II
111th CONGRESS
1st Session
S. 1262
IN THE SENATE OF THE UNITED STATES
June 15, 2009
Ms. Cantwell introduced the following bill; which was read twice and referred to the Committee on Finance
A BILL
To amend title VII of the Public Health Service Act and titles XVIII and XIX of the Social Security Act to provide additional resources for primary care services, to create new payment models for services under Medicare, to expand provision of non-institutionally-based long-term services, and for other purposes.
Short title
This Act may be cited as
the Medical Efficiency and Delivery
Improvement of Care Act (MEDIC) of 2009
.
Table of contents
The table of contents for this Act is as follows:
Sec. 1. Short title.
Sec. 2. Table of contents.
TITLE I—Loan Program Provisions
Sec. 1001. Short title.
Sec. 1002. Hospital residency loan program.
TITLE II—Primary Care Provisions
Sec. 2001. Short title.
Sec. 2002. Findings.
Sec. 2003. Definitions.
Subtitle A—Medical education
Sec. 2101. Recruitment incentives.
Sec. 2102. Debt forgiveness, scholarships, and service obligations.
Sec. 2103. Deferment of loans during residency and internships.
Sec. 2104. Educating medical students about primary care careers.
Sec. 2105. Training in family medicine, general internal medicine, general geriatrics, general pediatrics, physician assistant education, general dentistry, and pediatric dentistry.
Sec. 2106. Increased funding for National Health Service Corps Scholarship and loan repayment programs.
Subtitle B—Medicaid Related Provisions
Sec. 2201. Transformation grants to support patient-centered medical homes under Medicaid and CHIP.
Subtitle C—Medicare Provisions
Part I—Primary Care
Sec. 2301. Reforming payment systems under Medicare to support primary care.
Sec. 2302. Coverage of patient-centered medical home services.
Sec. 2303. Medicare primary care payment equity and access provision.
Sec. 2304. Additional incentive payment program for primary care services furnished in health professional shortage areas.
Sec. 2305. Permanent extension of Medicare incentive payment program for physician scarcity areas.
Sec. 2306. HHS study and report on the process for determining relative value under the Medicare physician fee schedule.
Part II—Preventive services
Sec. 2311. Eliminating time restriction for initial preventive physical examination.
Sec. 2312. Elimination of cost-sharing for preventive benefits under the Medicare program.
Sec. 2313. HHS study and report on facilitating the receipt of Medicare preventive services by Medicare beneficiaries.
Part III—Other provisions
Sec. 2321. HHS study and report on improving the ability of physicians and primary care providers to assist Medicare beneficiaries in obtaining needed prescriptions under Medicare part D.
Sec. 2322. HHS study and report on improved patient care through increased caregiver and physician interaction.
Sec. 2323. Improved patient care through expanded support for limited English proficiency (LEP) services.
Sec. 2324. HHS study and report on use of real-time Medicare claims adjudication.
Sec. 2325. Ongoing assessment by MedPAC of the impact of Medicare payments on primary care access and equity.
Sec. 2326. Distribution of additional residency positions.
Sec. 2327. Counting resident time in outpatient settings.
Sec. 2328. Rules for counting resident time for didactic and scholarly activities and other activities.
Sec. 2329. Preservation of resident cap positions from closed and acquired hospitals.
Sec. 2330. Quality improvement organization assistance for physician practices seeking to be patient-centered medical home practices.
Subtitle D—Studies
Sec. 2401. Study concerning the designation of primary care as a shortage profession.
Sec. 2402. Study concerning the education debt of medical school graduates.
Sec. 2403. Study on minority representation in primary care.
TITLE III—Medicare Payment Provisions
Sec. 3001. Short title.
Sec. 3002. Findings.
Sec. 3003. Value index under the Medicare physician fee schedule.
TITLE IV—Long-Term Services Provisions
Sec. 4001. Short title.
Subtitle A—Balancing Incentives
Sec. 4101. Enhanced FMAP for expanding the provision of non-institutionally-based long-term services and supports.
Subtitle B—Strengthening the Medicaid Home and Community-Based State Plan Amendment Option
Sec. 4201. Removal of barriers to providing home and community-based services under State plan amendment option for individuals in need.
Sec. 4202. Mandatory application of spousal impoverishment protections to recipients of home and community-based services.
Sec. 4203. State authority to elect to exclude up to 6 months of average cost of nursing facility services from assets or resources for purposes of eligibility for home and community-based services.
Subtitle C—Coordination of Home and Community-Based Waivers
Sec. 4301. Streamlined process for combined waivers under subsections (b) and (c) of section 1915.
TITLE V—Home and Community-Based Services Provisions
Sec. 5001. Short title.
Sec. 5002. Long-term services and supports.
Loan Program Provisions
Short title
This title may be cited
as the Physician Workforce Enhancement
Act of 2009
.
Hospital residency loan program
Subpart 2 of part E of title VII of the Public Health Service Act is amended by adding at the end the following new section:
Hospital residency loan program
Establishment
Not later than January 1, 2010, the Secretary, acting through the Administrator of the Health Resources and Services Administration, shall establish a loan program that provides loans to eligible hospitals to establish residency training programs.
Application
No loan may be provided under this section to an eligible hospital except pursuant to an application that is submitted and approved in a time, manner, and form specified by the Administrator of the Health Resources and Services Administration. A loan under this section shall be on such terms and conditions and meet such requirements as the Administrator determines appropriate, in accordance with the provisions of this section.
Eligibility; Preference for Rural and Small Urban Areas
Eligible hospital defined
For purposes of this section, an eligible
hospital
means, with respect to a loan under this section, a hospital
that, as of the date of the submission of an application under subsection (b),
meets, to the satisfaction of the Administrator of the Health Resources and
Services Administration, each of the following criteria:
The hospital does not operate a residency training program, has not previously operated such a program, and has not taken any significant action, such as the expenditure of a material amount of funds, before July 1, 2009, to establish such a program.
The hospital has secured initial accreditation by the American Council for Graduate Medical Education or the American Osteopathic Association.
The hospital provides assurances to the satisfaction of the Administrator of the Health Resources and Services Administration that such loan shall be used, consistent with subsection (d), only for the purposes of establishing and conducting an allopathic or osteopathic physician residency training program in at least one of the following medical specialties, or a combination of the following:
Family medicine.
Internal medicine.
Emergency medicine.
Obstetrics or gynecology.
General surgery.
Preventive Medicine.
Pediatrics.
Behavioral and Mental Health.
The hospital enters into an agreement with the Administrator that certifies the hospital will provide for the repayment of the loan in accordance with subsection (e).
Preference for rural and small areas
In making loans under this section, the Administrator of the Health Resources and Services Administration shall give preference to any applicant for such a loan that is a hospital located in a rural areas (as such term is defined in section 1886(d)(2)(D) of the Social Security Act) or an urban area that is not a large urban area (as such terms are respectively defined in such section).
Permissible Uses of Loan Funds
A loan provided under this section shall be used, with respect to a residency training program, only for costs directly attributable to the residency training program, except as otherwise provided by the Administrator of the Health Resources and Services Administration.
Repayment of Loans
Repayment plans
For purposes of subsection (c)(1)(D), a repayment plan for an eligible hospital is in accordance with this subsection if it provides for the repayment of the loan amount in installments, in accordance with a schedule that is agreed to by the Administrator of the Health Resources and Services Administration and the hospital and that is in accordance with this subsection.
Commencement of repayment
Repayment by an eligible hospital of a loan under this section shall commence not later than the date that is 18 months after the date on which the loan amount is disbursed to such hospital.
Repayment period
A loan made under this section shall be fully repaid not later than the date that is 24 months after the date on which the repayment is required to commence.
Loan payable in full if residency training program canceled
In the case that an eligible hospital borrows a loan under this section, with respect to a residency training program, and terminates such program before the date on which such loan has been fully repaid in accordance with a plan under paragraph (1), such loan shall be payable by the hospital not later than 45 days after the date of such termination.
No Interest Charged
The Administrator of the Health Resources and Services Administration may not charge or collect interest on any loan made under this section.
Limitation on Total Amount of Loan
The cumulative dollar amount of a loan made to an eligible hospital under this section may not exceed $1,000,000.
Penalties
The Administrator of the Health Resources and Services Administration shall establish penalties to which an eligible hospital receiving a loan under this section would be subject if such hospital is in violation of any of the criteria described in subsection (c)(1).
Reports
Not later than January 1, 2014, and annually thereafter (before January 2, 2020), the Administrator of the Health Resources and Services Administration shall submit to Congress a report on the efficacy of the program under this section in increasing the number of residents practicing in each medical specialty described in subsection (c)(1)(C) during such year and the extent to which the program resulted in an increase in the number of available practitioners in each of such medical specialties that serve medically underserved populations.
Funding
—
Authorization of appropriations
For the purpose of providing amounts for loans under this section, there are authorized to be appropriated $25,000,000 for the period of fiscal years 2010 through 2020.
Availability
Amounts appropriated under paragraph (1) shall remain available until expended.
Repaid loan amounts
Any amount repaid by, or recovered from, an eligible hospital under this section on or before the date of termination described in subsection (k) shall be credited to the appropriation account from which the loan amount involved was originally paid. Any amount repaid by, or recovered from, such a hospital under this section after such date shall be credited to the general fund in the Treasury.
Termination of Program
No loan may be made under this section after December 31, 2019.
.
Primary Care Provisions
Short title
This title may be cited
as the Preserving Patient Access to
Primary Care Act of 2009
.
Findings
Congress makes the following findings:
Approximately 21 percent of physicians who were board certified in general internal medicine during the early 1990s have left internal medicine, compared to a 5 percent departure rate for those who were certified in subspecialties of internal medicine.
The number of United States medical graduates going into family medicine has fallen by more than 50 percent from 1997 to 2005.
In 2007, only 88 percent of the available medicine residency positions were filled and only 42 percent of those were filled by United States medical school graduates.
In 2006, only 24 percent of third-year internal medicine resident intended to pursue careers in general internal medicine, down from 54 percent in 1998.
Primary care physicians serve as the point of first contact for most patients and are able to coordinate the care of the whole person, reducing unnecessary care and duplicative testing.
Primary care physicians and primary care providers practicing preventive care, including screening for illness and treating diseases, can help prevent complications that result in more costly care.
Patients with primary care physicians or primary care providers have lower health care expenditures and primary care is correlated with better health status, lower overall mortality, and longer life expectancy.
Higher proportions of primary care physicians are associated with significantly reduced utilization.
The United States has a higher ratio of specialists to primary care physicians than other industrialized nations and the population of the United States is growing faster than the expected rate of growth in the supply of primary care physicians.
The number of Americans age 65 and older, those eligible for Medicare and who use far more ambulatory care visits per person as those under age 65, is expected to double from 2000 to 2030.
A decrease in Federal spending to carry out programs authorized by title VII of the Public Health Service Act threatens the viability of one of the programs used to solve the problem of inadequate access to primary care.
The National Health Service Corps program has a proven record of supplying physicians to underserved areas, and has played an important role in expanding access for underserved populations in rural and inner city communities.
Individuals in many geographic areas, especially rural areas, lack adequate access to high quality preventive, primary health care, contributing to significant health disparities that impair America's public health and economic productivity.
About 20 percent of the population of the United States resides in primary medical care Health Professional Shortage Areas.
Definitions
General definitions
In this title:
Chronic Care Coordination
The term chronic care coordination means the coordination of services that is based on the Chronic Care Model that provides on-going health care to patients with chronic diseases that may include any of the following services:
The development of an initial plan of care, and subsequent appropriate revisions to such plan of care.
The management of, and referral for, medical and other health services, including interdisciplinary care conferences and management with other providers.
The monitoring and management of medications.
Patient education and counseling services.
Family caregiver education and counseling services.
Self-management services, including health education and risk appraisal to identify behavioral risk factors through self-assessment.
Providing access by telephone with physicians and other appropriate health care professionals, including 24-hour availability of such professionals for emergencies.
Management with the principal nonprofessional caregiver in the home.
Managing and facilitating transitions among health care professionals and across settings of care, including the following:
Pursuing the treatment option elected by the individual.
Including any advance directive executed by the individual in the medical file of the individual.
Information about, and referral to, hospice care, including patient and family caregiver education and counseling about hospice care, and facilitating transition to hospice care when elected.
Information about, referral to, and management with, community services.
Critical shortage health facility
The term critical shortage health facility means a public or private nonprofit health facility that does not serve a health professional shortage area (as designated under section 332 of the Public Health Service Act), but that has a critical shortage of physicians (as determined by the Secretary) in a primary care field.
Physician
The term physician has the meaning given such term in section 1861(r)(1) of the Social Security Act.
Primary care
The term primary care means the provision of integrated, high-quality, accessible health care services by health care providers who are accountable for addressing a full range of personal health and health care needs, developing a sustained partnership with patients, practicing in the context of family and community, and working to minimize disparities across population subgroups.
Primary care field
The term primary care field means any of the following fields:
The field of family medicine.
The field of general internal medicine.
The field of geriatric medicine.
The field of pediatric medicine
Primary care physician
The term primary care physician means a physician who is trained in a primary care field who provides first contact, continuous, and comprehensive care to patients.
Primary care provider
The term primary care provider means—
a nurse practitioner; or
a physician assistant practicing as a member of a physician-directed team;
Principal care
The term principal care means integrated, accessible health care that is provided by a physician who is a medical subspecialist that addresses the majority of the personal health care needs of patients with chronic conditions requiring the subspecialist’s expertise, and for whom the subspecialist assumes care management, developing a sustained physician-patient partnership and practicing within the context of family and community.
Secretary
The term Secretary means the Secretary of Health and Human Services.
Primary Medical Care Shortage Area
In general
In this title, the term primary medical care shortage area or PMCSA means a geographic area with a shortage of physicians (as designated by the Secretary) in a primary care field, as designated in accordance with paragraph (2).
Designation
To be designated by the Secretary as a PMCSA, the Secretary must find that the geographic area involved has an established shortage of primary care physicians for the population served. The Secretary shall make such a designation with respect to an urban or rural geographic area if the following criteria are met:
The area is a rational area for the delivery of primary care services.
One of the following conditions prevails within the area:
The area has a population to full-time-equivalent primary care physician ratio of at least 3,500 to 1.
The area has a population to full-time-equivalent primary care physician ratio of less than 3,500 to 1 and has unusually high needs for primary care services or insufficient capacity of existing primary care providers.
Primary care providers in contiguous geographic areas are overutilized.
Medically Underserved Area
In general
In this title, the term medically underserved
area or MUA means a rational service area with a
demonstrable shortage of primary healthcare resources relative to the needs of
the entire population within the service area as determined in accordance with
paragraph (2) through the use of the Index of Medical Underservice (referred to
in this subsection as the IMU
) with respect to data on a service
area.
Determinations
Under criteria to be established by the Secretary with respect to the IMU, if a service area is determined by the Secretary to have a score of 62.0 or less, such area shall be eligible to be designated as a MUA.
IMU variables
In establishing criteria under paragraph (2), the Secretary shall ensure that the following variables are utilized:
The ratio of primary medical care physicians per 1,000 individuals in the population of the area involved.
