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Compilation of the Social Security Laws, Vol II
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SEC. 1. [42 U.S.C. 1305 note] SHORT TITLE OF DIVISION.
This division may be cited as the “Medicare Improvements and Extension Act of 2006”.
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SEC. 101. PHYSICIAN PAYMENT AND QUALITY IMPROVEMENT
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(c) [42 U.S.C. 1395w-4 note] Transitional Bonus Incentive Payments for Quality Reporting in 2007and 2008[1].
(1) In general.—With respect to covered professional services furnished during a reporting period (as defined in paragraph (6)(C)) by an eligible professional, if—
(A) there are any quality measures that have been established under the physician reporting system that are applicable to any such services furnished by such professional for such period, and
(B) the eligible professional satisfactorily submits (as determined under paragraph (2)) to the Secretary data on such quality measures in accordance with such reporting system for such reporting period,
in addition to the amount otherwise paid under part B of title XVIII of the Social Security Act, subject to paragraph (3), there also shall be paid to the eligible professional (or to an employer or facility in the cases described in clause (A) of section 1842(b)(6) of the Social Security Act (42 U.S.C. 1395u(b)(6))) from the Federal Supplementary Medical Insurance Trust Fund established under section 1841 of such Act (42 U.S.C. 1395t) an amount equal to 1.5 percent of the Secretary's estimate (based on claims submitted not later than two months after the end of the reporting period) of the allowed charges under such part for all such covered professional services furnished during the reporting period.
(2) Satisfactory reporting described.—For purposes of paragraph (1), an eligible professional shall be treated as satisfactorily submitting data on quality measures for covered professional services for a reporting period if quality measures have been reported as follows:
(A) Three or fewer quality measures applicable.—If there are no more than 3 quality measures that are provided under the physician reporting system and that are applicable to such services of such professional furnished during the period, each such quality measure has been reported under such system in at least 80 percent of the cases in which such measure is reportable under the system.
(B) Four or more quality measures applicable.—If there are 4 or more quality measures that are provided under the physician reporting system and that are applicable to such services of such professional furnished during the period, at least 3 such quality measures have been reported under such system in at least 80 percent of the cases in which the respective measure is reportable under the system.
(3) Payment limitation.—
(A) In general.—In no case shall the total payment made under this subsection to an eligible professional (or to an employer or facility in the cases described in clause (A) of section 1842(b)(6) of the Social Security Act) exceed the product of—
(i) the total number of quality measures for which data are submitted under the physician reporting system for covered professional services of such professional that are furnished during the reporting period; and
(ii) 300 percent of the average per measure payment amount specified in subparagraph (B).
(B) Average per measure payment amount specified.—The average per measure payment amount specified in this subparagraph is an amount, estimated by the Secretary (based on claims submitted not later than two months after the end of the reporting period), equal to—
(i) the total of the amount of allowed charges under part B of title XVIII of the Social Security Act for all covered professional services furnished during the reporting period on claims for which quality measures are reported under the physician reporting system; divided by
(ii) the total number of quality measures for which data are reported under such system for covered professional services furnished during the reporting period.
(4) Form of payment.—The payment under this subsection shall be in the form of a single consolidated payment.
(5) Application.—
(A) Physician reporting system rules.—Paragraphs (5), (6), and (8) of section 1848(k) of the Social Security Act, as added by subsection (b), shall apply for purposes of this subsection in the same manner as they apply for purposes of such section.
(B) Coordination with other bonus payments.—The provisions of this subsection shall not be taken into account in applying subsections (m) and (u) of section 1833 of the Social Security Act (42 U.S.C. 1395l) and any payment under such subsections shall not be taken into account in computing allowable charges under this subsection.
(C) Implementation.—Notwithstanding any other provision of law, the Secretary may implement by program instruction or otherwise this subsection.
(D) Validation.—
(i) In general.—Subject to the succeeding provisions of this subparagraph, for purposes of determining whether a measure is applicable to the covered professional services of an eligible professional under paragraph (2), the Secretary shall presume that if an eligible professional submits data for a measure, such measure is applicable to such professional.
