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H.R. 4302 (113th): Protecting Access to Medicare Act of 2014

Section 212 of this bill pushed back the deadline to implement the ICD-10 code set to October 1, 2015. The Cutting Costly Codes Act of 2013, which would prevent ICD-10 from being implemented at all without further Congressional approval, has been introduced in House and Senate.

The ICD, which is maintained by the World Health Organization (WHO), is a health care classification system that helps internationally track, diagnose, and treat health problems. It is used for the WHO’s statistical tracking and resource allocation to member states. ICD-9 was ratified in 1975. ICD-10 was completed in 1992 and entered use in other countries starting in 1994.

The Health Insurance Portability and Accountability (HIPAA) code set is the U.S. method for implementing the ICD. These codes help doctors diagnose patients and insurance companies determine payouts for treatments. ICD-10 would require the U.S. medical industry, from family doctors to insurance companies, to reform the HIPAA codes they use to be in line with ICD-10, an overhaul estimated to cost millions of dollars for large practices. However, the Centers for Medicare and Medicaid Services (CMS), which is the federal agency that administers HIPAA and oversees federal healthcare programs, has estimated that pushbacks can also cost over one billion dollars.

Last updated Sep 22, 2014. View all GovTrack summaries.

The summary below was written by the Congressional Research Service, which is a nonpartisan division of the Library of Congress.

4/1/2014--Public Law. (This measure has not been amended since it was introduced. The summary has been expanded because action occurred on the measure.) Protecting Access to Medicare Act of 2014 - Title I: Medicare Extenders - (Sec. 101) Amends title XVIII (Medicare) of the Social Security Act (SSA) with respect to physician payment update to: (1) extend the update currently scheduled for January through March of 2014 to the entire calendar year of 2014, (2) freeze the update to the single conversion factor at 0.00% for January 1, 2015, through March 31, 2015, and (3) require that the conversion factor for April 1, 2015, through December 31, 2015, and for 2016 and subsequent years be computed as if such freeze had never applied.

(Sec. 102) Extends: (1) the geographic practice cost index (GPCI) floor through April 1, 2015; (2) the therapy cap exceptions process through March 15, 2015; (3) add-on payments for ground ambulance and super rural ground ambulance services through April 1, 2015; (4) the increased inpatient hospital payment adjustment for certain low-volume hospitals starting on April 1, 2015, for FY2016, and subsequent fiscal years; (5) the Medicare-Dependent Hospital (MDH) program through March 31, 2015; (6) specialized MedicareAdvantage (MA) plans for special needs individuals through December 31, 2016; (7) through December 31, 2016, authority to renew a reasonable cost reimbursement contract with a health maintenance organization and competitive medical plan; and (8) through March 31, 2015, the funding for any contract with a consensus-based entity regarding performance measurement as well as multi-stakeholder group input into selection of quality and efficiency measures (endorsement, input, and selection).

(Sec. 110) Amends the Medicare Improvements for Patients and Providers Act of 2008, as amended by the Patient Protection and Affordable Care Act (PPACA), the American Taxpayer Relief Act, and the Pathway for SGR Reform Act of 2013 to extend through March 31, 2015, the funding of various programs, including area agencies on aging, Aging and Disability Resource Centers, and the contract with the National Center for Benefits and Outreach Enrollment.

(Sec. 111) Authorizes the Secretary of Health and Human Services (HHS) to continue through June 2015 certain medical review activities related to the two-midnight rule.

(The two-midnight rule allows Medicare coverage of only hospital stays for which a physician admits to a hospital a beneficiary expected to require care that crosses two midnights, but generally denies coverage of care expected to require less than a two-midnight stay.)

Prohibits the Secretary, however, from conducting patient status reviews on a post-payment review basis through recovery audit contractors (RACs) for inpatient claims with dates of admission from October 1, 2013, through March 31, 2015, unless there is evidence of systematic gaming, fraud, abuse, or delays in the provision of care by a service provider.

(Sec. 112) Amends SSA title XVIII and the Medicare. Medicaid, and SCHIP Extension Act of 2007 with respect to Medicare long-term care hospital (LTCH) requirements, making technical changes.