The infant mortality rate in the area involved.
The percentage of the population involved with incomes below the poverty level.
The percentage of the population involved age 65 or over.
Patient-centered Medical Home
In general
In this title, the term patient-centered medical home means a physician-directed practice (or a nurse practitioner directed practice in those States in which such functions are included in the scope of practice of licensed nurse practitioners) that has been certified by an organization under paragraph (3) as meeting the following standards:
The practice
provides patients who elect to obtain care through a patient-centered medical
home (referred to as participating patients
) with direct and
ongoing access to a primary or principal care physician or a primary care
provider who accepts responsibility for providing first contact, continuous,
and comprehensive care to the whole person, in collaboration with teams of
other health professionals, including nurses and specialist physicians, as
needed and appropriate.
The practice applies standards for access to care and communication with participating beneficiaries.
The practice has readily accessible, clinically useful information on participating patients that enables the practice to treat such patients comprehensively and systematically.
The practice maintains continuous relationships with participating patients by implementing evidence-based guidelines and applying such guidelines to the identified needs of individual beneficiaries over time and with the intensity needed by such beneficiaries.
Recognition of NCQA approval
Such term also
includes a physician-directed (or nurse-practitioner-directed) practice that
has been recognized as a medical home through the Physician Practice
Connections—patient-centered Medical Home (PPC—PCMH
) voluntary
recognition process of the National Committee for Quality Assurance.
Standard Setting and Qualification Process for Medical Homes
The Secretary shall establish a process for the selection of a qualified standard setting and certification organization—
to establish standards, consistent with this subsection, to enable medical practices to qualify as patient-centered medical homes; and
to provide for the review and certification of medical practices as meeting such standards.
Treatment of certain practices
Nothing in this section shall be construed as preventing a nurse practitioner from leading a patient-centered medical home so long as—
all of the requirements of this section are met; and
the nurse practitioner is acting consistently with State law.
Application under Medicare, Medicaid, PHSA, etc
Unless otherwise provided, the provisions of the previous subsections shall apply for purposes of provisions of the Social Security Act, the Public Health Service Act, and any other Act amended by this title.
Medical education
Recruitment incentives
Title VII of the Higher Education Act of 1965 (20 U.S.C. 1133 et seq.) is amended by adding at the end the following:
Medical education recruitment incentives
Medical education recruitment incentives
In general
The Secretary is authorized to award grants or contracts to institutions of higher education that are graduate medical schools, to enable the graduate medical schools to improve primary care education and training for medical students.
Application
A graduate medical school that desires to receive a grant under this section shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.
Uses of funds
A graduate medical school that receives a grant under this section shall use such grant funds to carry out 1 or more of the following:
The creation of primary care mentorship programs.
Curriculum development for population-based primary care models of care, such as the patient-centered medical home.
Increased opportunities for ambulatory, community-based training.
Development of generalist curriculum to enhance care for rural and underserved populations in primary care or general surgery.
Authorization of appropriations
There is authorized to be appropriated to carry out this section $50,000,000 for each of the fiscal years 2010 through 2012.
.
Debt forgiveness, scholarships, and service obligations
Purpose
It is the purpose of this section to encourage individuals to enter and continue in primary care physician careers.
Amendment to the Public Health Service Act
Part D of title III of the Public Health Service Act (42 U.S.C. 254b et seq.) is amended by adding at the end the following:
Primary care medical education
Scholarships
In general
The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall award grants to critical shortage health facilities to enable such facilities to provide scholarships to individuals who agree to serve as physicians at such facilities after completing a residency in a primary care field (as defined in section 3(a)(5) of the Preserving Patient Access to Primary Care Act of 2009).
Scholarships
A health facility shall use amounts received under a grant under this section to enter into contracts with eligible individuals under which—
the facility agrees to provide the individual with a scholarship for each school year (not to exceed 4 school years) in which the individual is enrolled as a full-time student in a school of medicine or a school of osteopathic medicine; and
the individual agrees—
to maintain an acceptable level of academic standing;
to complete a residency in a primary care field; and
after completing the residency, to serve as a primary care physician at such facility in such field for a time period equal to the greater of—
one year for each school year for which the individual was provided a scholarship under this section; or
two years.
Amount
In general
The amount paid by a health facility to an individual under a scholarship under this section shall not exceed $35,000 for any school year.
Considerations
In determining the amount of a scholarship to be provided to an individual under this section, a health facility may take into consideration the individual's financial need, geographic differences, and educational costs.
Exclusion from gross income
For purposes of the Internal Revenue Code of 1986, gross income shall not include any amount received as a scholarship under this section.
Application of certain provisions
The provisions of subpart III of part D shall, except as inconsistent with this section, apply to the program established in subsection (a) in the same manner and to the same extent as such provisions apply to the National Health Service Corps Scholarship Program established in such subpart.
Definitions
In this section:
Critical shortage health facility
The term critical shortage health facility means a public or private nonprofit health facility that does not serve a health professional shortage area (as designated under section 332), but has a critical shortage of physicians (as determined by the Secretary) in a primary care field.
Eligible individual
The term eligible individual means an individual who is enrolled, or accepted for enrollment, as a full-time student in an accredited school of medicine or school of osteopathic medicine.
Loan repayment program
Purpose
It is the purpose of this section to alleviate critical shortages of primary care physicians and primary care providers.
Loan repayments
The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall establish a program of entering into contracts with eligible individuals under which—
the individual agrees to serve—
as a primary care physician or primary care provider in a primary care field; and
in an area that is not a health professional shortage area (as designated under section 332), but has a critical shortage of primary care physicians and primary care providers (as determined by the Secretary) in such field; and
the Secretary agrees to pay, for each year of such service, not more than $35,000 of the principal and interest of the undergraduate or graduate educational loans of the individual.
Service requirement
A contract entered into under this section shall allow the individual receiving the loan repayment to satisfy the service requirement described in subsection (a)(1) through employment in a solo or group practice, a clinic, a public or private nonprofit hospital, or any other appropriate health care entity.
Application of certain provisions
The provisions of subpart III of part D shall, except as inconsistent with this section, apply to the program established in subsection (a) in the same manner and to the same extent as such provisions apply to the National Health Service Corps Scholarship Program established in such subpart.
Definition
In this section, the term eligible individual means—
an individual with a degree in medicine or osteopathic medicine; or
a primary care provider (as defined in section 3(a)(7) of the Preserving Patient Access to Primary Care Act of 2009).
Loan repayments for physicians in the fields of obstetrics and gynecology and certified nurse midwives
Purpose
It is the purpose of this section to alleviate critical shortages of physicians in the fields of obstetrics and gynecology and certified nurse midwives.
Loan repayments
The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall establish a program of entering into contracts with eligible individuals under which—
the individual agrees to serve—
as a physician in the field of obstetrics and gynecology or as a certified nurse midwife; and
in an area that is not a health professional shortage area (as designated under section 332), but has a critical shortage of physicians in the fields of obstetrics and gynecology or certified nurse midwives (as determined by the Secretary), respectively; and
the Secretary agrees to pay, for each year of such service, not more than $35,000 of the principal and interest of the undergraduate or graduate educational loans of the individual.
Service requirement
A contract entered into under this section shall allow the individual receiving the loan repayment to satisfy the service requirement described in subsection (a)(1) through employment in a solo or group practice, a clinic, a public or private nonprofit hospital, or any other appropriate health care entity.
Application of certain provisions
The provisions of subpart III of part D shall, except as inconsistent with this section, apply to the program established in subsection (a) in the same manner and to the same extent as such provisions apply to the National Health Service Corps Scholarship Program established in such subpart.
Definition
In this section, the term eligible individual means—
a physician in the field of obstetrics and gynecology; or
a certified nurse midwife.
Reports
Not later than 18 months after the date of enactment of this section, and annually thereafter, the Secretary shall submit to Congress a report that describes the programs carried out under this subpart, including statements concerning—
the number of enrollees, scholarships, loan repayments, and grant recipients;
the number of graduates;
the amount of scholarship payments and loan repayments made;
which educational institution the recipients attended;
the number and placement location of the scholarship and loan repayment recipients at health care facilities with a critical shortage of primary care physicians;
the default rate and actions required;
the amount of outstanding default funds of both the scholarship and loan repayment programs;
to the extent that it can be determined, the reason for the default;
the demographics of the individuals participating in the scholarship and loan repayment programs;
the justification for the allocation of funds between the scholarship and loan repayment programs; and
an evaluation of the overall costs and benefits of the programs.
Authorization of appropriations
To carry out sections 340I, 340J, and 340K there are authorized to be appropriated $55,000,000 for fiscal year 2010, $90,000,000 for fiscal year 2011, and $125,000,000 for fiscal year 2012, to be used solely for scholarships and loan repayment awards for primary care physicians and primary care providers.
.
Deferment of loans during residency and internships
Loan requirements
Section 427(a)(2)(C)(i) of the Higher Education Act
of 1965 (20 U.S.C. 1077(a)(2)(C)(i)) is amended by inserting unless the
medical internship or residency program is in a primary care field (as defined
in section 3(a)(5) of the Preserving Patient Access to Primary Care Act of
2009)
after residency program
.
FFEL loans
Section 428(b)(1)(M)(i)
of the Higher Education Act of 1965 (20 U.S.C. 1078(b)(1)(M)(i)) is amended by
inserting unless the medical internship or residency program is in a
primary care field (as defined in section 3(a)(5) of the Preserving Patient
Access to Primary Care Act of 2009)
after residency
program
.
Federal Direct Loans
Section 455(f)(2)(A) of
the Higher Education Act of 1965 (20 U.S.C. 1087e(f)(2)(A)) is amended by
inserting unless the medical internship or residency program is in a
primary care field (as defined in section 3(a)(5) of the Preserving Patient
Access to Primary Care Act of 2009)
after residency
program
.
Federal Perkins Loans
Section 464(c)(2)(A)(i) of the Higher Education Act of 1965
(20 U.S.C. 1087dd(c)(2)(A)(i)) is amended by inserting unless the
medical internship or residency program is in a primary care field (as defined
in section 3(a)(5) of the Preserving Patient Access to Primary Care Act of
2009)
after residency program
.
Educating medical students about primary care careers
Part C of title VII of the Public Health Service Act (42 U.S.C. 293k) is amended by adding at the end the following:
Educating Medical Students about Primary Care Careers
In general
The Secretary shall award grants to eligible State and local government entities for the development of informational materials that promote careers in primary care by highlighting the advantages and rewards of primary care, and that encourage medical students, particularly students from disadvantaged backgrounds, to become primary care physicians.
Announcement
The grants described in subsection (a) shall be announced through a publication in the Federal Register and through appropriate media outlets in a manner intended to reach medical education institutions, associations, physician groups, and others who communicate with medical students.
Eligibility
To be eligible to receive a grant under this section an entity shall—
be a State or local entity; and
submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.
Use of funds
In general
An entity shall use amounts received under a grant under this section to support State and local campaigns through appropriate media outlets to promote careers in primary care and to encourage individuals from disadvantaged backgrounds to enter and pursue careers in primary care.
Specific uses
In carrying out activities under paragraph (1), an entity shall use grants funds to develop informational materials in a manner intended to reach as wide and diverse an audience of medical students as possible, in order to—
advertise and promote careers in primary care;
promote primary care medical education programs;
inform the public of financial assistance regarding such education programs;
highlight individuals in the community who are practicing primary care physicians; or
provide any other information to recruit individuals for careers in primary care.
Limitation
An entity shall not use amounts received under a grant under this section to advertise particular employment opportunities.
Authorization of appropriations
There is authorized to be appropriated to carry out this section, such sums as may be necessary for each of fiscal years 2010 through 2013.
.
Training in family medicine, general internal medicine, general geriatrics, general pediatrics, physician assistant education, general dentistry, and pediatric dentistry
Section 747(e) of the Public Health Service Act (42 U.S.C. 293k) is amended by striking paragraph (1) and inserting the following:
Authorization of appropriations
For the purpose of carrying out this section, there is authorized to be appropriated $198,000,000 for each of fiscal years 2010 through 2012.
.
Increased funding for National Health Service Corps Scholarship and loan repayment programs
In general
There is authorized to be appropriated $332,000,000 for the period of fiscal years 2010 through 2012 for the purpose of carrying out subpart III of part D of title III of the Public Health Service Act (42 U.S.C. 254l et seq.). Such authorization of appropriations is in addition to the authorization of appropriations in section 338H of such Act (42 U.S.C. 254q) and any other authorization of appropriations for such purpose.
Allocation
Of the amounts appropriated under subsection (a) for the period of fiscal years 2010 through 2012, the Secretary shall obligate $96,000,000 for the purpose of providing contracts for scholarships and loan repayments to individuals who—
are primary care physicians or primary care providers; and
have not previously received a scholarship or loan repayment under subpart III of part D of title III of the Public Health Service Act (42 U.S.C. 254l et seq.).
Medicaid Related Provisions
Transformation grants to support patient-centered medical homes under Medicaid and CHIP
In general
Section 1903(z) of the Social Security Act (42 U.S.C. 1396b(z)) is amended—
in paragraph (2), by adding at the end the following new subparagraph:
Methods for improving the effectiveness and efficiency of medical assistance provided under this title and child health assistance provided under title XXI by encouraging the adoption of medical practices that satisfy the standards established by the Secretary under paragraph (2) of section 3(d) of the Preserving Patient Access to Primary Care Act of 2009 for medical practices to qualify as patient-centered medical homes (as defined in paragraph (1) of such section).
; and
in paragraph (4)—
in subparagraph (A)—
in
clause (i), by striking and
at the end;
in
clause (ii), by striking the period at the end and inserting ;
and
; and
by inserting after clause (ii), the following new clause:
$25,000,000 for each of fiscal years 2010, 2011, and 2012.
; and
in subparagraph
(B), by striking the second and third sentences and inserting the following:
Such method shall provide that 100 percent of such funds for each of
fiscal years 2010, 2011, and 2012 shall be allocated among States that design
programs to adopt the innovative methods described in paragraph (2)(G), with
preference given to States that design programs involving multipayers
(including under title XVIII and private health plans) test projects for
implementation of the elements necessary to be recognized as a patient-centered
medical home practice under the National Committee for Quality Assurance
Physicians Practice Connection—PCMH module (or any other equivalent process, as
determined by the Secretary).
.
Effective date
The amendments made by this section take effect on October 1, 2010.
Medicare Provisions
Primary Care
Reforming payment systems under Medicare to support primary care
Increasing budget neutrality limits under the physician fee schedule To account for anticipated savings resulting from payments for certain services and the coordination of beneficiary care
Section 1848(c)(2)(B) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)(B)) is amended—
in clause
(ii)(II), by striking (iv) and (v)
and inserting (iv),
(v), and (vii)
; and
by adding at the end the following new clause:
Increase in limitation to account for certain anticipated savings
In general
Effective for fee schedules established beginning with 2010, the Secretary shall increase the limitation on annual adjustments under clause (ii)(II) by an amount equal to the anticipated savings under parts A, B, and D (including any savings with respect to items and services for which payment is not made under this section) which are a result of payments for designated primary care services and comprehensive care coordination services under section 1834(m) and the coverage of patient-centered medical home services under section 1861(s)(2)(FF) (as determined by the Secretary).