(ii) Method.—The Secretary shall validate (by sampling or other means as the Secretary determines to be appropriate) whether measures applicable to covered professional services of an eligible professional have been reported.
(iii) Denial of payment authority.—If the Secretary determines that an eligible professional has not reported measures applicable to covered professional services of such professional, the Secretary shall not pay the bonus incentive payment.
(E) Limitations on review.—
(i) In general.—There shall be no administrative or judicial review under section 1869 or 1878 of the Social Security Act or otherwise of—
(I) the determination of measures applicable to services furnished by eligible professionals under this subsection;
(II) the determination of satisfactory reporting under paragraph (2);
(III) the determination of the payment limitation under paragraph (3); and
(IV) the determination of the bonus incentive payment under this subsection.
(ii) Treatment of determinations.—A determination under this subsection shall not be treated as a determination for purposes of section 1869 of the Social Security Act.
(F)[2]Extension.—For 2008 and 2009, paragraph (3) shall not apply, and the Secretary shall establish alternative criteria for satisfactorily reporting under paragraph (2) and alternative reporting periods under paragraph (6)(C) for reporting groups of measures under paragraph (2)(B) of section 1848(k) of the Social Security Act (42 U.S.C. 1395w-4(k)) and for reporting using the method specified in paragraph (4) of such section.
(6) Definitions.—For purposes of this subsection:
(A) Eligible professional; covered professional services.—The terms “eligible professional” and “covered professional services” have the meanings given such terms in section 1848(k)(3) of the Social Security Act, as added by subsection (b).
(B) Physician reporting system.—The term “physician reporting system” means the system established under section 1848(k) of the Social Security Act, as added by subsection (b).
(C)[3] Reporting period.—The term “reporting period” means—
(i) for 2007, the period beginning on July 1, 2007, and ending on December 31, 2007; and
(ii) for 2008, all of 2008.
(D) Secretary.—The term “Secretary” means the Secretary of Health and Human Services.
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(e) [None Assigned] Implementation.—For purposes of implementing the provisions of, and amendments made by, this section, the Secretary of Health and Human Services shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund established under section 1841 of the Social Security Act (42 U.S.C. 1395t), of $60,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for the period of fiscal years 2007, 2008, and 2009.
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SEC. 103. UPDATE TO THE COMPOSITE RATE COMPONENT OF THE BASIC CASE-MIX ADJUSTED PROSPECTIVE PAYMENT SYSTEM FOR DIALYSIS SERVICES.
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(b) [None Assigned] Gao Report On Home Dialysis Payment.—Not later than January 1, 2009, the Comptroller General of the United States shall submit to Congress a report on the costs for home hemodialysis treatment and patient training for both home hemodialysis and peritoneal dialysis. Such report shall also include recommendations for a payment methodology for payment under section 1881 of the Social Security Act (42 U.S.C. 1395rr) that measures, and is based on, the costs of providing such services and takes into account the case mix of patients.
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SEC. 106. HOSPITAL MEDICARE REPORTS AND CLARIFICATIONS.
(a) [42 U.S.C. 1305ww note] Correction of Mid-Year Reclassification Expiration.—Notwithstanding any other provision of law, in the case of a subsection (d) hospital (as defined for purposes of section 1886 of the Social Security Act (42 U.S.C. 1395ww)) with respect to which a reclassification of its wage index for purposes of such section would (but for this subsection) expire on March 31, 2007, such reclassification of such hospital shall be extended through September 30, 2007. The previous sentence shall not be effected in a budget-neutral manner.
(b) [None Assigned] Revision of the Medicare Wage Index Classification System.—
(1) Medpac report.—
(A) In general.—The Medicare Payment Advisory Commission shall submit to Congress, by not later than June 30, 2007, a report on its study of the wage index classification system applied under Medicare prospective payment systems, including under section 1886(d)(3)(E) of the Social Security Act (42 U.S.C. 1395ww(d)(3)(E)). Such report shall include any alternatives the Commission recommends to the method to compute the wage index under such section.
(B) Funding.—Out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Medicare Payment Advisory Commission, $2,000,000 for fiscal year 2007 to carry out this paragraph.
