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H.R. 1021 (114th): Protecting the Integrity of Medicare Act of 2015

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The summary below was written by the Congressional Research Service, which is a nonpartisan division of the Library of Congress, and was published on Mar 18, 2015.

Protecting the Integrity of Medicare Act of 2015

(Sec. 2) Amends title II (Old Age, Survivors and Disability Insurance) of the Social Security Act (SSAct) to direct the Secretary of Health and Human Services to establish cost-effective procedures to ensure that: (1) a Social Security account number (or any derivative) is not displayed, coded, or embedded on the Medicare card issued to an individual entitled to benefits under part A (Hospital Insurance) of SSAct title XVIII (Medicare) or enrolled under Medicare part B (Supplementary Medical Insurance); and (2) any other identifier displayed on such card is not identifiable as a Social Security account number (or any derivative).

Directs the Secretary to make specified transfers during FY2015-FY2018 from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund to: (1) the Centers for Medicare and Medicaid Program Management Account, (2) the Social Security Administration Limitation on Administration Account, and (3) the Railroad Retirement Board Limitation on Administration Account.

(Sec. 3) Directs the Secretary to establish procedures to ensure that Medicare payment is not made for items and services furnished to an individual incarcerated, deceased, or otherwise ineligible and not lawfully present in the United States.

(Sec. 4) Directs the Secretary, if cost-effective and technologically viable, to consider appropriate measures to implement use of electronic Medicare beneficiary and provider smart cards.

(Sec. 5) Extends the Medicare durable medical equipment face-to-face encounter documentation requirement to include physician assistants, practitioners, or specialists as well as physicians (as under current law).

(Sec. 6) Requires each Medicare administrative contractor to establish an improper payment outreach and education program for service providers and suppliers in order to reduce improper Medicare payments.

Requires the Secretary to retain a portion of the amounts recovered by recovery audit contractors to improve the ability of chiropractors to provide documentation of services to the Secretary to ensure that they are reasonable and necessary.

(Sec.7) Requires the Secretary to develop a plan to revise the incentive program under the Health Insurance Portability and Accountability Act of 1996 to encourage greater participation by individuals to report fraud and abuse in the Medicare program.

(Sec. 8) Directs the Secretary to require a claim for a covered Medicare part D (Voluntary Prescription Drug Benefit Program) drug for an individual enrolled in a prescription drug plan or in a Medicare Advantage Prescription Drug plan (PDP) to include a valid prescriber National Provider Identifier.

(Sec. 9) Gives Medicare beneficiaries the option to receive the Medicare Summary Notice (explanation of benefits) electronically.

(Sec.10) Directs the Secretary to: (1) apply competitive procedures to selection of a Medicare administrative contractor at least once every 10 years (currently once every 5 years); and (3) study and, as appropriate, specify incentives for states to work with the Secretary under the Medicare-Medicaid Data Match Program to protect the federal and state share of expenditures.

(Sec. 12) Authorizes a PDP sponsor to establish a drug management program for at-risk beneficiaries.

Requires a PDP sponsor, with respect to covered part D drugs, to have in place, directly or through appropriate arrangements, a utilization management tool designed to prevent: (1) the abuse of frequently abused drugs by individuals, and (2) the diversion of such drugs at pharmacies.

Directs the Secretary to authorize Medicare drug integrity contractors (MEDICs) to accept directly an individual's prescription and necessary medical records from pharmacies, prescription drug plans, and physicians in order for MEDICs to provide information relevant to determining whether the individual is an at-risk beneficiary.

Requires the Government Accountability Office to study: (1) the implementation of these amendments; and (2) the effectiveness of the at-risk beneficiaries for prescription drug abuse drug management program.

(Sec. 13) Directs the Secretary to issue a clarification or modification with respect to the application of the Common Rule (governing the protection of human subjects in research) to activities involving clinical data registries.

(Sec. 14) Amends SSA title XI to eliminate civil monetary penalties for inducements to physicians to limit services that are not medically necessary. Retains such penalties for inducements to limit medically necessary services.

Directs the Secretary to report to Congress on options for amending existing Medicare fraud and abuse laws and regulations to permit gainsharing or similar arrangements between physicians and hospitals that would otherwise be subject to penalties.

(Sec. 15) Modifies the Medicare home health surety bond condition of participation requirement.

(Sec. 16) Directs the Secretary to: (1) implement a process for medical review of spinal subluxation services by a chiropractor, and (2) develop educational and training programs to improve the ability of chiropractors to document services in a manner that demonstrates they are reasonable and necessary.

(Sec. 17) Requires the Secretary to: (1) revise the testing in New Jersey, Pennsylvania, and South Carolina of a model of prior authorization for repetitive scheduled non-emergent ambulance transport to cover specified additional states; and (2) apply the prior authorization program to all states under certain conditions.

(Sec. 19) Directs the Secretary to submit a plan to Congress for including in the annual report of the Comprehensive Error Rate Testing programs data on services (other than medical visits) paid under the physician fee schedule where the fee schedule amount exceeds $250 and where the error rate exceeds 20%.

(Sec. 20) Removes funds for the Medicare Improvement Fund that were added by the Impact Act of 2014.