Mechanism to determine application of increase
The Secretary shall establish a mechanism for determining which relative value units established under this paragraph for physicians' services shall be subject to an adjustment under clause (ii)(I) as a result of the increase under subclause (I).
Additional funding as determined necessary by the secretary
In addition to any funding that may be made available as a result of an increase in the limitation on annual adjustments under subclause (I), there shall also be available to the Secretary, for purposes of making payments under this title for new services and capabilities to improve care provided to individuals under this title and to generate efficiencies under this title, such additional funds as the Secretary determines are necessary.
.
Separate medicare payment for designated primary care services and comprehensive care coordination services
In general
Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:
Payment for designated primary care services and comprehensive care coordination services
In general
The Secretary shall pay for designated primary care services and comprehensive care coordination services furnished to an individual enrolled under this part.
Payment amount
The Secretary shall determine the amount of payment for designated primary care services and comprehensive care coordination services under this subsection.
Documentation requirements
The Secretary shall propose appropriate documentation requirements to justify payments for designated primary care services and comprehensive care coordination services under this subsection.
Definitions
Comprehensive care coordination services
The term comprehensive care coordination services means care coordination services with procedure codes established by the Secretary (as appropriate) which are furnished to an individual enrolled under this part by a primary care provider or principal care physician.
Designated primary care services
The term designated primary care service means a service which the Secretary determines has a procedure code which involves a clinical interaction with an individual enrolled under this part that is inherent to care coordination, including interactions outside of a face-to-face encounter. Such term includes the following:
Care plan oversight.
Evaluation and management provided by phone.
Evaluation and management provided using internet resources.
Collection and review of physiologic data, such as from a remote monitoring device.
Education and training for patient self management.
Anticoagulation management services.
Any other service determined appropriate by the Secretary.
.
Effective date
The amendment made by this section shall apply to items and services furnished on or after January 1, 2010.
Coverage of patient-centered medical home services
In general
Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended—
in subparagraph
(DD), by striking and
at the end;
in subparagraph
(EE), by inserting and
at the end; and
by adding at the end the following new subparagraph:
patient-centered medical home services (as defined in subsection (hhh)(1));
.
Definition of patient-centered medical home services
Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:
Patient-centered medical home services
The term patient-centered medical home services means care coordination services furnished by a qualified patient-centered medical home.
The term qualified patient-centered medical home means a patient-centered medical home (as defined in section 3(d) of the Preserving Patient Access to Primary Care Act of 2009).
.
Monthly fee for patient-centered medical home services
Section 1848 of the Social Security Act (42 U.S.C. 1395w–4) is amended by adding at the end the following new subsection:
Monthly fee for patient-centered medical home services
Monthly fee
In general
Not later than January 1, 2012, the Secretary shall establish a payment methodology for patient-centered medical home services (as defined in paragraph (1) of section 1861(hhh)). Under such payment methodology, the Secretary shall pay qualified patient-centered medical homes (as defined in paragraph (2) of such section) a monthly fee for each individual who elects to receive patient-centered medical home services at that medical home. Such fee shall be paid on a prospective basis.
Considerations
The Secretary shall take into account the results of the Medicare medical home demonstration project under section 204 of the Medicare Improvement and Extension Act of 2006 (42 U.S.C. 1395b–1 note; division B of Public Law 109–432) in establishing the payment methodology under subparagraph (A).
Amount of payment
Considerations
In determining the amount of such fee, subject to paragraph (3), the Secretary shall consider the following:
The clinical work and practice expenses involved in providing care coordination services consistent with the patient-centered medical home model (such as providing increased access, care coordination, disease population management, and education) for which payment is not made under this section as of the date of enactment of this subsection.
Ensuring that the amount of payment is sufficient to support the acquisition, use, and maintenance of clinical information systems which—
are needed by a qualified patient-centered medical home; and
have been shown to facilitate improved outcomes through care coordination.
The establishment of a tiered monthly care management fee that provides for a range of payment depending on how advanced the capabilities of a qualified patient-centered medical home are in having the information systems needed to support care coordination.
Risk-adjustment
The Secretary shall use appropriate risk-adjustment in determining the amount of the monthly fee under this paragraph.
Funding
In general
The Secretary shall determine the aggregate estimated savings for a calendar year as a result of the implementation of this subsection on reducing preventable hospital admissions, duplicate testing, medication errors and drug interactions, and other savings under this part and part A (including any savings with respect to items and services for which payment is not made under this section).
Funding
Subject to subparagraph (C), the aggregate amount available for payment of the monthly fee under this subsection during a calendar year shall be equal to the aggregate estimated savings (as determined under subparagraph (A)) for the calendar year (as determined by the Secretary).
Additional funding
In the case where the amount of the aggregate actual savings during the preceding 3 years exceeds the amount of the aggregate estimated savings (as determined under subparagraph (A)) during such period, the aggregate amount available for payment of the monthly fee under this subsection during the calendar year (as determined under subparagraph (B)) shall be increased by the amount of such excess.
Additional funding as determined necessary by the secretary
In addition to any funding made available under subparagraphs (B) and (C), there shall also be available to the Secretary, for purposes of effectively implementing this subsection, such additional funds as the Secretary determines are necessary.
Performance-based bonus payments
The Secretary shall establish a process for paying a performance-based bonus to qualified patient-centered medical homes which meet or achieve substantial improvements in performance (as specified under clinical, patient satisfaction, and efficiency benchmarks established by the Secretary). Such bonus shall be in an amount determined appropriate by the Secretary.
No effect on payments for evaluation and management services
The monthly fee under this subsection shall have no effect on the amount of payment for evaluation and management services under this title.
.
Coinsurance
Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended—
by striking
and
before (W)
; and
by inserting
before the semicolon at the end the following: , and (X) with respect to
patient-centered medical home services (as defined in section 1861(hhh)(1)),
the amount paid shall be (i) in the case of such services which are physicians'
services, the amount determined under subparagraph (N), and (ii) in the case of
all other such services, 80 percent of the lesser of the actual charge for the
service or the amount determined under a fee schedule established by the
Secretary for purposes of this subparagraph
.
Effective date
The amendments made by this section shall apply to services furnished on or after January 1, 2012.
Medicare primary care payment equity and access provision
In general
Section 1848 of the Social Security Act (42 U.S.C. 1395w–4), as amended by section 2302(c), is amended by adding at the end the following new subsection:
Primary care payment equity and access
In general
Not later than January 1, 2010, the Secretary shall develop a methodology, in consultation with primary care physician organizations and primary care provider organizations, the Medicare Payment Advisory Commission, and other experts, to increase payments under this section for designated evaluation and management services provided by primary care physicians, primary care providers, and principal care providers through 1 or more of the following:
A service-specific modifier to the relative value units established for such services.
Service-specific bonus payments.
Any other methodology determined appropriate by the Secretary.
Inclusion of proposed criteria
The methodology developed under paragraph (1) shall include proposed criteria for providers to qualify for such increased payments, including consideration of—
the type of service being rendered;
the specialty of the provider providing the service; and
demonstration by the provider of voluntary participation in programs to improve quality, such as participation in the Physician Quality Reporting Initiative (as determined by the Secretary) or practice-level qualification as a patient-centered medical home.
Funding
Determination
The Secretary shall determine the aggregate estimated savings for a calendar year as a result of such increased payments on reducing preventable hospital admissions, duplicate testing, medication errors and drug interactions, Intensive Care Unit admissions, per capita health care expenditures, and other savings under this part and part A (including any savings with respect to items and services for which payment is not made under this section).
Funding
The aggregate amount available for such increased payments during a calendar year shall be equal to the aggregate estimated savings (as determined under subparagraph (A)) for the calendar year (as determined by the Secretary).
Additional funding as determined necessary by the secretary
In addition to any funding made available under subparagraph (B), there shall also be available to the Secretary, for purposes of effectively implementing this subsection, such additional funds as the Secretary determines are necessary.
.
Effective date
The amendment made by this section shall apply to services furnished on or after January 1, 2010.
Additional incentive payment program for primary care services furnished in health professional shortage areas
In general
Section 1833 of the Social Security Act (42 U.S.C. 1395l) is amended by adding at the end the following new subsection:
Additional incentive payments for primary care services furnished in health professional shortage areas
In general
In the case of primary care services furnished on or after January 1, 2010, by a primary care physician or primary care provider in an area that is designated (under section 332(a)(1)(A) of the Public Health Service Act) as a health professional shortage area as identified by the Secretary prior to the beginning of the year involved, in addition to the amount of payment that would otherwise be made for such services under this part, there also shall be paid (on a monthly or quarterly basis) an amount equal to 10 percent of the payment amount for the service under this part.
Definitions
In this subsection:
Primary care physician; primary care provider
The terms primary care physician and primary care provider have the meaning given such terms in paragraphs (6) and (7), respectively, of section 3(a) of the Preserving Patient Access to Primary Care Act of 2009.
Primary care services
The term primary care services means procedure codes for services in the category of the Healthcare Common Procedure Coding System, as established by the Secretary under section 1848(c)(5) (as of December 31, 2008, and as subsequently modified by the Secretary) consisting of evaluation and management services, but limited to such procedure codes in the category of office or other outpatient services, and consisting of subcategories of such procedure codes for services for both new and established patients.
Judicial review
There shall be no administrative or judicial review under section 1869, 1878, or otherwise, respecting the identification of primary care physicians, primary care providers, or primary care services under this subsection.
.
Conforming amendment
Section 1834(g)(2)(B) of the Social Security Act (42
U.S.C. 1395m(g)(2)(B)) is amended by adding at the end the following sentence:
Section 1833(x) shall not be taken into account in determining the
amounts that would otherwise be paid pursuant to the preceding
sentence.
.
Permanent extension of Medicare incentive payment program for physician scarcity areas
Section 1833(u) of the Social Security Act (42 U.S.C. 1395l(u)) is amended—
in paragraph (1)—
by inserting or on or after July 1,
2009
after before July 1, 2008
; and
by inserting
(or, in the case of services furnished on or after July 1, 2009, 10
percent)
after 5 percent
; and
in paragraph
(4)(D), by striking before July 1, 2008
and inserting
before January 1, 2010
.
HHS study and report on the process for determining relative value under the Medicare physician fee schedule
Study
The Secretary shall conduct a study on the process used by the Secretary for determining relative value under the Medicare physician fee schedule under section 1848(c) of the Social Security Act (42 U.S.C. 1395w–4(c)). Such study shall include an analysis of the following:
Whether the existing process includes equitable representation of primary care physicians (as defined in section 2003(a)(6)); and
any changes that may be necessary to ensure such equitable representation.
Whether the existing process provides the Secretary with expert and impartial input from physicians in medical specialties that provide primary care to patients with multiple chronic diseases, the fastest growing part of the Medicare population; and
any changes that may be necessary to ensure such input.
Whether the existing process includes equitable representation of physician medical specialties in proportion to their relative contributions toward caring for Medicare beneficiaries, as determined by the percentage of Medicare billings per specialty, percentage of Medicare encounters by specialty, or such other measures of relative contributions to patient care as determined by the Secretary; and
any changes that may be necessary to reflect such equitable representation.
Whether the existing process, including the application of budget neutrality rules, unfairly disadvantages primary care physicians, primary care providers, or other physicians who principally provide evaluation and management services; and
any changes that may be necessary to eliminate such disadvantages.
Report
Not later than 12 months after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.
Preventive services
Eliminating time restriction for initial preventive physical examination
In general
Section 1862(a)(1)(K)
of the Social Security Act (42 U.S.C. 1395y(a)(1)(K)) is amended by striking
more than
and all that follows before the comma at the end and
inserting more than one time during the lifetime of the
individual
.
Effective date
The amendments made by this section shall apply to services furnished on or after January 1, 2010.
Elimination of cost-sharing for preventive benefits under the Medicare program
Definition of preventive services
Section 1861(ddd) of the Social Security Act (42 U.S.C. 1395w(dd)) is amended—
in the heading, by
inserting ; preventive
services
after services
;
in paragraph (1),
by striking not otherwise described in this title
and inserting
not described in subparagraphs (A) through (N) of paragraph (3)
;
and
by adding at the end the following new paragraph:
The term preventive services means the following:
Prostate cancer screening tests (as defined in subsection (oo)).
Colorectal cancer screening tests (as defined in subsection (pp)).
Diabetes outpatient self-management training services (as defined in subsection (qq)).
Screening for glaucoma for certain individuals (as described in subsection (s)(2)(U)).
Medical nutrition therapy services for certain individuals (as described in subsection (s)(2)(V)).
An initial preventive physical examination (as defined in subsection (ww)).
Cardiovascular screening blood tests (as defined in subsection (xx)(1)).
Diabetes screening tests (as defined in subsection (yy)).
Ultrasound screening for abdominal aortic aneurysm for certain individuals (as described in subsection (s)(2)(AA)).
Pneumococcal and influenza vaccine and their administration (as described in subsection (s)(10)(A)).
Hepatitis B vaccine and its administration for certain individuals (as described in subsection (s)(10)(B)).
Screening mammography (as defined in subsection (jj)).
Screening pap smear and screening pelvic exam (as described in subsection (s)(14)).
Bone mass measurement (as defined in subsection (rr)).
Additional preventive services (as determined under paragraph (1)).
.
Coinsurance
General application
In general
Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), as amended by section 2302, is amended—
in
subparagraph (T), by striking 80 percent
and inserting
100 percent
;
in
subparagraph (W), by striking 80 percent
and inserting
100 percent
;
by
striking and
before (X)
; and
by inserting
before the semicolon at the end the following: , and (Y) with respect to
preventive services described in subparagraphs (A) through (O) of section
1861(ddd)(3), the amount paid shall be 100 percent of the lesser of the actual
charge for the services or the amount determined under the fee schedule that
applies to such services under this part
.
Elimination of coinsurance for screening sigmoidoscopies and colonoscopies
Section 1834(d) of the Social Security Act (42 U.S.C. 1395m(d)) is amended—
in paragraph (2)—
in
subparagraph (A), by inserting , except that payment for such tests
under such section shall be 100 percent of the payment determined under such
section for such tests
before the period at the end; and
in subparagraph (C)—
by striking clause (ii); and
in clause (i)—
by
striking (i) In
general.—Notwithstanding
and inserting
Notwithstanding
;
by redesignating subclauses (I) and (II) as clauses (i) and (ii), respectively, and moving such clauses 2 ems to the left; and
in
the flush matter following clause (ii), as so redesignated, by inserting
100 percent of
after based on
; and
in paragraph (3)—
in
subparagraph (A), by inserting , except that payment for such tests
under such section shall be 100 percent of the payment determined under such
section for such tests
before the period at the end; and
in subparagraph (C)—
by striking clause (ii); and
in clause (i)—
by
striking (i) In
general.—Notwithstanding
and inserting
Notwithstanding
; and
by
inserting 100 percent of
after based on
.