(2) Proposal to revise the hospital wage index classification system.—The Secretary of Health and Human Services, taking into account the recommendations described in the report under paragraph (1), shall include in the proposed rule published under section 1886(e)(5)(A) of the Social Security Act (42 U.S.C. 1395ww(e)(5)(A)) for fiscal year 2009 one or more proposals to revise the wage index adjustment applied under section 1886(d)(3)(E) of such Act (42 U.S.C. 1395ww(d)(3)(E)) for purposes of the Medicare prospective payment system for inpatient hospital services. Such proposal (or proposals) shall consider each of the following:
(A) Problems associated with the definition of labor markets for purposes of such wage index adjustment.
(B) The modification or elimination of geographic reclassifications and other adjustments.
(C) The use of Bureau of Labor Statistics data, or other data or methodologies, to calculate relative wages for each geographic area involved.
(D) Minimizing variations in wage index adjustments between and within Metropolitan Statistical Areas and Statewide rural areas.
(E) The feasibility of applying all components of the proposal to other settings, including home health agencies and skilled nursing facilities.
(F) Methods to minimize the volatility of wage index adjustments, while maintaining the principle of budget neutrality in applying such adjustments.
(G) The effect that the implementation of the proposal would have on health care providers and on each region of the country.
(H) Methods for implementing the proposal, including methods to phase-in such implementation.
(I) Issues relating to occupational mix, such as staffing practices and any evidence on the effect on quality of care and patient safety and any recommendations for alternative calculations
SEC. 108. PAYMENT PROCESS UNDER THE COMPETITIVE ACQUISITION PROGRAM (CAP).
(b) [42 U.S.C. 1395w-3b note] Construction.—Nothing in this section shall be construed as—
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(1) requiring the conduct of any additional competition under subsection (b)(1) of section 1847B of the Social Security Act (42 U.S.C. 1395w-3b); or
(2) requiring any additional process for elections by physicians under subsection (a)(1)(A)(ii) of such section or additional selection by a selecting physician of a contractor under subsection (a)(5) of such section.
(c) [42 U.S.C. 1395w-3b note] Effective date.—The amendments made by subsection (a) shall apply to payment for drugs and biologicals supplied under section 1847B of the Social Security Act (42 U.S.C. 1395w-3b)—
(1) on or after April 1, 2007; and
(2) on or after July 1, 2006, and before April 1, 2007, for claims that are unpaid as of April 1, 2007.
SEC. 111. [None Assigned] CLARIFICATION OF HOSPICE SATELLITE DESIGNATION.
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Notwithstanding any other provision of law, for purposes of calculating the hospice aggregate payment cap for 2004, 2005, and 2006 for a hospice program under section 1814(i)(2)(A) of the Social Security Act (42 U.S.C. 1395f(i)(2)(A)) for hospice care provided on or after November 1, 2003, and before December 27, 2005, Medicare provider number 29-1511 is deemed to be a multiple location of Medicare provider number 29-1500.
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SEC. 202. PAYMENT FOR ADMINISTRATION OF PART D VACCINES.
(a) [None Assigned] Transition for 2007.—Notwithstanding any other provision of law, in the case of a vaccine that is a covered part D drug under section 1860D-2(e) of the Social Security Act (42 U.S.C. 1395w-102(e)) and that is administered during 2007, the administration of such vaccine shall be paid under part B of title XVIII of such Act as if it were the administration of a vaccine described in section 1861(s)(10)(B) of such Act (42 U.S.C. 1395w(s)(10)(B)).
SEC. 203. [42 U.S.C. 1395w-102 note] OIG STUDY OF NEVER EVENTS.
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(a) Study.—
(1) In general.—The Inspector General in the Department of Health and Human Services shall conduct a study on—
(A) incidences of never events for Medicare beneficiaries, including types of such events and payments by any party for such events;
(B) the extent to which the Medicare program paid, denied payment, or recouped payment for services furnished in connection with such events and the extent to which beneficiaries paid for such services; and
(C) the administrative processes of the Centers for Medicare & Medicaid Services to detect such events and to deny or
(2) Conduct of study.—In conducting the study under paragraph (1), the Inspector General—
(A) shall audit a representative sample of claims and medical records of Medicare beneficiaries to identify never events and any payment (or recoupment) for services furnished in connection with such events;
(B) may request access to such claims and records from any Medicare contractor; and
(C) shall not release individually identifiable information or facility-specific information.
