this subsection; and 2 ‘‘(iv) shall require that payment 3 amounts for CRT items be adjusted annu- 4 ally by the increase in the Consumer Price 5 Index-Urban All Item for the 12-month pe- 6 riod ending the preceding June 30th. 7 ‘‘(C) PAYMENT AMOUNT CALCULATION.— 8 For purposes of subparagraph (B)(ii), the 9 methodology described in this subparagraph for 10 calculating payment amounts for CRT items 11 identified by the codes specified in such sub- 12 paragraph is as follows: 13 ‘‘(i) Identify commercial price infor- 14 mation (such as manufacturer suggested 15 retail price lists, but not mail order prices 16 or internet retail prices) for CRT items in 17 the applicable code in effect during the 18 base year (which, for purposes of this sub- 19 paragraph is the calendar year ending De- 20 cember 1986), except that if the only avail- 21 able commercial price information is from 22 a period other than the base year, the Sec- 23 retary shall use the oldest available pricing 24 for the items and deflate the pricing data 25 VerDate Sep 11 2014 21:29 May 02, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H2408.IH H2408 pbinns on DSK79D2C42PROD with BILLS 12 •HR 2408 IH to the mid-point of the base year using the 1 deflation factors used by the Centers for 2 Medicare & Medicaid Services for durable 3 medical equipment at the time of enact- 4 ment of this section. 5 ‘‘(ii) Using the base year prices, iden- 6 tify the median price for all CRT items in 7 the code. 8 ‘‘(iii) Increase the median price by 1.7 9 percent and inflate to the payment year 10 using the durable medical equipment fee 11 schedule update factors required by law 12 through 2005 and full consumer price 13 index for all urban consumers update fac- 14 tors starting in 2006 and for each subse- 15 quent year, adjusted to reflect applicable 16 sale [Text truncated for display. 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