Elimination of coinsurance in outpatient hospital settings
Exclusion from OPD fee schedule
Section 1833(t)(1)(B)(iv) of the Social Security
Act (42 U.S.C. 1395l(t)(1)(B)(iv)) is amended by striking and diagnostic
mammography
and inserting , diagnostic mammography, and
preventive services (as defined in section 1861(ddd)(3))
.
Conforming amendments
Section 1833(a)(2) of the Social Security Act (42 U.S.C. 1395l(a)(2)) is amended—
in
subparagraph (F), by striking and
after the semicolon at the
end;
in
subparagraph (G)(ii), by adding and
at the end; and
by adding at the end the following new subparagraph:
with respect to preventive services (as defined in section 1861(ddd)(3)) furnished by an outpatient department of a hospital, the amount determined under paragraph (1)(W) or (1)(X), as applicable;
.
Waiver of application of deductible
The first sentence of section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)) is amended—
in clause (1), by
striking items and services described in section 1861(s)(10)(A)
and inserting preventive services (as defined in section
1861(ddd)(3))
;
by inserting
and
before (4)
; and
by striking
, (5)
and all that follows up to the period at the end.
HHS study and report on facilitating the receipt of Medicare preventive services by Medicare beneficiaries
Study
The Secretary, in consultation with provider organizations and other appropriate stakeholders, shall conduct a study on—
ways to assist primary care physicians and primary care providers (as defined in section 2003(a)) in—
furnishing appropriate preventive services (as defined in section 1861(ddd)(3) of the Social Security Act, as added by section 2312) to individuals enrolled under part B of title XVIII of such Act; and
referring such individuals for other items and services furnished by other physicians and health care providers; and
the advisability and feasability of making additional payments under the Medicare program to physicians and primary care providers for—
the work involved in ensuring that such individuals receive appropriate preventive services furnished by other physicians and health care providers; and
incorporating the resulting clinical information into the treatment plan for the individual.
Report
Not later than 12 months after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.
Other provisions
HHS study and report on improving the ability of physicians and primary care providers to assist Medicare beneficiaries in obtaining needed prescriptions under Medicare part D
Study
The Secretary, in consultation with physician organizations and other appropriate stakeholders, shall conduct a study on the development and implementation of mechanisms to facilitate increased efficiency relating to the role of physicians and primary care providers in Medicare beneficiaries obtaining needed prescription drugs under the Medicare prescription drug program under part D of title XVIII of the Social Security Act. Such study shall include an analysis of ways to—
improve the accessibility of formulary information;
streamline the prior authorization, exception, and appeals processes, through, at a minimum, standardizing formats and allowing electronic exchange of information; and
recognize the work of the physician and primary care provider involved in the prescribing process, especially work that may extend beyond the amount considered to be bundled into payment for evaluation and management services.
Report
Not later than 12 months after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.
HHS study and report on improved patient care through increased caregiver and physician interaction
Study
The Secretary, in consultation with appropriate stakeholders, shall conduct a study on the development and implementation of mechanisms to promote and increase interaction between physicians or primary care providers and the families of Medicare beneficiaries, as well as other caregivers who support such beneficiaries, for the purpose of improving patient care under the Medicare program. Such study shall include an analysis of—
ways to recognize the work of physicians and primary care providers involved in discussing clinical issues with caregivers that relate to the care of the beneficiary; and
regulations under the Medicare program that are barriers to interactions between caregivers and physicians or primary care providers and how such regulations should be revised to eliminate such barriers.
Report
Not later than 12 months after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.
Improved patient care through expanded support for limited English proficiency (LEP) services
Additional payments for primary care physicians and primary care providers
Section 1833 of the Social Security Act (42 U.S.C. 1395l), as amended by section 2304, is amended by adding at the end the following new subsection:
Additional payments for providing services to individuals with limited English proficiency
In general
In the case of primary care providers’ services furnished on or after January 1, 2010, to an individual with limited English proficiency by a provider, in addition to the amount of payment that would otherwise be made for such services under this part, there shall also be paid an appropriate amount (as determined by the Secretary) in order to recognize the additional time involved in furnishing the service to such individual.
Judicial review
There shall be no administrative or judicial review under section 1869, 1878, or otherwise, respecting the determination of the amount of additional payment under this subsection.
.
National clearinghouse
Not later than 180 days after the date of enactment of this Act, the Secretary shall establish a national clearinghouse to make available to the primary care physicians, primary care providers, patients, and States translated documents regarding patient care and education under the Medicare program, the Medicaid program, and the State Children's Health Insurance Program under titles XVIII, XIX, and XXI, respectively, of the Social Security Act.
Grants To support language translation services in underserved communities
Authority to award grants
The Secretary shall award grants to support language translation services for primary care physicians and primary care providers in medically underserved areas (as defined in section 2003(c)).
Authorization of appropriations
There are authorized to be appropriated to the Secretary to award grants under this subsection, such sums as are necessary for fiscal years beginning with fiscal year 2010.
HHS study and report on use of real-time Medicare claims adjudication
Study
The Secretary shall conduct a study to assess the ability of the Medicare program under title XVIII of the Social Security Act to engage in real-time claims adjudication for items and services furnished to Medicare beneficiaries.
Consultation
In conducting the study under subsection (a), the Secretary consult with stakeholders in the private sector, including stakeholders who are using or are testing real-time claims adjudication systems.
Report
Not later than January 1, 2011, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.
Ongoing assessment by MedPAC of the impact of Medicare payments on primary care access and equity
The Medicare Payment Advisory Commission, beginning in 2010 and in each of its subsequent annual reports to Congress on Medicare physician payment policies, shall provide an assessment of the impact of changes in Medicare payment policies in improving access to and equity of payments to primary care physicians and primary care providers. Such assessment shall include an assessment of the effectiveness, once implemented, of the Medicare payment-related reforms required by this Act to support primary care as well as any other payment changes that may be required by Congress to improve access to and equity of payments to primary care physicians and primary care providers.
Distribution of additional residency positions
In general
Section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)) is amended—
in paragraph
(4)(F)(i), by striking paragraph (7)
and inserting
paragraphs (7) and (8)
;
in paragraph
(4)(H)(i), by striking paragraph (7)
and inserting
paragraphs (7) and (8)
; and
by adding at the end the following new paragraph:
Distribution of additional residency positions
Additional residency positions
Reduction in limit based on unused positions
In general
The Secretary shall reduce the otherwise applicable resident limit for a hospital that the Secretary determines had residency positions that were unused for all 5 of the most recent cost reporting periods ending prior to the date of enactment of this paragraph by an amount that is equal to the number of such unused residency positions.
Exception for rural hospitals and certain other hospitals
This subparagraph shall not apply to a hospital—
located in a rural area (as defined in subsection (d)(2)(D)(ii));
that has participated in a voluntary reduction plan under paragraph (6); or
that has participated in a demonstration project approved as of October 31, 2003, under the authority of section 402 of Public Law 90–248.
Number available for distribution
The number of additional residency positions available for distribution under subparagraph (B) shall be an amount that the Secretary determines would result in a 15 percent increase in the aggregate number of full-time equivalent residents in approved medical training programs (as determined based on the most recent cost reports available at the time of distribution). One-third of such number shall only be available for distribution to hospitals described in subclause (I) of subparagraph (B)(ii) under such subparagraph.
Distribution
In general
The Secretary shall increase the otherwise applicable resident limit for each qualifying hospital that submits an application under this subparagraph by such number as the Secretary may approve for portions of cost reporting periods occurring on or after the date of enactment of this paragraph. The aggregate number of increases in the otherwise applicable resident limit under this subparagraph shall be equal to the number of additional residency positions available for distribution under subparagraph (A)(ii).
Distribution to hospitals already operating over resident limit
In general
Subject to subclause (II), in the case of a hospital in which the reference resident level of the hospital (as defined in clause (ii)) is greater than the otherwise applicable resident limit, the increase in the otherwise applicable resident limit under this subparagraph shall be an amount equal to the product of the total number of additional residency positions available for distribution under subparagraph (A)(ii) and the quotient of—
the number of resident positions by which the reference resident level of the hospital exceeds the otherwise applicable resident limit for the hospital; and
the number of resident positions by which the reference resident level of all such hospitals with respect to which an application is approved under this subparagraph exceeds the otherwise applicable resident limit for such hospitals.
Requirements
A hospital described in subclause (I)—
is not eligible for an increase in the otherwise applicable resident limit under this subparagraph unless the amount by which the reference resident level of the hospital exceeds the otherwise applicable resident limit is not less than 10 and the hospital trains at least 25 percent of the full-time equivalent residents of the hospital in primary care and general surgery (as of the date of enactment of this paragraph); and
shall continue to train at least 25 percent of the full-time equivalent residents of the hospital in primary care and general surgery for the 10-year period beginning on such date.
Clarification regarding eligibility for other additional residency positions
Nothing in this clause shall be construed as preventing a hospital described in subclause (I) from applying for additional residency positions under this paragraph that are not reserved for distribution under this clause.
Reference resident level
In general
Except as otherwise provided in subclause (II), the reference resident level specified in this clause for a hospital is the resident level for the most recent cost reporting period of the hospital ending on or before the date of enactment of this paragraph, for which a cost report has been settled (or, if not, submitted (subject to audit)), as determined by the Secretary.
Use of most recent accounting period to recognize expansion of existing program or establishment of new program
If a hospital submits a timely request to increase its resident level due to an expansion of an existing residency training program or the establishment of a new residency training program that is not reflected on the most recent cost report that has been settled (or, if not, submitted (subject to audit)), after audit and subject to the discretion of the Secretary, the reference resident level for such hospital is the resident level for the cost reporting period that includes the additional residents attributable to such expansion or establishment, as determined by the Secretary.
Considerations in redistribution
In determining for which hospitals the increase in the otherwise applicable resident limit is provided under subparagraph (B) (other than an increase under subparagraph (B)(ii)), the Secretary shall take into account the demonstrated likelihood of the hospital filling the positions within the first 3 cost reporting periods beginning on or after July 1, 2010, made available under this paragraph, as determined by the Secretary.
Priority for certain areas
In determining for which hospitals the increase in the otherwise applicable resident limit is provided under subparagraph (B) (other than an increase under subparagraph (B)(ii)), the Secretary shall distribute the increase to hospitals based on the following criteria:
The Secretary shall give preference to hospitals that submit applications for new primary care and general surgery residency positions. In the case of any increase based on such preference, a hospital shall ensure that—
the position made available as a result of such increase remains a primary care or general surgery residency position for not less than 10 years after the date on which the position is filled; and
the total number of primary care and general surgery residency positions in the hospital (determined based on the number of such positions as of the date of such increase, including any position added as a result of such increase) is not decreased during such 10-year period.
The Secretary shall give preference to hospitals that emphasizes training in community health centers and other community-based clinical settings.
The Secretary shall give preference to hospitals in States that have more medical students than residency positions available (including a greater preference for those States with smaller resident-to-medical-student ratios). In determining the number of medical students in a State for purposes of the preceding sentence, the Secretary shall include planned students at medical schools which have provisional accreditation by the Liaison Committee on Medical Education or the American Osteopathic Association.
The Secretary shall give preference to hospitals in States that have low resident-to-population ratios (including a greater preference for those States with lower resident-to-population ratios).
Limitation
In general
Except as provided in clause (ii), in no case may a hospital (other than a hospital described in subparagraph (B)(ii)(I), subject to the limitation under subparagraph (B)(ii)(III)) apply for more than 50 full-time equivalent additional residency positions under this paragraph.
Increase in number of additional positions available for distribution
The Secretary shall increase the number of full-time equivalent additional residency positions a hospital may apply for under this paragraph if the Secretary determines that the number of additional residency positions available for distribution under subparagraph (A)(ii) exceeds the number of such applications approved.
Application of per resident amounts for primary care and nonprimary care
With respect to additional residency positions in a hospital attributable to the increase provided under this paragraph, the approved FTE resident amounts are deemed to be equal to the hospital per resident amounts for primary care and nonprimary care computed under paragraph (2)(D) for that hospital.
Distribution
The Secretary shall distribute the increase to hospitals under this paragraph not later than 2 years after the date of enactment of this paragraph.
.
IME
In general
Section 1886(d)(5)(B)(v) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence, is amended—
by striking
subsection (h)(7)
and inserting subsections (h)(7) and
(h)(8)
; and
by striking
it applies
and inserting they apply
.
Conforming provision
Section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end the following clause:
For discharges occurring on or after the date of enactment of this clause, insofar as an additional payment amount under this subparagraph is attributable to resident positions distributed to a hospital under subsection (h)(8)(B), the indirect teaching adjustment factor shall be computed in the same manner as provided under clause (ii) with respect to such resident positions.
.
Counting resident time in outpatient settings
D–GME
Section 1886(h)(4)(E) of the Social Security Act (42 U.S.C. 1395ww(h)(4)(E)) is amended—
by striking
under an approved medical residency training program
; and
by striking
if the hospital incurs all, or substantially all, of the costs for the
training program in that setting
and inserting if the hospital
continues to incur the costs of the stipends and fringe benefits of the
resident during the time the resident spends in that setting
.
IME
Section 1886(d)(5)(B)(iv) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amended—
by striking
under an approved medical residency training program
; and
by striking
if the hospital incurs all, or substantially all, of the costs for the
training program in that setting
and inserting if the hospital
continues to incur the costs of the stipends and fringe benefits of the intern
or resident during the time the intern or resident spends in that
setting
.
Effective dates; application
In general
Effective for cost reporting periods beginning on or after July 1, 2009, the Secretary of Health and Human Services shall implement the amendments made by this section in a manner so as to apply to cost reporting periods beginning on or after July 1, 2009.
Application
The amendments made by this section shall not be applied in a manner that requires reopening of any settled hospital cost reports as to which there is not a jurisdictionally proper appeal pending as of the date of the enactment of this Act on the issue of payment for indirect costs of medical education under section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct graduate medical education costs under section 1886(h) of such Act (42 U.S.C. 1395ww(h)).
Rules for counting resident time for didactic and scholarly activities and other activities
GME
Section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)), as amended by section 2327(a), is amended—
in paragraph (4)(E)—
by designating the
first sentence as a clause (i) with the heading In general
and appropriate
indentation and by striking Such rules
and inserting
Subject to clause (ii), such rules
; and
by adding at the end the following new clause:
Treatment of certain nonhospital and didactic activities
Such rules shall provide that all time spent by an intern or resident in an approved medical residency training program in a nonhospital setting that is primarily engaged in furnishing patient care (as defined in paragraph (5)(K)) in non-patient care activities, such as didactic conferences and seminars, but not including research not associated with the treatment or diagnosis of a particular patient, as such time and activities are defined by the Secretary, shall be counted toward the determination of full-time equivalency.
;
in paragraph (4), by adding at the end the following new subparagraph:
In determining the hospital’s number of full-time equivalent residents for purposes of this subsection, all the time that is spent by an intern or resident in an approved medical residency training program on vacation, sick leave, or other approved leave, as such time is defined by the Secretary, and that does not prolong the total time the resident is participating in the approved program beyond the normal duration of the program shall be counted toward the determination of full-time equivalency.