(b) Report.—Not later than 2 years after the date of the enactment of this Act, the Inspector General shall submit a report to Congress on the study conducted under this section. Such report shall include recommendations for such legislation and administrative action, such as a noncoverage policy or denial of payments, as the Inspector General determines appropriate, including—
(1) recommendations on processes to identify never events and to deny or recoup payments for services furnished in connection with such events; and
(2) a recommendation on a potential process (or processes) for public disclosure of never events which—
(A) will ensure protection of patient privacy; and
(B) will permit the use of the disclosed information for a root cause analysis to inform the public and the medical community about safety issues involved.
(c) Funding.—Out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Inspector General of the Department of Health and Human Services $3,000,000 to carry out this section, to be available until January 1, 2010.
(d) Never Events Defined.—For purposes of this section, the term “never event” means an event that is listed and endorsed as a serious reportable event by the National Quality Forum as of November 16, 2006.
Sec. 204. [42 U.S.C. 1395b-1 note] MEDICARE MEDICAL HOME DEMONSTRATION PROJECT.
(a) In General.—The Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall establish under title XVIII of the Social Security Act a medical home demonstration project (in this section referred to as the “project”) to redesign the health care delivery system to provide targeted, accessible, continuous and coordinated, family-centered care to high-need populations and under which—
(1) care management fees are paid to persons performing services as personal physicians; and
(2) incentive payments are paid to physicians participating in practices that provide services as a medical home under subsection (d).
For purposes of this subsection, the term “high-need population” means individuals with multiple chronic illnesses that require regular medical monitoring, advising, or treatment.
(b) Details.—
(1) Duration; scope.—The project shall operate during a period of three years and shall include urban, rural, and underserved areas in a total of no more than 8 States.
(2) Encouraging participation of small physician practices.—The project shall be designed to include the participation of physicians in practices with fewer than three full-time equivalent physicians, as well as physicians in larger practices particularly in rural and underserved areas.
(c) Personal Physician Defined.—
(1) In general.—For purposes of this section, the term “personal physician” means a physician (as defined in section 1861(r)(1) of the Social Security Act (42 U.S.C. 1395x(r)(1)) who—
(A) meets the requirements described in paragraph (2); and
(B) performs the services described in paragraph (3).
Nothing in this paragraph shall be construed as preventing such a physician from being a specialist or subspecialist for an individual requiring ongoing care for a specific chronic condition or multiple chronic conditions (such as severe asthma, complex diabetes, cardiovascular disease, rheumatologic disorder) or for an individual with a prolonged illness.
(2) Requirements.—The requirements described in this paragraph for a personal physician are as follows:
(A) The physician is a board certified physician who provides first contact and continuous care for individuals under the physician's care.
(B) The physician has the staff and resources to manage the comprehensive and coordinated health care of each such individual.
(3) Services performed.—A personal physician shall perform or provide for the performance of at least the following services:
(A) Advocates for and provides ongoing support, oversight, and guidance to implement a plan of care that provides an integrated, coherent, cross-discipline plan for ongoing medical care developed in partnership with patients and including all other physicians furnishing care to the patient involved and other appropriate medical personnel or agencies (such as home health agencies).
(B) Uses evidence-based medicine and clinical decision support tools to guide decision-making at the point-of-care based on patient-specific factors.
(C) Uses health information technology, that may include remote monitoring and patient registries, to monitor and track the health status of patients and to provide patients with enhanced and convenient access to health care services.
(D) Encourages patients to engage in the management of their own health through education and support systems.
(d) Medical Home Defined.—For purposes of this section, the term “medical home” means a physician practice that—
(1) is in charge of targeting beneficiaries for participation in the project; and
(2) is responsible for—
(A) providing safe and secure technology to promote patient access to personal health information;
(B) developing a health assessment tool for the individuals targeted; and
(C) providing training programs for personnel involved in the coordination of care.