Exempts from the moratorium on the establishment of LTCHs any LTCH that: (1) began its qualifying period for payment on or before the date of enactment of this exemption; (2) has a binding written agreement as of the same date with an outside, unrelated party for the actual construction, renovation, lease, or demolition for a LTCH, and has expended, before that date, at least 10% of the project's estimated cost (or, if less, $2.5 million); or (3) has obtained an approved certificate of need in a state where one is required on or before that date of enactment.

Title II: Other Health Provisions - (Sec. 201) Amends SSA title XIX (Medicaid) to extend: (1) through March 31, 2015, the qualifying individual (QI) and transitional medical assistance (TMA) programs, and (2) through September 30, 2015, express lane program eligibility under both Medicaid and SSA title XXI (Children's Health Insurance Program) (CHIP).

(Sec. 204) Amends the Public Health Service Act (PHSA) to extend special diabetes programs for Type I diabetes and for Indians through FY2015.

(Sec. 205) Amends SSA title V (Maternal and Child Health Services Block Grant) to extend: (1) the abstinence education grant and personal responsibility education (PREP) programs through FY2015, and (2) the family-to-family health information centers through March 31, 2015.

(Sec. 208) Amends SSA title XX (Block Grants to States for Social Services) to extend the health workforce demonstration project for low-income individuals through FY2015.

(Sec. 209) Extends the maternal, infant, and early childhood home visiting programs under SSA title V through March 31, 2015.

(Sec. 210) Amends SSA title XI to earmark funding for pediatric quality measures for improving the quality of children's health care. Requires the aggregate amount awarded by the Secretary for grants and contracts for the development, testing, and validation of emerging and innovative evidence-based measures under such program to equal the aggregate amount awarded by the Secretary for grants as part of the program to advance pediatric quality measures.

(Sec. 211) Delays the effective date for Medicaid amendments in the Bipartisan Budget Act of 2013 relating to beneficiary liability settlements.

(Sec. 212) Delays until October 1, 2015, the transition from International Statistical Classification of Diseases (ICD)-9 to ICD-10.

(Sec. 213) Amends PPACA to repeal the limitation on cost-sharing (deductibles) for employer-sponsored health plans.

(Sec. 214) Directs the Comptroller General (GAO), if the Children's Hospital GME Support Reauthorization Act of 2013 is enacted into law, to evaluate the children's hospital graduate medical education (GME) program.