; and
in paragraph (5), by adding at the end the following new subparagraph:
Nonhospital setting that is primarily engaged in furnishing patient care
The term nonhospital setting that is primarily engaged in furnishing patient care means a nonhospital setting in which the primary activity is the care and treatment of patients, as defined by the Secretary.
.
IME determinations
Section 1886(d)(5)(B) of such Act (42 U.S.C. 1395ww(d)(5)(B)), as amended by section 2326(b), is amended by adding at the end the following new clause:
The provisions of subparagraph (I) of subsection (h)(4) shall apply under this subparagraph in the same manner as they apply under such subsection.
In determining the hospital’s number of full-time equivalent residents for purposes of this subparagraph, all the time spent by an intern or resident in an approved medical residency training program in non-patient care activities, such as didactic conferences and seminars, as such time and activities are defined by the Secretary, that occurs in the hospital shall be counted toward the determination of full-time equivalency if the hospital—
is recognized as a subsection (d) hospital;
is recognized as a subsection (d) Puerto Rico hospital;
is reimbursed under a reimbursement system authorized under section 1814(b)(3); or
is a provider-based hospital outpatient department.
In determining the hospital’s number of full-time equivalent residents for purposes of this subparagraph, all the time spent by an intern or resident in an approved medical residency training program in research activities that are not associated with the treatment or diagnosis of a particular patient, as such time and activities are defined by the Secretary, shall not be counted toward the determination of full-time equivalency.
.
Effective dates; application
In general
Except as otherwise provided, the Secretary of Health and Human Services shall implement the amendments made by this section in a manner so as to apply to cost reporting periods beginning on or after January 1, 1983.
Direct GME
Section 1886(h)(4)(E)(ii) of the Social Security Act, as added by subsection (a)(1)(B), shall apply to cost reporting periods beginning on or after July 1, 2009.
IME
Section 1886(d)(5)(B)(xi)(III) of the Social Security Act, as added by subsection (b), shall apply to cost reporting periods beginning on or after October 1, 2001. Such section, as so added, shall not give rise to any inference on how the law in effect prior to such date should be interpreted.
Application
The amendments made by this section shall not be applied in a manner that requires reopening of any settled hospital cost reports as to which there is not a jurisdictionally proper appeal pending as of the date of the enactment of this Act on the issue of payment for indirect costs of medical education under section 1886(d)(5)(B) of the Social Security Act or for direct graduate medical education costs under section 1886(h) of such Act.
Preservation of resident cap positions from closed and acquired hospitals
GME
Section 1886(h)(4)(H) of the Social Security Act (42 U.S.C. 1395ww(h)(4)(H)) is amended by adding at the end the following new clauses:
Redistribution of residency slots after a hospital closes
In general
Subject to the succeeding provisions of this clause, the Secretary shall, by regulation, establish a process under which, in the case where a hospital with an approved medical residency program closes on or after the date of enactment of the Balanced Budget Act of 1997, the Secretary shall increase the otherwise applicable resident limit under this paragraph for other hospitals in accordance with this clause.
Priority for hospitals in certain areas
Subject to the succeeding provisions of this clause, in determining for which hospitals the increase in the otherwise applicable resident limit is provided under such process, the Secretary shall distribute the increase to hospitals located in the following priority order (with preference given within each category to hospitals that are members of the same affiliated group (as defined by the Secretary under clause (ii)) as the closed hospital):
First, to hospitals located in the same core-based statistical area as, or a core-based statistical area contiguous to, the hospital that closed.
Second, to hospitals located in the same State as the hospital that closed.
Third, to hospitals located in the same region of the country as the hospital that closed.
Fourth, to all other hospitals.
Requirement hospital likely to fill position within certain time period
The Secretary may only increase the otherwise applicable resident limit of a hospital under such process if the Secretary determines the hospital has demonstrated a likelihood of filling the positions made available under this clause within 3 years.
Limitation
The aggregate number of increases in the otherwise applicable resident limits for hospitals under this clause shall be equal to the number of resident positions in the approved medical residency programs that closed on or after the date described in subclause (I).
Special rule for acquired hospitals
In general
In the case of a hospital that is acquired (through any mechanism) by another entity with the approval of a bankruptcy court, during a period determined by the Secretary (but not less than 3 years), the applicable resident limit of the acquired hospital shall, except as provided in subclause (II), be the applicable resident limit of the hospital that was acquired (as of the date immediately before the acquisition), without regard to whether the acquiring entity accepts assignment of the Medicare provider agreement of the hospital that was acquired, so long as the acquiring entity continues to operate the hospital that was acquired and to furnish services, medical residency programs, and volume of patients similar to the services, medical residency programs, and volume of patients of the hospital that was acquired (as determined by the Secretary) during such period.
Limitation
Subclause (I) shall only apply in the case where an acquiring entity waives the right as a new provider under the program under this title to have the otherwise applicable resident limit of the acquired hospital re-established or increased.
.
IME
Section
1886(d)(5)(B)(v) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in
the second sentence, as amended by section 2326(b), is amended by striking
subsections (h)(7) and (h)(8)
and inserting subsections
(h)(4)(H)(vi), (h)(4)(H)(vii), (h)(7), and (h)(8)
.
Application
The amendments made by this section shall not be applied in a manner that requires reopening of any settled hospital cost reports as to which there is not a jurisdictionally proper appeal pending as of the date of the enactment of this Act on the issue of payment for indirect costs of medical education under section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct graduate medical education costs under section 1886(h) of such Act (42 U.S.C. 1395ww(h)).
No affect on temporary FTE cap adjustments
The amendments made by this section shall not affect any temporary adjustment to a hospital's FTE cap under section 413.79(h) of title 42, Code of Federal Regulations (as in effect on the date of enactment of this Act).
Quality improvement organization assistance for physician practices seeking to be patient-centered medical home practices
Not later than 90 days after the date of enactment of this Act, the Secretary of Health and Human Services shall revise the 9th Statement of Work under the Quality Improvement Program under part B of title XI of the Social Security Act to include a requirement that, in order to be an eligible Quality Improvement Organization (in this section referred to as a QIO) for the 9th Statement of Work contract cycle, a QIO shall provide assistance, including technical assistance, to physicians under the Medicare program under title XVIII of the Social Security Act that seek to acquire the elements necessary to be recognized as a patient-centered medical home practice under the National Committee for Quality Assurance's Physician Practice Connections—PCMH module (or any successor module issued by such Committee).
Studies
Study concerning the designation of primary care as a shortage profession
In general
Not later than June 30, 2010, the Secretary of Labor shall conduct a study and submit to the Committee on Education and Labor of the House of Representatives and the Committee on Health, Education, Labor, and Pensions a report that contains—
a description of the criteria for the designation of primary care physicians as professions in shortage as defined by the Secretary under section 212(a)(5)(A) of the Immigration and Nationality Act;
the findings of the Secretary on whether primary care physician professions will, on the date on which the report is submitted, or within the 5-year period beginning on such date, satisfy the criteria referred to in paragraph (1); and
if the Secretary finds that such professions will not satisfy such criteria, recommendations for modifications to such criteria to enable primary care physicians to be so designated as a profession in shortage.
Requirements
In conducting the study under subsection (a), the Secretary of Labor shall consider workforce data from the Health Resources and Services Administration, the Council on Graduate Medical Education, the Association of American Medical Colleges, and input from physician membership organizations that represent primary care physicians.
Study concerning the education debt of medical school graduates
Study
The Comptroller General of the United States shall conduct a study to evaluate the higher education-related indebtedness of medical school graduates in the United States at the time of graduation from medical school, and the impact of such indebtedness on specialty choice, including the impact on the field of primary care.
Report
Submission and dissemination of report
Not later than 1 year after the date of enactment of this Act, the Comptroller General shall submit a report on the study required by subsection (a) to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Education and Labor of the House of Representatives, and shall make such report widely available to the public.
Additional reports
The Comptroller General may periodically prepare and release as necessary additional reports on the topic described in subsection (a).
Study on minority representation in primary care
Study
The Secretary of Health and Human Services, acting through the Administrator of the Health Resources and Services Administration, shall conduct a study of minority representation in training, and in practice, in primary care specialties.
Report
Not later than 1 year after the date of enactment of this Act, the Secretary of Health and Human Services, acting through the Administrator of the Health Resources and Services Administration, shall submit to the appropriate committees of Congress a report concerning the study conducted under subsection (a), including recommendations for achieving a primary care workforce that is more representative of the population of the United States.
Medicare Payment Provisions
Short title
This title may be cited
as the Medicare Payment Improvement
Act of 2009
.
Findings
Congress makes the following findings:
The health care delivery system must be realigned to provide better clinical outcomes, safety, and patient satisfaction at lower cost. This should be a common goal for all health care professionals, hospitals, and other groups. Today’s reimbursement system pays the most to those who perform the most services, and therefore can provide disincentives to efficient and high-quality providers.
The regional inequities in Medicare reimbursement penalize areas that have cost-effective health care delivery systems and reward those States that have high utilization rates and provide inefficient care.
According to the Dartmouth Health Atlas, over the past 10 years, a number of studies have explored the relationship between higher spending and the quality and outcomes of care. The findings are remarkably consistent, concluding that higher spending does not result in better quality of care.
New payment models should be developed to move away from paying for quantity and instead paying for improving health and truly rewarding effective and efficient care.
Value index under the Medicare physician fee schedule
In general
Section 1848(e)(5) of the Social Security Act (42 U.S.C. 1395w–4(e)) is amended by adding at the end the following new paragraph:
Value index
In general
The Secretary shall determine a value index for each fee schedule area. The value index shall be the ratio of the quality component under subparagraph (B) to the cost component under subparagraph (C) for that fee schedule area.
Quality component
In general
The quality component shall be based on a composite score that reflects quality measures available on a State or fee schedule area basis. The measures shall reflect health outcomes and health status for the Medicare population, patient safety, and patient satisfaction. The Secretary shall use the best data available, after consultation with the Agency for Healthcare Research and Quality and with private entities that compile quality data.
Advisory group
In general
Not later than 60 days after the date of enactment of the Medicare Payment Improvement Act of 2009, the Secretary shall establish a group of experts and stakeholders to make consensus recommendations to the Secretary regarding development of the quality component. The membership of the advisory group shall at least reflect providers, purchasers, health plans, researchers, relevant Federal agencies, and individuals with technical expertise on health care quality.
Duties
In the development of recommendations with respect to the quality component, the group established under subclause (I) shall consider at least the following areas:
High cost procedures as determined by data under this title.
Health outcomes and functional status of patients.
The continuity, management, and coordination of health care and care transitions, including episodes of care, for patients across the continuum of providers, health care settings, and health plans.
Patient, caregiver, and authorized representative experience, quality and relevance of information provided to patients, caregivers, and authorized representatives, and use of information by patients, caregivers, and authorized representatives to inform decision making.
The safety, effectiveness, and timeliness of care.
The appropriate use of health care resources and services.
Other items determined appropriate by the Secretary.
Requirement
In establishing the quality component under this subparagraph, the Secretary shall—
take into account the recommendations of the group established under clause (ii)(I); and
provide for an open and transparent process for the activities conducted pursuant to the convening of such group with respect to the development of the quality component.
Establishment
The quality component for each fee schedule area shall be the ratio of the quality score for such area to the national average quality score.
Quality baseline
If the quality component for a fee schedule area does not rank in the top 25th percentile as compared to the national average (as determined by the Secretary) and the amount of reimbursement for services under this section is greater than the amount of reimbursement for such services that would have applied under this section if the amendments made by section 2 of the Medicare Payment Improvement Act of 2009 had not been enacted, this section shall be applied as if such amendments had not been enacted.
Application
In the case of a fee schedule area that is less than an entire State, if available quality data is not sufficient to measure quality at the sub-State level, the quality component for a sub-State fee schedule area shall be the quality component for the entire State.
Cost component
In general
The cost component shall be total annual per beneficiary Medicare expenditures under part A and this part for the fee schedule area. The Secretary may use total per beneficiary expenditures under such parts in the last two years of life as an alternative measure if the Secretary determines that such measure better takes into account severity differences among fee schedule areas.
Establishment
The cost component for a fee schedule area shall be the ratio of the cost per beneficiary for such area to the national average cost per beneficiary.
.
Conforming amendments
Section 1848 of the Social Security Act (42 U.S.C. 1395w–4) is amended—
in subsection
(b)(1)(C), by striking geographic
and inserting
geographic and value
; and
in subsection (e)—
in paragraph (1)—
in
the heading, by inserting and value
after geographic
;
in subparagraph (A), by striking clause (iii) and inserting the following new clause:
a value index (as defined in paragraph (6)) applicable to physician work.
;
in subparagraph
(C), by inserting and value
after geographic
in
the first sentence;
in
subparagraph (D), by striking physician work effort
and
inserting value
;
by striking subparagraph (E); and
by striking subparagraph (G);
by striking paragraph (2) and inserting the following new paragraph:
Computation of geographic and value adjustment factor
For purposes of subsection (b)(1)(C), for all physicians’ services for each fee schedule area the Secretary shall establish a geographic and value adjustment factor equal to the sum of the geographic cost-of-practice adjustment factor (specified in paragraph (3)), the geographic malpractice adjustment factor (specified in paragraph (4)), and the value adjustment factor (specified in paragraph (5)) for the service and the area.
; and
by striking paragraph (5) and inserting the following new paragraph:
Physician work value adjustment factor
For purposes of paragraph (2), the
physician work value adjustment factor
for a service for a fee
schedule area, is the product of—
the proportion of the total relative value for the service that reflects the relative value units for the work component; and
the value index score for the area, based on the value index established under paragraph (6).
.
Availability of quality component prior to implementation
The Secretary of Health and Human Services shall make the quality component described in section 1848(c)(6)(B) of the Social Security Act, as added by subsection (a), for each fee schedule area available to the public by not later than July 1, 2011.
Effective date
Subject to subsection (e), the amendments made by this section shall apply to the Medicare physician fee schedule for 2012 and each subsequent year.
Transition
Notwithstanding the amendments made by the preceding provisions of this section, the Secretary of Health and Human Services shall provide for an appropriate transition to the amendments made by this section. Under such transition, in the case of payments under such fee schedule for services furnished during—
2012, 25 percent of such payments shall be based on the amount of payment that would have applied to the services if such amendments had not been enacted and 75 percent of such payment shall be based on the amount of payment that would have applied to the services if such amendments had been fully implemented;
2013, 50 percent of such payment shall be based on the amount of payment that would have applied to the services if such amendments had not been enacted and 50 percent of such payment shall be based on the amount of payment that would have applied to the services if such amendments had been fully implemented; and
2014 and subsequent years, 100 percent of such payment shall be based on the amount of payment that is applicable under such amendments.
Long-Term Services Provisions
Short title
This title may be cited
as the Home and Community Balanced
Incentives Act of 2009
.