(e) Payment Mechanisms.—
(1) Personal physician care management fee.—Under the project, the Secretary shall provide for payment under section 1848 of the Social Security Act (42 U.S.C. 1395w-4) of a care management fee to personal physicians providing care management under the project. Under such section and using the relative value scale update committee (RUC) process under such section, the Secretary shall develop a care management fee code for such payments and a value for such code.
(2) Medical home sharing in savings.—The Secretary shall provide for payment under the project of a medical home based on the payment methodology applied to physician group practices under section 1866A of the Social Security Act (42 U.S.C. 1395cc-1). Under such methodology, 80 percent of the reductions in expenditures under title XVIII of the Social Security Act resulting from participation of individuals that are attributable to the medical home (as reduced by the total care managements fees paid to the medical home under the project) shall be paid to the medical home. The amount of such reductions in expenditures shall be determined by using assumptions with respect to reductions in the occurrence of health complications, hospitalization rates, medical errors, and adverse drug reactions.
(3) Source.—Payments paid under the project shall be made from the Federal Supplementary Medical Insurance Trust Fund under section 1841 of the Social Security Act (42 U.S.C. 1395t).
(f) Evaluations and reports.—
(1) Annual interim evaluations and reports.—For each year of the project, the Secretary shall provide for an evaluation of the project and shall submit to Congress, by a date specified by the Secretary, a report on the project and on the evaluation of the project for each such year.
(2)Final evaluation and report.—The Secretary shall provide for an evaluation of the project and shall submit to Congress, not later than one year after completion of the project, a report on the project and on the evaluation of the project.
SEC. 302. EXTENSION AND EXPANSION OF RECOVERY AUDIT CONTRACTOR PROGRAM UNDER THE MEDICARE INTEGRITY PROGRAM.
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(b) [42 U.S.C. 1395 ddd note] Access to Coordination of Benefits Contractor Database.—The Secretary of Health and Human Services shall provide for access by recovery audit contractors conducting audit and recovery activities under section 1893(h) of the Social Security Act, as added by subsection (a), to the database of the Coordination of Benefits Contractor of the Centers for Medicare & Medicaid Services with respect to the audit and recovery periods described in paragraph (4) of such section 1893(h).
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SEC. 304. [None Assigned] IMPLEMENTATION FUNDING.
For purposes of implementing the provisions of, and amendments made by, this title and titles I and II of this division, other than section 203, the Secretary of Health and Human Services shall provide for the transfer, in appropriate part from the Federal Hospital Insurance Trust Fund established under section 1817 of the Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary Medical Insurance Trust Fund established under section 1841 of such Act (42 U.S.C. 1395t), of $45,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for the period of fiscal years 2007 and 2008.
SEC. 401. [None Assigned] EXTENSION OF TRANSITIONAL MEDICAL ASSISTANCE (TMA) AND ABSTINENCE EDUCATION PROGRAM.
Activities authorized by sections 510 and 1925 of the Social Security Act shall continue through September 30[4], 2007, in the manner authorized for fiscal year 2006, notwithstanding section 1902(e)(1)(A) of such Act, and out of any money in the Treasury of the United States not otherwise appropriated, there are hereby appropriated such sums as may be necessary for such purpose. Grants and payments may be made pursuant to this authority through the third quarter[5] of fiscal year 2007 at the level provided for such activities through the fourth quarter of fiscal year 2006.
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[Internal References.—SSAct Title XVIII, §§1814(i), 1833, 1847B, 1848, 1860D-2, 1886, and 1893(b) have footnotes referring to P.L. 109-432.]
[1] P.L. 110-173, §101(b)(2)(A), inserted “and 2008”, effective December 29, 2007.
[2] P.L. 110-173, §101(b)(2)(B), added subparagraph (F), effective December 29, 2007.
[3] P.L. 110-173, §101(b)(2)(C), amended subparagraph (C) in its entirety, effective December 29, 2007.
[4] P.L. 110-48, §1(a), struck out “June 30” and substituted “September 30”, effective July 18,2007.
[5] P.L. 110-48, §1(b), struck out “third quarter” and substituted “fourth quarter”, effective July 18,2007.
