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H.R. 2 (114th): Medicare Access and CHIP Reauthorization Act of 2015

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), (H.R. 2, Pub.L. 114–10) commonly called the Permanent Doc Fix, is a United States statute. It changes the payment system for doctors who treat Medicare patients. It revises the Balanced Budget Act of 1997. It was the largest scale change to the American health care system following the Affordable Care Act ("ObamaCare") in 2010.

This summary is from Wikipedia.

Last updated Oct 11, 2018. Source: Wikipedia

The summary below was written by the Congressional Research Service, which is a nonpartisan division of the Library of Congress, and was published on Apr 17, 2015.

(This measure has not been amended since it was introduced. The expanded summary of the House passed version is repeated here.)

Medicare Access and CHIP Reauthorization Act of 2015 TITLE I--SGR REPEAL AND MEDICARE PROVIDER PAYMENT MODERNIZATION (Sec. 101) Amends title XVIII (Medicare) of the Social Security Act (SSAct) to: (1) remove sustainable growth rate (SGR) methodology from the determination of annual conversion factors in the formula for payment for physicians' services, and (2) revise the update in rates for 2015 and subsequent years.

Requires two separate conversion factors for each year beginning with 2026, one for items and services furnished by a qualifying alternative payment model (APM) participant (qualifying APM conversion factor), and the other for other items and services (nonqualifying APM conversion factor).

Freezes the update to the single conversion factor at 0.0% for January through June 2015.

Sets the same update at 0.5% for July1 through December 31, 2015, as well as for 2016 through 2019, then reduces it to 0.00% for 2020 through 2025.

Sets the update to the qualifying APM conversion factor at 0.75%, and the update to the nonqualifying APM conversion factor at .0.25%, for 2026 and each subsequent year.

Directs the Medicare Payment Advisory Commission (MEDPAC) to report to Congress on the relationship between: (1) physician and other health professional utilization and expenditures (and their rate of increase) of items and services for which Medicare payment is made; and (2) total utilization and expenditures (and their rate of increase) under Medicare parts A (Hospital Insurance), B (Supplementary Medical Insurance), and D (Voluntary Prescription Drug Benefit Program). Requires a separate report on the 2015-2019 update to physicians' services under Medicare.

Directs the Secretary of Health and Human Services to consolidate components of the three specified existing performance incentive programs into a new Merit-based Incentive Payment (MIP) system under which eligible professionals (including physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists, but excluding most APM participants) shall receive annual payment increases or decreases based on their performance as measured by standards the Secretary shall establish according to specified criteria.

Requires the Government Accountability Office (GAO) to: (1) evaluate the MIP System; (2) examine the similarities and differences in the use of quality measures under the original Medicare fee-for-service program under SSAct title XVIII parts A (Hospital Insurance) and B (Supplementary Medical Insurance), the Medicare Advantage program under SSAct title XVIII part C (Medicare+Choice), selected state medical assistance programs under SSA title XIX (Medicaid), and private payer arrangements; and (3) make recommendations on how to reduce the administrative burden in applying such measures.

Directs GAO also to: (1) examine whether entities that pool financial risk for physician practices, such as independent risk managers, can play a role in supporting such practices, particularly small physician practices, in assuming financial risk for the treatment of patients; (2) report on the transition of professionals in rural areas, health professional shortage areas, or medically underserved areas to an APM; and (3) make recommendations for removing administrative barriers to such arrangements, on the one hand, and practices, including small practices, in such areas to participate in APM models.

Establishes an ad hoc Physician-Focused Payment Technical Advisory Committee to make comments and recommendations to the Secretary on physician-focused payment models..

Prescribes requirements for incentive payments to eligible APM participants.

Directs the Secretary to study: (1) the feasibility of integrating APMs into the Medicare Advantage payment system; and (2) the applicability of federal fraud prevention laws to items and services paid for under an APM.

(Sec. 102) Directs the Secretary to draft a plan for development of quality measures to assess professionals, including non-patient-facing professionals.