Balancing Incentives
Enhanced FMAP for expanding the provision of non-institutionally-based long-term services and supports
Enhanced FMAP To encourage expansion
Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended—
in the first sentence of subsection (b)—
by striking
, and (4)
and inserting , (4)
; and
by inserting
before the period the following: , and (5) in the case of a balancing
incentive payment State, as defined in subsection (y)(1), that meets the
conditions described in subsection (y)(2), the Federal medical assistance
percentage shall be increased by the applicable number of percentage points
determined under subsection (y)(3) for the State with respect to medical
assistance described in subsection (y)(4)
; and
by adding at the end the following new subsection:
State balancing incentive payments program
For purposes of clause (5) of the first sentence of subsection (b):
Balancing incentive payment state
A balancing incentive payment State is a State—
in which less than 50 percent of the total expenditures for medical assistance for fiscal year 2009 for long-term services and supports (as defined by the Secretary, subject to paragraph (5)) are for non-institutionally-based long-term services and supports described in paragraph (5)(B);
that submits an application and meets the conditions described in paragraph (2); and
that is selected by the Secretary to participate in the State balancing incentive payment program established under this subsection.
Conditions
The conditions described in this paragraph are the following:
Application
The State submits an application to the Secretary that includes the following:
A description of the availability of non-institutionally-based long-term services and supports described in paragraph (5)(B) available (for fiscal years beginning with fiscal year 2009).
A description of eligibility requirements for receipt of such services.
A projection of the number of additional individuals that the State expects to provide with such services to during the 5-fiscal-year period that begins with fiscal year 2011.
An assurance of the State's commitment to a consumer-directed long-term services and supports system that values quality of life in addition to quality of care and in which beneficiaries are empowered to choose providers and direct their own care as much as possible.
A proposed budget that details the State's plan to expand and diversify medical assistance for non-institutionally-based long-term services and supports described in paragraph (5)(B) during such 5-fiscal-year period, and that includes—
a description of the new or expanded offerings of such services that the State will provide; and
the projected costs of the services identified in subclause (I).
A description of how the State intends to achieve the target spending percentage applicable to the State under subparagraph (B).
An assurance that the State will not use Federal funds, revenues described in section 1903(w)(1), or revenues obtained through the imposition of beneficiary cost-sharing for medical assistance for non-institutionally-based long-term services and supports described in paragraph (5)(B) for the non-Federal share of expenditures for medical assistance described in paragraph (4).
Target spending percentages
In the case of a balancing incentive payment State in which less than 25 percent of the total expenditures for home and community-based services under the State plan and the various waiver authorities for fiscal year 2009 are for such services, the target spending percentage for the State to achieve by not later than October 1, 2015, is that 25 percent of the total expenditures for home and community-based services under the State plan and the various waiver authorities are for such services.
In the case of any other balancing incentive payment State, the target spending percentage for the State to achieve by not later than October 1, 2015, is that 50 percent of the total expenditures for home and community-based services under the State plan and the various waiver authorities are for such services.
Maintenance of eligibility requirements
The State does not apply eligibility standards, methodologies, or procedures for determining eligibility for medical assistance for non-institutionally-based long-term services and supports described in paragraph (5)(B)) that are more restrictive than the eligibility standards, methodologies, or procedures in effect for such purposes on December 31, 2010.
Use of additional funds
The State agrees to use the additional Federal funds paid to the State as a result of this subsection only for purposes of providing new or expanded offerings of non-institutionally-based long-term services and supports described in paragraph (5)(B) (including expansion through offering such services to increased numbers of beneficiaries of medical assistance under this title).
Structural changes
The State agrees to make, not later than the end of the 6-month period that begins on the date the State submits and application under this paragraph, such changes to the administration of the State plan (and, if applicable, to waivers approved for the State that involve the provision of long-term care services and supports) as the Secretary determines, by regulation or otherwise, are essential to achieving an improved balance between the provision of non-institutionally-based long-term services and supports described in paragraph (5)(B) and other long-term services and supports, and which shall include the following:
No wrong
door
—single entry point system
Development of a statewide system to enable consumers to access all long-term services and supports through an agency, organization, coordinated network, or portal, in accordance with such standards as the State shall establish and that—
shall require such agency, organization, network, or portal to provide—
consumers with information regarding the availability of such services, how to apply for such services, and other referral services; and
information regarding, and make recommendations for, providers of such services; and
may, at State option, permit such agency, organization, network, or portal to—
determine financial and functional eligibility for such services and supports; and
provide or refer eligible individuals to services and supports otherwise available in the community (under programs other than the State program under this title), such as housing, job training, and transportation.
Presumptive Eligibility
At the option of the State, provision of a 60-day period of presumptive eligibility for medical assistance for non-institutionally-based long-term services and supports described in paragraph (5)(B) for any individual whom the State has reason to believe will qualify for such medical assistance (provided that any expenditures for such medical assistance during such period are disregarded for purposes of determining the rate of erroneous excess payments for medical assistance under section 1903(u)(1)(D)).
Case Management
Development, in accordance with guidance from the Secretary, of conflict-free case management services to—
address transitioning from receipt of institutionally-based long-term services and supports described in paragraph (5)(A) to receipt of non-institutionally-based long-term services and supports described in paragraph (5)(B); and
in conjunction with the beneficiary, assess the beneficiary's needs and , if appropriate, the needs of family caregivers for the beneficiary, and develop a service plan, arrange for services and supports, support the beneficiary (and, if appropriate, the caregivers) in directing the provision of services and supports, for the beneficiary, and conduct ongoing monitoring to assure that services and supports are delivered to meet the beneficiary's needs and achieve intended outcomes.
Core standardized assessment instruments
Development of core standardized assessment instruments for determining eligibility for non-institutionally-based long-term services and supports described in paragraph (5)(B), which shall be used in a uniform manner throughout the State, to—
assess a beneficiary's eligibility and functional level in terms of relevant areas that may include medical, cognitive, and behavioral status, as well as daily living skills, and vocational and communication skills;
based on the assessment conducted under subclause (I), determine a beneficiary's needs for training, support services, medical care, transportation, and other services, and develop an individual service plan to address such needs;
conduct ongoing monitoring based on the service plan; and
require reporting of collect data for purposes of comparison among different service models.
Data Collection
Collecting from providers of services and through such other means as the State determines appropriate the following data:
Services data
Services data from providers of non-institutionally-based long-term services and supports described in paragraph (5)(B) on a per-beneficiary basis and in accordance with such standardized coding procedures as the State shall establish in consultation with the Secretary.
Quality data
Quality data on a selected set of core quality measures agreed upon by the Secretary and the State that are linked to population-specific outcomes measures and accessible to providers.
Outcomes measures
Outcomes measures data on a selected set of core population-specific outcomes measures agreed upon by the Secretary and the State that are accessible to providers and include—
measures of beneficiary and family caregiver experience with providers;
measures of beneficiary and family caregiver satisfaction with services; and
measures for achieving desired outcomes appropriate to a specific beneficiary, including employment, participation in community life, health stability, and prevention of loss in function.
Applicable number of percentage points increase in fmap
The applicable number of percentage points are—
in the case of a balancing incentive payment State subject to the target spending percentage described in paragraph (2)(B)(i), 5 percentage points; and
in the case of any other balancing incentive payment State, 2 percentage points.
Eligible medical assistance expenditures
In general
Subject to subparagraph (B), medical assistance described in this paragraph is medical assistance for non-institutionally-based long-term services and supports described in paragraph (5)(B) that is provided during the period that begins on October 1, 2011, and ends on September 30, 2015.
Limitation on payments
In no case may the aggregate amount of payments made by the Secretary to balancing incentive payment States under this subsection during the period described in subparagraph (A), or to a State to which paragraph (6) of the first sentence of subsection (b) applies, exceed $3,000,000,000.
Long-term services and supports defined
In this subsection, the term long-term services and supports has the meaning given that term by Secretary and shall include the following:
Institutionally-based long-term services and supports
Services provided in an institution, including the following:
Nursing facility services.
Services in an intermediate care facility for the mentally retarded described in subsection (a)(15).
Non-institutionally-based long-term services and supports
Services not provided in an institution, including the following:
Home and community-based services provided under subsection (c), (d), or (i), of section 1915 or under a waiver under section 1115.
Home health care services.
Personal care services.
Services described in subsection (a)(26) (relating to PACE program services).
Self-directed personal assistance services described in section 1915(j)
.
Enhanced FMAP for certain states To maintain the provision of home and community-based services
The first sentence of section 1905(b) of such Act (42 U.S.C. 1396d(b)), as amended by subsection (a), is amended—
by striking
, and (5)
and inserting , (5)
; and
by inserting
before the period the following: , and (6) in the case of a State in
which at least 50 percent of the total expenditures for medical assistance for
fiscal year 2009 for long-term services and supports (as defined by the
Secretary for purposes of subsection (y)) are for non-institutionally-based
long-term services and supports described in subsection (y)(5)(B), and which
satisfies the requirements of subparagraphs (A) (other than clauses (iii), (v),
and (vi)), (C), and (F) of subsection (y)(2), and has implemented the
structural changes described in each clause of subparagraph (E) of that
subsection, the Federal medical assistance percentage shall be increased by 1
percentage point with respect to medical assistance described in subparagraph
(A) of subsection (y)(4) (but subject to the limitation described in
subparagraph (B) of that subsection)
.
Grants To support structural changes
In General
The Secretary of Health and Human Services shall award grants to States for the following purposes:
To support the development of common national set of coding methodologies and databases related to the provision of non-institutionally-based long-term services and supports described in paragraph (5)(B) of section 1905(y) of the Social Security Act (as added by subsection (a)).
To make structural changes described in paragraph (2)(E) of section 1905(y) to the State Medicaid program.
Priority
In awarding grants for the purpose described in paragraph (1)(A), the Secretary of Health and Human Services shall give priority to States in which at least 50 percent of the total expenditures for medical assistance under the State Medicaid program for fiscal year 2009 for long-term services and supports, as defined by the Secretary for purposes of section 1905(y) of the Social Security Act, are for non-institutionally-based long-term services and supports described in paragraph (5)(B) of such section.
Collaboration
States awarded a grant for the purpose described in paragraph (1)(A) shall collaborate with other States, the National Governor's Association, the National Conference of State Legislatures, the National Association of State Medicaid Directors, the National Association of State Directors of Developmental Disabilities, and other appropriate organizations in developing specifications for a common national set of coding methodologies and databases.
Authorization of appropriations
There are authorized to be appropriated to carry out this subsection, such sums as may be necessary for each of fiscal years 2010 through 2012.
Authority for individualized budgets under waivers To provide home and community-based services
In the case of any waiver to provide home and community-based services under subsection (c) or (d) of section 1915 of the Social Security Act (42 U.S.C. 1396n) or section 1115 of such Act (42 U.S.C. 1315), that is approved or renewed after the date of enactment of this Act, the Secretary of Health and Human Services shall permit a State to establish individualized budgets that identify the dollar value of the services and supports to be provided to an individual under the waiver.
Oversight and assessment
Development of standardized reporting requirements
Standardization of data and outcome measures
The Secretary of Health and Human Services shall consult with States and the National Governor's Association, the National Conference of State Legislatures, the National Association of State Medicaid Directors, the National Association of State Directors of Developmental Disabilities, and other appropriate organizations to develop specifications for standardization of—
reporting of assessment data for long-term services and supports (as defined by the Secretary for purposes of section 1905(y)(5) of the Social Security Act) for each population served, including information standardized for purposes of certified EHR technology (as defined in section 1903(t)(3)(A) of the Social Security Act (42 U.S.C. 1396b(t)(3)(A)) and under other electronic medical records initiatives; and
outcomes measures that track assessment processes for long-term services and supports (as so defined) for each such population that maintain and enhance individual function, independence, and stability.
Administration of home and community services
The Secretary of Health and Human Services shall promulgate regulations to ensure that all States develop service systems that are designed to—
allocate resources for services in a manner that is responsive to the changing needs and choices of beneficiaries receiving non-institutionally-based long-term services and supports described in paragraph (5)(B) of section 1905(y) of the Social Security Act (as added by subsection (a)) (including such services and supports that are provided under programs other the State Medicaid program), and that provides strategies for beneficiaries receiving such services to maximize their independence;
provide the support and coordination needed for a beneficiary in need of such services (and their family caregivers or representative, if applicable) to design an individualized, self-directed, community-supported life; and
improve coordination among all providers of such services under federally and State-funded programs in order to—
achieve a more consistent administration of policies and procedures across programs in relation to the provision of such services; and
oversee and monitor all service system functions to assure—
coordination of, and effectiveness of, eligibility determinations and individual assessments; and
development and service monitoring of a complaint system, a management system, a system to qualify and monitor providers, and systems for role-setting and individual budget determinations.
Monitoring
The Secretary of Health and Human Services shall assess on an ongoing basis and based on measures specified by the Agency for Healthcare Research and Quality, the safety and quality of non-institutionally-based long-term services and supports described in paragraph (5)(B) of section 1905(y) of that Act provided to beneficiaries of such services and supports and the outcomes with regard to such beneficiaries’ experiences with such services. Such oversight shall include examination of—
the consistency, or lack thereof, of such services in care plans as compared to those services that were actually delivered; and
the length of time between when a beneficiary was assessed for such services, when the care plan was completed, and when the beneficiary started receiving such services.
GAO study and report
The Comptroller General of the United States shall study the longitudinal costs of Medicaid beneficiaries receiving long-term services and supports (as defined by the Secretary for purposes of section 1905(y)(5) of the Social Security Act) over 5-year periods across various programs, including the non-institutionally-based long-term services and supports described in paragraph (5)(B) of such section, PACE program services under section 1894 of the Social Security Act (42 U.S.C. 1395eee, 1396u–4), and services provided under specialized MA plans for special needs individuals under part C of title XVIII of the Social Security Act.
Strengthening the Medicaid Home and Community-Based State Plan Amendment Option
Removal of barriers to providing home and community-based services under State plan amendment option for individuals in need
Parity with income eligibility standard for institutionalized individuals
Paragraph (1) of section 1915(i) of the
Social Security Act (42 U.S.C. 1396n(i)) is amended by striking 150
percent of the poverty line (as defined in section 2110(c)(5))
and
inserting 300 percent of the supplemental security income benefit rate
established by section 1611(b)(1)
.
Additional state options
Section 1915(i) of the Social Security Act (42 U.S.C. 1396n(i)) is amended by adding at the end the following new paragraphs:
State option to provide home and community-based services to individuals eligible for services under a waiver
In general
A State that provides home and community-based services in accordance with this subsection to individuals who satisfy the needs-based criteria for the receipt of such services established under paragraph (1)(A) may, in addition to continuing to provide such services to such individuals, elect to provide home and community-based services in accordance with the requirements of this paragraph to individuals who are eligible for home and community-based services under a waiver approved for the State under subsection (c), (d), or (e) or under section 1115 to provide such services, but only for those individuals whose income does not exceed 300 percent of the supplemental security income benefit rate established by section 1611(b)(1).
Application of same requirements for individuals satisfying needs-based criteria
Subject to subparagraph (C), a State shall provide home and community-based services to individuals under this paragraph in the same manner and subject to the same requirements as apply under the other paragraphs of this subsection to the provision of home and community-based services to individuals who satisfy the needs-based criteria established under paragraph (1)(A).
