I 118TH CONGRESS 1ST SESSION H. R. 2853 To amend title XVIII of the Social Security Act to expand access to clinical care in the home, and for other purposes. IN THE HOUSE OF REPRESENTATIVES APRIL 25, 2023 Mr. SMITH of Nebraska (for himself and Mrs. DINGELL) 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 expand access to clinical care in the home, 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; TABLE OF CONTENTS. 3 (a) SHORT TITLE.—This Act may be cited as the 4 ‘‘Expanding Care in the Home Act’’. 5 (b) TABLE OF CONTENTS.—the table of contents of 6 this Act is as follows: 7 Sec. 1. Short title; table of contents. Sec. 2. Enhancing primary care in the home. Sec. 3. Improving coverage for Medicare home infusion. VerDate Sep 11 2014 01:31 May 03, 2023 Jkt 039200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6211 E:\BILLS\H2853.IH H2853 SSpencer on DSK30NT082PROD with BILLS 2 •HR 2853 IH Sec. 4. Establishing payment for staff-assisted home dialysis. Sec. 5. Ensuring Medicare beneficiaries have access to in-home labs. Sec. 6. Expanding advanced diagnostic imaging in the home. Sec. 7. Delivering personal care services to Medicare beneficiaries. Sec. 8. Building the future of the home-based care workforce. SEC. 2. ENHANCING PRIMARY CARE IN THE HOME. 1 (a) IN GENERAL.—The Secretary of Health and 2 Human Services (HHS Secretary) shall allow primary 3 care providers (PCPs) enrolled in Medicare Part B to elect 4 to receive a monthly capitated payment for Primary Care 5 Qualified Evaluation and Management Services (PQEM) 6 as an alternative to fee-for-service reimbursement. Pro- 7 viders shall be allowed to elect to receive a monthly 8 capitated payment for a period of time ranging from one 9 to five years. 10 (b) COVERED SERVICES.—The HHS Secretary shall 11 annually identify PQEM services no later than October 1 12 each year. At a minimum, these services shall include the 13 following services when billed by a primary care provider 14 or a nonprimary care specialist (as outlined by the Sec- 15 retary): 16 (1) Office or Other Outpatient Services 17 (99201–99205, 99211–99215). 18 (2) Domiciliary, Rest Home or Custodial Care 19 Services (99324–99328, 99334–99337). 20 (3) Domiciliary, Rest Home or Home Care Plan 21 Oversight Services 99339–99340). 22 VerDate Sep 11 2014 01:31 May 03, 2023 Jkt 039200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H2853.IH H2853 SSpencer on DSK30NT082PROD with BILLS 3 •HR 2853 IH (4) Home Services (99341–99345, 99347– 1 99350). 2 (5) Transitional Care Management Services 3 (99495–99496). 4 (6) Care Coordination Management Services 5 (99490). 6 (7) Wellness Visits (G0402, G0438, G0439). 7 (c) PAYMENT.—The capitated payment system de- 8 signed by the HHS Secretary shall have the following: 9 (1) Base capitated payments should reflect the 10 previous 3 years excluding the period during which 11 there was an active public health emergency for 12 COVID–19. 13 (2) There should be an increase in payments to 14 reflect the need for PCPs to invest in changing their 15 office practice workflow. 16 (3) Higher PCP payment could be possible 17 through greater bonuses related to improving value 18 through total cost of care and quality. 19 (4) PCPs electing capitated payments should be 20 permitted to offer incentives to engage patients to be 21 assigned to their patient care panels. 22 (d) ATTRIBUTION.—The HHS Secretary shall ensure 23 that PCPs electing to receive a capitated payment have 24 visibility and input into the attribution model used to at- 25 VerDate Sep 11 2014 01:31 May 03, 2023 Jkt 039200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H2853.IH H2853 SSpencer on DSK30NT082PROD with BILLS 4 •HR 2853 IH tribute patients to them. At a minimum, the attribution 1 methodology should— 2 (1) patient attribution to panels should be pro- 3 spective; 4 (2) panels should be updated monthly or quar- 5 terly; and 6 (3) PCPs should have a mechanism and incen- 7 tives to enroll patients so they can influence who is 8 attributed to their panel. 9 SEC. 3. IMPROVING COVERAGE FOR MEDICARE HOME IN- 10 FUSION. 11 (a) IN GENERAL.—The HHS Secretary shall estab- 12 lish reimbursement for home infusion services and associ- 13 ated equipment and items under part B. 14 (b) COVERED SERVICES AND SUPPLIES.—Home In- 15 fusion Therapy (HIT) and associated equipment are de- 16 fined to include— 17 (1) equipment (e.g., mechanical pumps) for 18 drug administration of Eligible Infusion Drugs; 19 (2) items (other than drugs and equipment) 20 used in connection with the delivery of Eligible Infu- 21 sion Drugs such as disposable supplies for the drug 22 administration (e.g., tubing, elastomeric pumps) and 23 for the routine maintenance of the infusion access 24 device; 25 VerDate Sep 11 2014 01:31 May 03, 2023 Jkt 039200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H2853.IH H2853 SSpencer on DSK30NT082PROD with BILLS 5 •HR 2853 IH (3) 24/7 availability of pharmacist professional 1 services such as assessments, drug preparation and 2 compounding, dispensing, clinical monitoring, ad- 3 ministrative, and education; and 4 (4) 24/7 availability of nursing services (when 5 not provided as part of a home health episode). 