(Sec. 103) Directs the Secretary to make payments for chronic care management services furnished by a physician, physician assistant or nurse practitioner, clinical nurse specialist, or certified nurse midwife.

Directs the Secretary to conduct an education and outreach campaign to inform relevant professionals and Medicare part B enrollees of the benefits of chronic care management services.

(Sec. 104) Directs the Secretary to make publicly available, on an annual basis, information with respect to physicians and other eligible professionals on items and services furnished to Medicare beneficiaries.

(Sec. 105) Expands the kinds of uses of Medicare data available to qualified entities for quality improvement activities.

Directs the Secretary to provide Medicare data to qualified clinical data registries to facilitate quality improvement or patient safety.

(Sec. 106) Allows continuing renewals of any two-year period for which a physician or practitioner opts out of the Medicare claims process under a private contract.

Directs the Secretary to make publicly available through an appropriate HHS website information on the number and characteristics of opt-out physicians and practitioners.

Declares it a national objective to achieve widespread exchange of health information through interoperable certified electronic health records (EHR) technology nationwide by December 31, 2018. Directs the Secretary to establish related metrics.

Requires the Secretary to examine the feasibility of establishing one or more mechanisms to assist providers in comparing and selecting certified EHR technology products

Directs GAO to study specified telehealth and remote patient monitoring services.


Subtitle A--Medicare Extenders

(Sec. 201) Amends SSAct title XVIII to extend through calendar year 2017 the current 1.0 floor for the work geographic practice cost index for adjusting the Medicare fee schedule for physician services.

(Sec. 202) Extends through calendar year 2017 the process under which an individual may, upon request, obtain an exception from the uniform dollar limitation for physical therapy services, speech-language pathology services, and occupational therapy services.

Directs the Secretary, in place of the manual medical review process, to implement a targeted medical review process to identify and conduct medical reviews for outpatient therapy services furnished by a service provider or supplier.

(Sec. 203) Extends through calendar year 2017 the temporary increase in payment for ground ambulance services, including urban, rural, and super rural ground ambulance services.

(Sec. 204) Extends through FY2017 the increased inpatient hospital payment adjustment for certain low-volume (subsection [d]) hospitals. (Generally, a subsection [d] hospital is an acute care hospital, particularly one that receives payments under Medicare's inpatient prospective payment system when providing covered inpatient services to eligible beneficiaries.)

(Sec. 205) Extends through FY2016 the Medicare-dependent hospital program for certain small rural subsection (d) hospitals.

(Sec. 206) Extends through calendar year 2018 the authority of specialized MA plans for special needs individuals to restrict enrollment to individuals within one or more classes of special needs individuals. (Sec. 207) Extends through FY2017 increased funding for contracts with a consensus-based entity regarding health care performance measurement (endorsement, input, and selection).

(Sec. 208) Amends the Medicare Improvements for Patients and Providers Act of 2008 to provide through FY2017 additional funding for: (1) state health insurance programs, (2) area agencies on aging, (3) Aging and Disability Resource Centers, and (4) Secretary's contract with the National Center for Benefits and Outreach Enrollment.

(Sec. 209) Revises requirements for reasonable cost reimbursement contracts for health maintenance organizations whose contracts cannot be renewed or extended for a service area which, during the entire previous year, was within the service area of two or more MA regional or local plans meeting certain minimum enrollment requirements and offered by different MA organizations.

Allows extension of such a contract for the two years following 2016 only if the organization converts into a Medicare Advantage (MA) plan under Medicare part C.

Allows reasonable cost plans that otherwise meet MA plan requirements to transition voluntarily into MA plans.

Deems an MA eligible individual, unless electing otherwise, to have elected to receive benefits through an applicable MA plan, and to be enrolled in it, if the individual is enrolled in a reasonable cost reimbursement contract in the previous plan year and the applicable MA plan is the plan that was converted from that reasonable cost reimbursement contract.