Authority to offer different type, amount, duration, or scope of home and community-based services
A State may offer home and community-based services to individuals under this paragraph that differ in type, amount, duration, or scope from the home and community-based services offered for individuals who satisfy the needs-based criteria established under paragraph (1)(A), so long as such services are within the scope of services described in paragraph (4)(B) of subsection (c) for which the Secretary has the authority to approve a waiver and do not include room or board.
State option to offer home and community-based services to specific, targeted populations
In general
A State may elect in a State plan amendment under this subsection to target the provision of home and community-based services under this subsection to specific populations and to differ the type, amount, duration, or scope of such services to such specific populations.
5-year term
In general
An election by a State under this paragraph shall be for a period of 5 years.
Phase-in of services and eligibility permitted during initial 5-year period
A State making an election under this paragraph may, during the first 5-year period for which the election is made, phase-in the enrollment of eligible individuals, or the provision of services to such individuals, or both, so long as all eligible individuals in the State for such services are enrolled, and all such services are provided, before the end of the initial 5-year period.
Renewal
An election by a State under this paragraph may be renewed for additional 5-year terms if the Secretary determines, prior to beginning of each such renewal period, that the State has—
adhered to the requirements of this subsection and paragraph in providing services under such an election; and
met the State's objectives with respect to quality improvement and beneficiary outcomes.
.
Removal of limitation on scope of services
Paragraph (1) of section 1915(i) of the
Social Security Act (42 U.S.C. 1396n(i)), as amended by subsection (a), is
amended by striking or such other services requested by the State as the
Secretary may approve
.
Optional eligibility category To provide full medicaid benefits to individuals receiving home and community-based services under a State plan amendment
In general
Section 1902(a)(10)(A)(ii) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)) is amended—
in subclause
(XVIII), by striking or
at the end;
in subclause
(XIX), by adding or
at the end; and
by inserting after subclause (XIX), the following new subclause:
who are eligible for home and community-based services under needs-based criteria established under paragraph (1)(A) of section 1915(i), or who are eligible for home and community-based services under paragraph (6) of such section, and who will receive home and community-based services pursuant to a State plan amendment under such subsection;
.
Conforming amendments
Section
1903(f)(4) of the Social Security Act (42 U.S.C. 1396b(f)(4)) is amended in the
matter preceding subparagraph (A), by inserting
1902(a)(10)(A)(ii)(XX),
after
1902(a)(10)(A)(ii)(XIX),
.
Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) is amended in the matter preceding paragraph (1)—
in
clause (xii), by striking or
at the end;
in
clause (xiii), by adding or
at the end; and
by inserting after clause (xiii) the following new clause:
individuals who are eligible for home and community-based services under needs-based criteria established under paragraph (1)(A) of section 1915(i), or who are eligible for home and community-based services under paragraph (6) of such section, and who will receive home and community-based services pursuant to a State plan amendment under such subsection,
.
Elimination of option To limit number of eligible individuals or length of period for grandfathered individuals if eligibility criteria is modified
Paragraph (1) of section 1915(i) of such Act (42 U.S.C. 1396n(i)) is amended—
by striking subparagraph (C) and inserting the following:
Projection of number of individuals to be provided home and community-based services
The State submits to the Secretary, in such form and manner, and upon such frequency as the Secretary shall specify, the projected number of individuals to be provided home and community-based services.
; and
in subclause (II)
of subparagraph (D)(ii), by striking to be eligible for such services
for a period of at least 12 months beginning on the date the individual first
received medical assistance for such services
and inserting to
continue to be eligible for such services after the effective date of the
modification and until such time as the individual no longer meets the standard
for receipt of such services under such pre-modified criteria
.
Elimination of option To waive statewideness; addition of option to waive comparability
Paragraph (3)
of section 1915(i) of such Act (42 U.S.C. 1396n(3)) is amended by striking
1902(a)(1) (relating to statewideness)
and inserting
1902(a)(10)(B) (relating to comparability)
.
Effective date
The amendments made by this section take effect on the first day of the first fiscal year quarter that begins after the date of enactment of this Act.
Mandatory application of spousal impoverishment protections to recipients of home and community-based services
In general
Section 1924(h)(1)(A)
of the Social Security Act (42 U.S.C. 1396r–5(h)(1)(A)) is amended by striking
(at the option of the State) is described in section
1902(a)(10)(A)(ii)(VI)
and inserting is eligible for medical
assistance for home and community-based services under subsection (c), (d),
(e), or (i) of section 1915
.
Effective date
The amendment made by subsection (a) takes effect on October 1, 2009.
State authority to elect to exclude up to 6 months of average cost of nursing facility services from assets or resources for purposes of eligibility for home and community-based services
In general
Section 1917 of the Social Security Act (42 U.S.C. 1396p) is amended by adding at the end the following new subsection:
State authority To exclude up to 6 months of average cost of nursing facility services from home and community-based services eligibility determinations
Nothing in this section or any other provision of this title, shall be construed as prohibiting a State from excluding from any determination of an individual's assets or resources for purposes of determining the eligibility of the individual for medical assistance for home and community-based services under subsection (c), (d), (e), or (i) of section 1915 (if a State imposes an limitation on assets or resources for purposes of eligibility for such services), an amount equal to the product of the amount applicable under subsection (c)(1)(E)(ii)(II) (at the time such determination is made) and such number, not to exceed 6, as the State may elect.
.
Rule of construction
Nothing in the amendment made by subsection (a) shall be construed as affecting a State's option to apply less restrictive methodologies under section 1902(r)(2) for purposes of determining income and resource eligibility for individuals specified in that section.
Coordination of Home and Community-Based Waivers
Streamlined process for combined waivers under subsections (b) and (c) of section 1915
Not later than 90 days
after the date of enactment of this Act, the Secretary of Health and Human
Services shall create a template to streamline the process of approving,
monitoring, evaluating, and renewing State proposals to conduct a program that
combines the waiver authority provided under subsections (b) and (c) of section
1915 of the Social Security Act (42 U.S.C. 1396n) into a single program under
which the State provides home and community-based services to individuals based
on individualized assessments and care plans (in this section referred to as
the combined waivers program
). The template required under this
section shall provide for the following:
A standard 5-year term for conducting a combined waivers program.
Harmonization of any requirements under subsections (b) and (c) of such section that overlap.
An option for States to elect, during the first 5-year term for which the combined waivers program is approved to phase-in the enrollment of eligible individuals, or the provision of services to such individuals, or both, so long as all eligible individuals in the State for such services are enrolled, and all such services are provided, before the end of the initial 5-year period.
Examination by the Secretary, prior to each renewal of a combined waivers program, of how well the State has—
adhered to the combined waivers program requirements; and
performed in meeting the State's objectives for the combined waivers program, including with respect to quality improvement and beneficiary outcomes.
Home and Community-Based Services Provisions
Short title
This Act may be cited as
the Project 2020: Building on the
Promise of Home and Community-Based Services Act of
2009
.
Long-term services and supports
The Social Security Act (42 U.S.C. 301 et seq.) is amended by adding at the end the following:
Long-term services and supports
Definitions
Except as otherwise provided, the terms used in this title have the meanings given the terms in section 102 of the Older Americans Act of 1965 (42 U.S.C. 3002).
Single-entry point system program
State single-entry point systems
Definitions
In this title:
Long-term services and supports
The term long-term services and supports means any service (including a disease prevention and health promotion service, an in-home service, or a case management service), care, or item (including an assistive device) that is—
intended to assist individuals in coping with, and, to the extent practicable, compensating for, functional impairment in carrying out activities of daily living;
furnished at home, in a community care setting, including a small community care setting (as defined in section 1929(g)(1)) and a large community care setting (as defined in section 1929(h)(1)), or in a long-term care facility; and
not furnished to diagnose, treat, or cure a medical disease or condition.
Single-entry point system
The term single-entry point system means any coordinated system for providing—
comprehensive information to consumers and caregivers on the full range of available public and private long-term services and supports, options, service providers, and resources, including information on the availability of integrated long-term care, including consumer directed care options;
personal counseling to assist individuals in assessing their existing or anticipated long-term care needs, and developing and implementing a plan for long-term care designed to meet their specific needs and circumstances; and
consumers and caregivers access to the range of publicly supported and privately supported long-term services and supports that are available.
Program
The Secretary shall establish and carry out a single-entry point system program. In carrying out the program, the Secretary shall make grants to States, from allotments described in subsection (c), to pay for the Federal share of the cost of establishing State single-entry point systems.
Allotments
Allotments to Indian tribes and territories
Reservation
The Secretary shall reserve from the funds made available under subsection (g)—
for fiscal year 2010, $1,962,456; and
for each subsequent fiscal year, $1,962,456, increased by the percentage increase in the Consumer Price Index for All Urban Consumers, between October of the fiscal year preceding the subsequent fiscal year and October 2007.
Allotments
The Secretary shall use the funds reserved under subparagraph (A) to make allotments to—
Indian tribes; and
Guam, American Samoa, the Commonwealth of the Northern Mariana Islands, the Commonwealth of Puerto Rico, and the United States Virgin Islands.
Allotments to States
In general
Amount
The Secretary shall allot to each eligible State for a fiscal year the sum of the fixed amount determined under subparagraph (B), and the allocation determined under subparagraph (C), for the State.
Subgrants to area agencies on aging
In general
Each State agency receiving an allotment under clause (i) shall use such allotment to make subgrants to area agencies on aging that can demonstrate performance capacity to carry out activities described in this section whether such area agency on aging carries out the activities directly or through contract with an aging network or disability entity.
Subgrants to other entities
A State agency may make subgrants described in subclause (I) to other qualified aging network or disability entities only if the area agency on aging chooses not to apply for a subgrant or is not able to demonstrate performance capacity to carry out the activities described in this section.
Subgrantee recipient subgrants
An administrator of a single-entry point system established by a State receiving an allotment under clause (i) shall make any necessary subgrants to key partners involved in developing, planning, or implementing the single-entry point system. Such partners may include centers for independent living (as defined in section 702 of the Rehabilitation Act of 1973 (29 U.S.C. 796a)).
Fixed amounts for States
Reservation
The Secretary shall reserve from the funds made available under subsection (g)—
for fiscal year 2010, $15,759,000; and
for each subsequent fiscal year, $15,759,000, increased by the percentage increase in the Consumer Price Index for All Urban Consumers, between October of the fiscal year preceding the subsequent fiscal year and October 2007.
Fixed amounts
The Secretary shall use the funds reserved under clause (i) to provide equal fixed amounts to the States.
Allocation for States
The Secretary shall allocate to each eligible State for a fiscal year an amount that bears the same relationship to the funds made available under subsection (g) (and not reserved under paragraph (1) or subparagraph (B)) for that fiscal year as the number of persons who are either older individuals or individuals with disabilities in that State bears to the number of such persons or individuals in all the States.
Determination of number of persons
Older individuals
The number of older individuals in any State and in all States shall be determined by the Secretary on the basis of the most recent data available from the Bureau of the Census, and other reliable demographic data satisfactory to the Secretary.
Individuals with disabilities
The number of individuals with disabilities in any State and in all States shall be determined by the Secretary on the basis of the most recent data available from the American Community Survey, and other reliable demographic data satisfactory to the Secretary, on individuals who have a sensory disability, physical disability, mental disability, self-care disability, go-outside-home disability, or employment disability.
Eligibility
In addition to the States determined by the Secretary to be eligible for a grant under this section, a State that receives a Federal grant for an aging and disability resource center is eligible for a grant under this section.
Definition
In
this subsection, the term State
shall not include any
jurisdiction described in paragraph (1)(B)(ii).
Applications
In general
To be eligible to receive an initial grant under this section, a State agency shall, after consulting and coordinating with consumers, other stakeholders, and area agencies on aging in the State, if any, submit an application to the Secretary at such time, in such manner, and containing the following information:
Evidence of substantial involvement of stakeholders and agencies in the State that are administering programs that will be the subject of referrals.
The applicant shall establish or designate a collaborative board to ensure meaningful involvement of stakeholders in the development, planning, implementation, and evaluation of a single-entry point system consistent with the following:
The collaborative board shall be composed of—
individuals representing all populations served by the applicant’s single-entry point system, including older adults and individuals from diverse backgrounds who have a disability or a chronic condition requiring long-term support;
a representative from the local center for independent living (as defined in section 702 of the Rehabilitation Act of 1973 (29 U.S.C. 796a)), and representatives from other organizations that provide services to the individuals served by the system and those who advocate on behalf of such individuals; and
representatives of the government and non-governmental agencies that are affected by the system.
The applicant shall work in conjunction with the collaborative board on—
the design and operations of the single-entry point system;
stakeholder input; and
other program and policy development issues related to the single-entry point system.
An advisory board established under the Real Choice Systems Change Program or for an existing single-entry point system may be used to carry out the activities of a collaborative board under this subparagraph if such advisory board meets the requirements under clause (i).
The applicant’s plan for providing—
comprehensive information on the full range of available public and private long-term services and supports options, providers, and resources, including building awareness of the single-entry point system as a resource;
objective, neutral, and personal information, counseling, and assistance to individuals and their caregivers in assessing their existing or anticipated long-term care needs, and developing and implementing a plan for long-term care to meet their needs;
for eligibility screening and referral for services;
for stakeholder input;
for a management information system; and
for an evaluation of the effectiveness of the single-entry point system.
A specification of the period of the grant request, which shall include not less than 3 consecutive fiscal years in the 5-fiscal-year period beginning with fiscal year 2010.
Such other information as the Secretary determines appropriate.
Application for continuation
In general
A State that receives an initial grant under this section shall apply, after consulting and coordinating with the area agencies on aging, for a continuation of the initial grant, which includes a description of any significant changes to the information provided in the initial application and such data concerning performance measures related to the requirements in the initial application as the Secretary shall require.
Effect
The requirement under subparagraph (A) shall be in effect through fiscal year 2020.
Use of funds
In general
A State that receives a grant under this section shall use the funds made available through the grant to—
establish a State single-entry point system, to enable older individuals and individuals with disabilities and their caregivers to obtain resources concerning long-term services and supports options; and
provide information on, access to, and assistance regarding long-term services and supports.
Services
In particular, the State single-entry point system shall be the referral source to—
provide information about long-term care planning and available long-term services and supports through a variety of media (such as websites, seminars, and pamphlets);
provide assistance with making decisions about long-term services and supports and determining the most appropriate services through options counseling, future financial planning, and case management;
provide streamlined access to and assistance with applying for federally funded long-term care benefits (including medical assistance under title XIX, Medicare skilled nursing facility services, services under title III of the Older Americans Act of 1965 (42 U.S.C. 3021 et seq.), the services of Aging and Disability Resource Centers), and State-funded and privately funded long-term care benefits, through efforts to shorten and simplify the eligibility processes for older individuals and individuals with disabilities;
provide referrals to the State evidence-based disease prevention and health promotion programs under subtitle B;
allocate the State funds available under subtitle C and carry out the State enhanced nursing home diversion program under subtitle C; and
and provide information about, other services available in the State that may assist an individual to remain in the community, including the Medicare and Medicaid programs, the State health insurance assistance program, the supplemental nutrition assistance program established under the Food and Nutrition Act of 2008 (7 U.S.C. 2011 et seq.), and the Low-Income Home Energy Assistance Program under the Low-Income Home Energy Assistance Act of 1981 (42 U.S.C. 8621 et seq.), and such other services, as the State shall include.