6 (c) QUALIFIED PROVIDERS.—Provided by a qualified 7 home infusion therapy services supplier as defined in sec- 8 tion 1861(iii)(3)(C) of this Act. 9 (d) ELIGIBLE INFUSION DRUGS.—Eligible part B 10 and part D Infusion Drugs are defined as parenteral 11 drugs or biologics administered through intravenous, 12 intrathecal, intra-arterial, or subcutaneous access device, 13 except— 14 (1) drugs and biologics on the self-administered 15 drug list; and 16 (2) drugs and biologics covered under Part B 17 Durable Medical Equipment, Prosthetics, Orthotics 18 and Supplies (DMEPOS). 19 (e) CURRENT OR FUTURE INFUSION DRUGS.—Pro- 20 vided, nothing in this section shall be construed to change 21 the coverage status of any current or future infusion drugs 22 that meet the definition of a covered part D drug as de- 23 fined at section 1860D–2(e) and which are paid under 24 Medicare part D. 25 VerDate Sep 11 2014 01:31 May 03, 2023 Jkt 039200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H2853.IH H2853 SSpencer on DSK30NT082PROD with BILLS 6 •HR 2853 IH (f) REFERRING PROVIDERS.—Patients must be 1 under the care of a physician, nurse practitioner, or physi- 2 cian assistant. 3 (g) SAFETY AND QUALITY.—Consistent with stand- 4 ards of care found within commercial, Medicare Advan- 5 tage, and State Medicaid programs with regard to sterile 6 preparation of the drug to a final, useable form; timeliness 7 of initiation of care; billing of drugs, items, and pharmacy 8 services by a single entity; performing periodic assess- 9 ments of patient satisfaction and collection and evaluation 10 of quality outcome data; and maintaining a consolidated 11 patient record of services provided in accordance with the 12 plan of care. 13 (h)(1) REIMBURSEMENT.—A per infusion day pay- 14 ment is established and defined as ‘‘a payment for the 15 date on which a drug was administered to the individual 16 at home (regardless of whether a skilled professional was 17 physically present in the home of such individual on such 18 date)’’. 19 (2) MARKET RATES.—Such payment may be based 20 on a market analysis of rates paid for home infusion sup- 21 plies and services by the commercial sector and Medicare 22 Advantage programs. 23 (3) PAYMENT ELIGIBILITY.—Nothing shall prevent a 24 home infusion supplier from being paid a per infusion day 25 VerDate Sep 11 2014 01:31 May 03, 2023 Jkt 039200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H2853.IH H2853 SSpencer on DSK30NT082PROD with BILLS 7 •HR 2853 IH payment when a qualified home health agency provides the 1 nursing services for the infusion therapy under the part 2 A home health benefit. 3 SEC. 4. ESTABLISHING PAYMENT FOR STAFF-ASSISTED 4 HOME DIALYSIS. 5 (a) IN GENERAL.—Section 1881(b)(14) of the Social 6 Security Act (42 U.S.C. 1395rr(b)(14)) is amended by 7 adding at the end the following new subparagraph: 8 ‘‘(J)(i) For services furnished on or after 9 the date which is 1 year after the date of the 10 enactment of this subparagraph which are staff- 11 assisted home dialysis (as defined in clause 12 (iv)(III)), the Secretary shall increase the single 13 payment that would otherwise apply under this 14 paragraph for renal dialysis services furnished 15 to new and respite individuals in accordance 16 with the payment system established under 17 clause (iii) by qualified providers. 18 ‘‘(ii)(I) Subject to subclause (II), staff-as- 19 sisted home dialysis may only be furnished dur- 20 ing— 21 ‘‘(aa) with respect to an individual de- 22 scribed in subclause (iv)(I)(aa), one 90-day 23 period which may be renewed up to two 24 30-day periods; and 25 VerDate Sep 11 2014 01:31 May 03, 2023 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H2853.IH H2853 SSpencer on DSK30NT082PROD with BILLS 8 •HR 2853 IH ‘‘(bb) with respect to an individual de- 1 scribed in subclause (iv)(I)(bb) and not- 2 withstanding whether such an individual 3 receives any respite care under part A, any 4 30-day period. 5 ‘‘(II) Notwithstanding the limits described 6 in subclause (I), staff-assisted home dialysis 7 may be furnished for as long as the Secretary 8 determines appropriate to an individual who— 9 ‘‘(aa) is blind; 10 ‘‘(bb) has a cognitive or neurological 11 impairment (including a stroke, Alz- 12 heimer’s, dementia amyotrophic lateral 13 sclerosis, or any other impairment deter- 14 mined by the Secretary); or 15 ‘‘(cc) has any other illness or injury 16 that reduces mobility (including cerebral 17 palsy, spinal cord injuries, or any other ill- 18 ness or injury determined by the Sec- 19 retary). 