Gives beneficiaries the option to discontinue or change the MA plan or MA prescription plan after deemed enrollment.

(Sec. 210) Amends the Medicare Prescription Drug Improvement and Modernization Act of 2003 to extend through calendar 2017 the payment increase for home health services provided in rural areas.

Subtitle B--Other Health Extenders (Sec. 211) Makes permanent the qualifying individual (QI) program under which states pay Medicare Part B premiums for low-income Medicare beneficiaries with income between 120% and 135% of the federal poverty level. Extends funding for the QI program through FY2016, with a formula for increasing subsequent allocations.

(Sec. 212) Makes permanent the work-related transitional medical assistance (TMA) program requiring states to provide from 6 to 12 additional months of coverage for families that lose Medicaid eligibility because of increased hours of work or income from employment or from the loss of a time-limited earned income disregard.

(Sec. 213) Amends the Public Health Service Act to extend through FY2017 the two special diabetes programs for type 1 diabetes and for Indians.

(Sec. 214) Amends SSAct title V (Maternal and Child Health Services) to extend through FY2017 at increased levels the separate formula grant program for premarital sexual abstinence education.

Requires the baseline to be calculated assuming that no grant shall be made under the program after FY2017.

(Sec. 215) Extends through FY2017 the personal responsibility education program of formula grants to states to support evidence-based programs designed to educate adolescents about sexual abstinence, contraception, and adulthood.

(Sec. 216) Extends through FY2017 Family-to-Family Health Information Centers providing information and resources to families of children with special health care needs.

(Sec. 217) Amends SSAct title XX (Block Grants to States for Social Services) to extend through FY2017 demonstration projects to aid low-income individuals to train for health care professions.

(Sec. 218) Amends SSAct title V to extend through FY2017 the Maternal, Infant, and Early Childhood Home Visiting programs.

(Sec. 219) Amends SSAct title XIX to specify the FY2015-FY2025 allotments for Tennessee for disproportionate share hospital (DSH) payments to hospitals treating large numbers of low-income patients.

(Sec. 220) Amends the Bipartisan Budget Act of 2013, as amended by the Protecting Access to Medicare Act of 2014, to delay until October 1, 2017, the effective date for certain Medicaid amendments relating to third-party liability settlements and judgments received by Medicaid beneficiaries from all portions of which a state may recover Medicaid payments.

(Sec. 221) Amends the Patient Protection and Affordable Care Act to extend through FY2017 funding for Community Health Centers and the National Health Service Corps.

Amends the Public Health Service Act to extend through FY2017 funding for direct and indirect graduate medical education payments to teaching health centers.

TITLE III--CHIP (Sec. 301) Amends SSAct title XXI (State Children's Health Insurance Program) (CHIP) to extend the CHIP program through FY2017, with revised allotment requirements. Prescribes a special rule formula for FY2016.

Extends through FY2017 a qualifying state's option to use their CHIP allotment funds to finance the difference between the Medicaid and CHIP matching rates.

Extends through FY2017 the Child Enrollment Contingency Fund.

(Sec. 302) Amends SSAct XIX to extend through FY2017 the state option to rely on express lane agency determinations of CHIP eligibility.

(Sec. 303) Extends the outreach and enrollment program under CHIP through FY2017.

(Sec. 304) Extends through FY2017 the childhood obesity demonstration project and the pediatric quality measures program under SSA title XI.

(Sec. 305) Directs the HHS Inspector General to report to Congress to: (1) provide data on the number of individuals enrolled in the Medicaid program and in CHIP through the use of the Express Lane option, (2) assess the extent to which individuals so enrolled meet the eligibility requirements under Medicaid or CHIP, and (3) provide data on federal and state expenditures under Medicaid and CHIP for individuals so enrolled.


Subtitle A--Medicare Beneficiary Reforms

(Sec. 401) Amends SSAct title XVIII to deny Medigap policies that cover Part B deductibles to Medicare beneficiaries newly eligible on or after January 1, 2020.