Collaborative arrangements
Center for independent living
Each entity receiving an allotment under subsection (c) shall involve in the planning and implementation of the single-entry point system the local center for independent living (as defined in section 702 of the Rehabilitation Act of 1973 (29 U.S.C. 796a)), which provides information, referral, assistance, or services to individuals with disabilities.
Other entities
To the extent practicable, the State single-entry point system is encouraged to enter into collaborative arrangements with aging and disability programs, service providers, agencies, the direct care work force, and other entities in order to ensure that information about such services may be made available to individuals accessing the State single-entry point system.
Federal share
In general
The Federal share of the cost described in subsection (b) shall be 75 percent.
Non-Federal share
The State may provide the non-Federal share of the cost in cash or in-kind, fairly evaluated, including plant, equipment, or services. The State may provide the non-Federal share from State, local, or private sources.
Funding
In general
The Secretary shall use amounts made available under paragraph (2) to make the grants described in subsection (b).
Funding
There are authorized to be appropriated to carry out this section—
$30,900,000 for fiscal year 2010;
$38,264,000 for fiscal year 2011;
$48,410,000 for fiscal year 2012;
$53,560,000 for fiscal year 2013;
$63,860,000 for fiscal year 2014;
$69,010,000 for fiscal year 2015;
$74,160,000 for fiscal year 2016;
$79,310,000 for fiscal year 2017;
$84,460,000 for fiscal year 2018;
$89,610,000 for fiscal year 2019; and
$95,790,000 for fiscal year 2020.
Availability
Funds appropriated under paragraph (2) shall remain available until expended.
Healthy living program
Evidence-based disease prevention and health promotion programs
Program
The Secretary shall establish and carry out a healthy living program. In carrying out the program, the Secretary shall make grants to State agencies, from allotments described in subsection (b), to pay for the Federal share of the cost of carrying out evidence-based disease prevention and health promotion programs.
Allotments
Allotments to Indian tribes and territories
Reservation
The Secretary shall reserve from the funds made available under subsection (g)—
for fiscal year 2010, $1,500,952; and
for each subsequent fiscal year, $1,500,952, increased by the percentage increase in the Consumer Price Index for All Urban Consumers, between October of the fiscal year preceding the subsequent fiscal year and October 2007.
Allotments
The Secretary shall use the reserved funds under subparagraph (A) to make allotments to—
Indian tribes; and
Guam, American Samoa, the Commonwealth of the Northern Mariana Islands, the Commonwealth of Puerto Rico, and the United States Virgin Islands.
In general
Amounts
In general
Except as provided in paragraph (3), the Secretary shall allot to each eligible State for a fiscal year an amount that bears the same relationship to the funds made available under this section and not reserved under paragraph (1) for that fiscal year as the number of older individuals in the State bears to the number of older individuals in all the States.
Older individuals
The number of older individuals in any State and in all States shall be determined by the Secretary on the basis of the most recent data available from the Bureau of the Census, and other reliable demographic data satisfactory to the Secretary.
Subgrants
In general
Each State agency that receives an amount under subparagraph (A) shall award subgrants to area agencies on aging that can demonstrate performance capacity to carry out activities under this section whether such area agency on aging carries out the activities directly or through contract with an aging network entity.
Subgrants to other entities
A State agency may make subgrants described in clause (i) to other qualified aging network entities only if the area agency on aging chooses not to apply for a subgrant or is not able to demonstrate performance capacity to carry out the activities described in this section.
Minimum allotment
No State shall receive an allotment under this section for a fiscal year that is less than 0.5 percent of the funds made available to carry out this section for that fiscal year and not reserved under paragraph (1).
Eligibility
In addition to the States determined by the Secretary to be eligible for a grant under this section, a State that receives a Federal grant for evidence-based disease prevention is eligible for a grant under this section.
Applications
To be eligible to receive a grant under this section, a State agency shall, after consulting and coordinating with consumers, other stakeholders, and area agencies on aging in the State, if any, submit an application to the Secretary at such time, in such manner, and containing the following information:
A description of the evidence-based disease prevention and health promotion program.
Sufficient information to demonstrate that the infrastructure exists to support the program.
A specification of the period of the grant request, which shall include not less than 3 consecutive fiscal years in the 5-fiscal-year period beginning with fiscal year 2010.
Such other information as the Secretary determines appropriate.
Application for continuation
In general
A State that receives an initial grant under this section shall apply, after consulting and coordinating with the area agencies on aging, for a continuation of the initial grant, which application shall include—
a description of any significant changes to the information provided in the initial application; and
such data concerning performance measures related to the requirements in the initial application as the Secretary shall require.
Effect
The requirement under paragraph (1) shall be in effect through fiscal year 2020.
Use of funds
A State that receives a grant under this section shall use the funds made available through the grant to carry out—
an evidence-based chronic disease self-management program;
an evidence-based falls prevention program; or
another evidence-based disease prevention and health promotion program.
Federal share
In general
The Federal share of the cost described in subsection (a) shall be 85 percent.
Non-Federal share
The State may provide the non-Federal share of the cost in cash or in-kind, fairly evaluated, including plant, equipment, or services. The State may provide the non-Federal share from State, local, or private sources.
Funding
In general
The Secretary shall use amounts made available under paragraph (2) to make the grants described in subsection (a).
Funding
There are authorized to be appropriated to carry out this section—
$36,050,000 for fiscal year 2010;
$41,200,000 for fiscal year 2011;
$56,650,000 for fiscal year 2012;
$77,250,000 for fiscal year 2013;
$92,700,000 for fiscal year 2014;
$103,000,000 for fiscal year 2015;
$118,450,000 for fiscal year 2016;
$133,900,000 for fiscal year 2017;
$149,350,000 for fiscal year 2018;
$157,590,000 for fiscal year 2019; and
$173,040,000 for fiscal year 2020.
Availability
Funds appropriated under paragraph (2) shall remain available until expended.
Diversion Programs
Enhanced nursing home diversion programs
Definition
In this section:
Low-income senior
The term low-income senior means an individual who—
is age 75 or older; and
is from a household with a household income that is not less than 150 percent, and not more than 300 percent, of the poverty line.
Nursing home
The term nursing home means—
a skilled nursing facility, as defined in section 1819(a); or
a nursing facility, as defined in section 1919(a).
Program
In general
The Secretary shall establish and carry out a diversion program. In carrying out the program, the Secretary shall make grants to States, from allotments described in subsection (c), to pay for the Federal share of the cost of carrying out enhanced nursing home diversion programs.
Cohorts
The Secretary shall make the grants to—
a first year cohort consisting of one third of the States, for fiscal year 2010;
a second year cohort consisting of the cohort described in subparagraph (A) and an additional one third of the States, for fiscal year 2011; and
a third year cohort consisting of all the eligible States, for fiscal year 2012 and each subsequent fiscal year.
Readiness
In determining whether to include an eligible State in the first year, second year, or third year and subsequent year cohort, the Secretary shall consider the readiness of the State to carry out an enhanced nursing home diversion program under this section. Readiness shall be determined based on a consideration of the following factors:
Availability of a comprehensive array of home and community-based services.
Sufficient home and community-based services provider capacity.
Availability of housing.
Availability of supports for consumer-directed services, including whether a fiscal intermediary is in place.
Ability to perform timely eligibility determinations and assessment for services.
Existence of a quality assessment and improvement program for home and community-based services.
Such other factors as the Secretary determines appropriate.
Allotments
In general
Amount
The Secretary shall allot to an eligible State (within the applicable cohort) for a fiscal year an amount that bears the same relationship to the funds made available under subsection (i) for that fiscal year as the number of low-income seniors in the State bears to the number of low-income seniors within States in the applicable cohort for that fiscal year.
Low-income seniors
The number of low-income seniors in any State and in all States shall be determined by the Secretary on the basis of the most recent data available from the American Community Survey, and other reliable demographic data satisfactory to the Secretary.
Eligibility
In addition to the States determined by the Secretary to be eligible for a grant under this section, a State that receives a Federal grant for a nursing home diversion is eligible for a grant under this section.
Applications
To be eligible to receive a grant under this section, a State agency shall, after consulting and coordinating with consumers, other stakeholders, and area agencies on aging in the State, if any, submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require, including a specification of the period of the grant request, which shall include not less than 3 consecutive fiscal years in the 5-fiscal-year period beginning with the fiscal year prior to the year of application.
Application for continuation
In general
A State that receives an initial grant under this section shall apply, after consulting and coordinating with the area agencies on aging, for a continuation of the initial grant, which application shall include—
a description of any significant changes to the information provided in the initial application; and
such data concerning performance measures related to the requirements in the initial application as the Secretary shall require.
Effect
The requirement under paragraph (1) shall be in effect through fiscal year 2020.
Use of funds
In general
A State that receives a grant under this section shall carry out the following:
Use the funds made available through the grant to carry out an enhanced nursing home diversion program that enables eligible individuals to avoid admission into nursing homes by enabling the individuals to obtain alternative long-term services and supports and remain in their communities.
Award subgrants to area agencies on aging that can demonstrate performance capacity to carry out activities under this section whether such area agency on aging carries out the activities directly or through contract with an aging network entity. A State may make subgrants to other qualified aging network entities only if the area agency on aging chooses not to apply for a subgrant or is not able to demonstrate performance capacity to carry out the activities described in this section.
Case management
In general
The State, through the State single-entry point system established under subtitle A, shall provide for case management services to the eligible individuals.
Use of existing services
In carrying out subparagraph (A), the State agency or area agency on aging may utilize existing case management services delivery networks if—
the networks have adequate safeguards against potential conflicts of interest; and
the State agency or area agency on aging includes a description of such safeguards in the grant application.
Care plan
The State shall provide for development of a care plan for each eligible individual served, in consultation with the eligible individual and their caregiver, as appropriate. In developing the care plan, the State shall explain the option of consumer directed care and assist an individual, who so requests, with developing a consumer-directed care plan that shall include arranging for support services and funding. Such assistance shall include providing information and outreach to individuals in the hospital, in a nursing home for post-acute care, or undergoing changes in their health status or caregiver situation.
Eligible individuals
In this section,
the term eligible individual
means an individual—
who has been determined by the State to be at high functional risk of nursing home placement, as defined by the State agency in the State agency's grant application;
who is not eligible for medical assistance under title XIX; and
who meets the income and asset eligibility requirements established by the State and included in such State’s grant application for approval by the Secretary.
Federal share
In general
The Federal share of the cost described in subsection (b) shall be, for a State and for a fiscal year, the sum of—
the Federal medical assistance percentage applicable to the State for the year under section 1905(b); and
5 percentage points.
Non-Federal share
The State may provide the non-Federal share of the cost in cash or in-kind, fairly evaluated, including plant, equipment, or services. The State may provide the non-Federal share from State, local, or private sources.
Funding
In general
The Secretary shall use amounts made available under paragraph (2) to make the grants described in subsection (b).
Funding
There are authorized to be appropriated to carry out this section—
$111,825,137 for fiscal year 2010;
$337,525,753 for fiscal year 2011;
$650,098,349 for fiscal year 2012;
$865,801,631 for fiscal year 2013;
$988,504,887 for fiscal year 2014;
$1,124,547,250 for fiscal year 2015;
$1,276,750,865 for fiscal year 2016;
$1,364,488,901 for fiscal year 2017;
$1,466,769,052 for fiscal year 2018;
$1,712,755,702 for fiscal year 2019; and
$1,712,755,702 for fiscal year 2020.
Availability
Funds appropriated under paragraph (2) shall remain available until expended.
Administration, evaluation, and technical assistance
Administration, evaluation, and technical assistance
Administration and expenses
For purposes of carrying out this title, there are authorized to be appropriated for administration and expenses—
of the area agencies on aging—
$16,825,895 for fiscal year 2010;
$39,246,141 for fiscal year 2011;
$50,766,948 for fiscal year 2012;
$66,999,101 for fiscal year 2013;
$76,979,152 for fiscal year 2014;
$87,163,513 for fiscal year 2015;
$98,780,562 for fiscal year 2016;
$106,063,792 for fiscal year 2017;
$114,324,642 for fiscal year 2018;
$123,312,948 for fiscal year 2019; and
$133,215,845 for fiscal year 2020;
of the State agencies—
$8,412,948 for fiscal year 2010;
$19,623,071 for fiscal year 2011;
$25,383,474 for fiscal year 2012;
$33,499,551 for fiscal year 2013;
$38,489,576 for fiscal year 2014;
$43,581,756 for fiscal year 2015;
$49,390,281 for fiscal year 2016;
$53,031,896 for fiscal year 2017;
$57,162,321 for fiscal year 2018;
$61,656,474 for fiscal year 2019; and
$66,607,923 for fiscal year 2020; and
of the Administration—
$2,103,237 for fiscal year 2010;
$4,905,768 for fiscal year 2011;
$6,345,868 for fiscal year 2012;
$8,374,888 for fiscal year 2013;
$9,622,394 for fiscal year 2014;
$10,895,439 for fiscal year 2015;
$12,347,570 for fiscal year 2016;
$13,257,974 for fiscal year 2017;
$14,290,580 for fiscal year 2018;
$15,414,118 for fiscal year 2019; and
$16,651,981 for fiscal year 2020.
Evaluation and technical assistance
Conditions to receipt of grant
In awarding grants under this title, the Secretary shall condition receipt of the grant for the second and subsequent grant years on a satisfactory determination that the State agency is meeting benchmarks specified in the grant agreement for each grant awarded under this title.
Evaluations
The Secretary shall measure and evaluate, either directly or through grants or contracts, the impact of the programs authorized under this title. Not later than June 1 of the year that is 6 years after the year of the date of enactment of the Project 2020: Building on the Promise of Home and Community-Based Services Act of 2009 and every 2 years thereafter, the Secretary shall—
compile the reports of the measures and evaluations of the grantees;
establish benchmarks to show progress toward savings; and
present a compilation of the information under this paragraph to Congress.
Technical assistance grants
The Secretary shall award technical assistance grants, including State-specific grants whenever practicable, to carry out the programs authorized under this title.
Transfer
There are authorized to be appropriated for such evaluation and technical assistance under this subsection—
$4,206,474 for fiscal year 2010;
$9,811,535 for fiscal year 2011;
$8,461,158 for fiscal year 2012;
$11,166,517 for fiscal year 2013;
$12,829,859 for fiscal year 2014;
$14,527,252 for fiscal year 2015;
$16,463,427 for fiscal year 2016;
$17,677,299 for fiscal year 2017;
$19,054,107 for fiscal year 2018;
$20,552,158 for fiscal year 2019; and
$22,202,641 for fiscal year 2020.
Availability
Funds appropriated under this section shall remain available until expended.
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