20 ‘‘(iii) The Secretary shall establish a pro- 21 spective payment system through regulations to 22 determine the amounts payable to qualified pro- 23 viders for staff-assisted home dialysis. In estab- 24 VerDate Sep 11 2014 01:31 May 03, 2023 Jkt 039200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H2853.IH H2853 SSpencer on DSK30NT082PROD with BILLS 9 •HR 2853 IH lishing such system, the Secretary may con- 1 sider— 2 ‘‘(I) the costs of furnishing staff-as- 3 sisted home dialysis; 4 ‘‘(II) consultations with dialysis pro- 5 viders, dialysis patients, private payers, 6 and MA plans; 7 ‘‘(III) payment amounts for similar 8 items and services under parts A and B; 9 and 10 ‘‘(IV) payment amounts established 11 by MA plans under part C, group health 12 plans, and health insurance coverage of- 13 fered by health insurance issuers. 14 ‘‘(iv) In this subparagraph: 15 ‘‘(I) The term ‘new and respite indi- 16 vidual’ means an individual described in 17 subsection (a) who is either— 18 ‘‘(aa) initiating either peritoneal 19 or home hemodialysis; or 20 ‘‘(bb) receiving home dialysis and 21 is unable to self-dialyze due to illness, 22 injury, caregiver issues, or other tem- 23 porary circumstances. 24 VerDate Sep 11 2014 01:31 May 03, 2023 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H2853.IH H2853 SSpencer on DSK30NT082PROD with BILLS 10 •HR 2853 IH ‘‘(II) The term ‘qualified provider’ 1 means a trained professional (as deter- 2 mined by the Secretary, including nurses 3 and certified patient technicians) who fur- 4 nishes renal dialysis services and— 5 ‘‘(aa) meets requirements (as de- 6 termined by the Secretary) that en- 7 sures competency in patient care and 8 modality usage; and 9 ‘‘(bb) provides in-person assist- 10 ance to a patient for at least 75 per- 11 cent of staff-assisted home dialysis 12 sessions during a period described in 13 clause (ii)(i). 14 ‘‘(III)(aa) The term ‘staff-assisted 15 home dialysis’ means home dialysis using 16 trained professionals to assist individuals 17 who have been determined to have end 18 stage renal disease, and the frequency of 19 such home dialysis is determined by such 20 professionals in coordination with the pa- 21 tient and his or her care partner, and out- 22 lined in a patient plan of care. 23 ‘‘(bb) In this subclause, the term ‘care 24 partner’ means anyone who is designated 25 VerDate Sep 11 2014 01:31 May 03, 2023 Jkt 039200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H2853.IH H2853 SSpencer on DSK30NT082PROD with BILLS 11 •HR 2853 IH by the patient who assists the individual 1 with the furnishing of home dialysis. 2 ‘‘(cc) In this subclause, the term ‘pa- 3 tient plan of care’ has the meaning given 4 such term in section 494.90 of title 42, 5 Code of Federal Regulations.’’. 6 (b) PATIENT EDUCATION AND TRAINING RELATING 7 TO STAFF-ASSISTED HOME DIALYSIS.—Section 8 1881(b)(5) of the Social Security Act (42 U.S.C. 9 1395rr(b)(5)) is amended— 10 (1) in subparagraph (C), by striking at the end 11 ‘‘and’’; 12 (2) in subparagraph (D), by striking the period 13 at the end and inserting a semicolon; and 14 (3) by adding at the end the following new sub- 15 paragraphs: 16 ‘‘(D) educate patients of the opportunity to 17 receive staff-assisted home dialysis (as defined 18 in paragraph (14)(J)(iv)(III)) during the period 19 beginning 30 days after the first day such facil- 20 ity furnishes renal dialysis services to an indi- 21 vidual and ending 60 days after such day; and 22 ‘‘(E) provide for nurses, certified patient 23 technicians, or other professionals to train pa- 24 tients and their care partners in skills and pro- 25 VerDate Sep 11 2014 01:31 May 03, 2023 Jkt 039200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H2853.IH H2853 SSpencer on DSK30NT082PROD with BILLS 12 •HR 2853 IH cedures needed to perform home dialysis (as de- 1 fined in paragraph (14)(J)(iv)(III)) treat- 2 ment— 3 ‘‘(i) regularly and independently; 4 ‘‘(ii) through telehealth services or 5 through group training (as described in the 6 interpretive guidance relating to tag num- 7 ber V590 of ‘Advance Copy—End Stage 8 Renal Disease (ESRD) Program Interpre- 9 tive Guidance Version 1.1’ (published on 10 October 3, 2008)) in accordance with the 11 Federal regulations (concerning the privacy 12 of individually identifiable health informa- 13 tion) promulgated under section 264(c) of 14 the Health Insurance Portability and Ac- 15 countability Act of 1996; and 16 ‘‘(iii) in the home or resident of a pa- 17 tient, in a dialysis facility, or the place i [Text truncated for display. 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