(Sec. 215) Directs the Secretary to: (1) specify a skilled nursing facility (SNF) all-cause all-condition hospital readmission measure (or any successor) by October 1, 2015; (2) specify a measure to reflect an all-condition risk-adjusted potentially preventable hospital readmission rate for SNFs by October 1, 2016; (3) devise a methodology to achieve a high level of reliability and validity, especially for SNFs with a low volume of readmissions; (4) provide confidential feedback reports to SNFs on their performance with respect to such a readmission or resource use measure; and (5) establish procedures for making available to the public by posting on the Nursing Home Compare Medicare website information on the performance of SNFs with respect to such measures. Directs the Secretary to establish a SNF value-based purchasing (SNF VBP) program under which value-based incentive payments (VBPs) are made in a fiscal year to SNFs, applying first a readmission measure, then as soon as practicable a resource use measure in lieu of the readmission measure. Requires the Secretary to: (1) establish performance standards with respect to the measure applied for a performance period for a fiscal year; (2) develop a methodology for assessing the total performance of each SNF based on such performance standards; (3) rank the SNF performance scores determined from low to high; (4) increase the adjusted federal per diem rate otherwise applicable to a SNF by the VBP, which may include a zero percentage; (5) reduce that adjusted federal per diem rate by 2% beginning FY2019; and (9) make information about SNF performance under the SNF VBP program available to the public on the Nursing Home Compare Medicare website. Directs the Medicare Payment Advisory Commission (MEDPAC) to report to Congress on the progress of SNF VBP program and recommend improvements to it. (Sec. 216) Amends SSA title XVIII to prescribe requirements for establishment of Medicare payment rates for clinical diagnostic laboratory tests and new advanced diagnostic laboratory tests. Requires a Medicare administrative contractor to issue a coverage policy with respect to a clinical diagnostic test only in accordance with the process for making a local coverage determination. Directs the Comptroller General (GAO) to study implementation of the new payment rates for clinical diagnostic laboratory tests. (Sec. 217) Amends the American Taxpayer Relief Act of 2012 to delay to January 1, 2024, the implementation of oral-only end stage renal disease (ESRD)-related drugs in the ESRD prospective payment system. Revises Medicare requirements for the Medicare end state renal disease (ESRD) prospective payment system, including with respect to: (1) the adjustment to the ESRD bundled payment rate to account for changes in the utilization of certain drugs and biologicals, and (2) quality measures related to conditions treated by oral-only drugs under the ESRD quality incentive program. Requires the Secretary, as part of the promulgation of annual rule for the Medicare ESRD prospective payment system for calendar year 2016, to establish a process for: (1) determining when a product is no longer an oral-only drug, and (2) including new injectable and intravenous products into the bundled payment under such system. Directs the Secretary to audit Medicare cost reports, beginning during 2012, for a representative sample of service providers and renal dialysis facilities. (Sec. 218) Prescribes quality incentives to promote patient safety and health, including penalties, for certain computed tomography services. Directs the Secretary through rulemaking to specify appropriate use criteria for imaging services only from those developed or endorsed by national professional medical specialty societies or other provider-led entities. Requires the Secretary then to promote the application of such criteria by ordering professionals and furnishing professionals to imaging services furnished in a physician's office, a hospital outpatient department (including an emergency department), an ambulatory surgical center, and any other provider-led outpatient setting. (Sec. 219) Eliminates FY2014-FY2015 funding for the Medicare Improvement Fund. (Sec. 220) Authorizes the Secretary to collect and use certain information on physicians' services in the determination of relative values in the formulae for setting physicians' fees. Authorizes the Secretary to establish or adjust practice expense relative values using cost, charge, or other data from suppliers or service providers. Revises and expands the list of codes which the Secretary must examine to identify potentially misvalued codes. Sets a target for relative value adjustments for misvalued services for 2017-2020. Phases-in over a two-year period significant relative value unit (RVU) reductions Requires the GAO to study the processes used by the Relative Value Scale Update Committee (RUC) to make recommendations to the Secretary regarding relative values for specific services under the Medicare physician fee schedule. Makes metropolitan statistical areas in California fee schedule areas for calculation of the geographical adjustment factor in the formulae for setting physicians' fees. Directs the Secretary to make publicly available the information used to establish the multiple procedure payment reduction policy to the professional component of imaging services in a specified final rule. (Sec. 221) Amends SSA title XIX to increase the amounts of reductions to Medicaid disproportionate share hospital (DSH) allotments for FY2017-FY2024. Requires the Medicaid and CHIP Payment and Access Commission (MACPAC) to review and report annually to Congress on DSH payments. (Sec. 222) Amends the Balanced Budget and Emergency Deficit Control Act of 1985 (Gramm-Rudman-Hollings Act) to adjust the 2% maximum reduction for specified Medicare programs for FY2024 under any presidential sequestration order to make it 4% for the first 6 months of FY2024 and 0% for the last 6 months. (Sec. 223) Requires the Secretary to publish criteria for a state-certified community behavioral health clinic to participate in a mental health services demonstration program participated in by a state.

Directs the Secretary, through the Administrator of the Centers for Medicare & Medicaid Services, to issue guidance for the establishment of a prospective payment system that shall apply only to medical assistance for mental health services furnished by a certified community behavioral health clinic participating in a demonstration program.

Requires the Secretary to award planning grants to states to develop proposals to participate in two-year demonstration programs.

Makes appropriations for FY2014 and FY2016.

(Sec. 224) Directs the Secretary to establish a 4-year pilot program to award up to 50 grants each year to eligible entities for assisted outpatient treatment programs for individuals with serious mental illness. Authorizes appropriations for FY2015-FY2018.

(Sec. 225) Excludes the budgetary effects of this Act from the PAYGO scorecard under the Statutory Pay-As-You-Go Act of 2010 as well as from the Senate PAYGO scorecard.