(Sec. 402) Adjusts income thresholds for Medicare part B (Supplementary Medical Insurance) premiums for years beginning with 2018.

Subtitle B--Other Offsets (Sec. 411) Amends SSA title XVIII to set 1% market basket percentage increases or annual updates for hospice, long-term care hospital, and other providers.

(Sec. 412) Revises or sets the aggregate reductions in Medicaid DSH allotments for FY2018-FY2025.

(Sec. 413) Amends the Internal Revenue Code to increase from 30% to 100% the amount of a levy applied against a tax payer for any specified payment due a Medicare provider or supplier.

(Sec. 414) Amends the TMA, Abstinence Education, and QI Programs Extension Act of 2007, as amended by the American Taxpayer Relief Act of 2012, to adjust inpatient hospital payment rates for discharges occurring during FY2018-FY2023.


Subtitle A--Protecting the Integrity of Medicare

(Sec. 501) Amends SSAct II (Old Age Survivors and Disability Insurance) to direct the Secretary to establish procedures to ensure that a Social Security number is not displayed on an individual's Medicare card.

(Sec. 502) Directs the Secretary to establish procedures to ensure that Medicare payments are not furnished to incarcerated individuals, individuals not lawfully present in the United States, and deceased individuals.

(Sec. 503) Requires the use of Medicare beneficiary smart cards, subject to certain conditions.

(Sec. 504) Modifies the requirement that a physician order for Medicare durable medical equipment (DME) document that the physician, physician assistant, practitioner, or specialist concerned has had face-to-face encounter with the patient.

(Sec. 505) Requires Medicare administrative contractors (MACs) to establish an improper payment outreach and education program.

(Sec. 506) Directs 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 in reporting fraud and abuse in the Medicare program.

(Sec. 507) Directs the Secretary to require valid prescriber National Provider Identifiers on pharmacy claims for part D drugs.

(Sec. 508) Allows individuals the option to receive the Medicare summary notice electronically.

(Sec. 509) Requires the Secretary to: (1) provide for the application of competitive procedures under a contract with a MAC once every 10 years (currently once every 5 years); and (2) make available to the public the performance of each MAC.

(Sec. 510) Requires the Secretary to study and specify incentives for states to work with the Secretary under the Medicare-Medicaid Data Match Program to coordinate appropriate actions to protect the federal and state share of expenditures under the Medicare and Medicaid programs.

(Sec. 511) Directs the Secretary to issue a clarification or modification with respect to the application of certain regulations (commonly known as "the Common Rule") to qualified clinical data registries.

(Sec. 512) Eliminates civil monetary penalties for inducements to physicians to limit services that are not medically necessary. Applies such penalties only where the services reduced or limited are medically necessary.

Requires the Secretary to report to Congress on permitting gainsharing arrangements between physicians and hospitals that improve care while reducing waste and increasing efficiency.

(Sec. 513) Requires Medicare home health agencies to post a surety bond of at least $50,000 or an amount commensurate with the volume of payments to the agency.

(Sec. 514) Requires a medical review process for spinal subluxation services to a Medicare beneficiary by a chiropractor.

Directs the Secretary to develop educational and training programs to improve the ability of the chiropractors to provide documentation to the Secretary

Requires GAO to study the effectiveness of the process for such a medical review.

(Sec. 515) Adds a new requirement for the testing of a prior authorization model for repetitive scheduled non-emergent ambulance transport in New Jersey, Pennsylvania, and South Carolina. Directs the Secretary to revise the testing to cover additional, specified states located in MAC regions L and 11. Requires the Secretary to expand such model to all states in certain circumstances.

(Sec. 517) Requires the Secretary to submit to Congress a plan for expanding data in the annual Comprehensive Error Rate Testing program report.

(Sec. 518) Amends SSA title XVIII to remove funds for the Medicare Improvement Fund that were added by the Improving Medicare Post-Acute Care Transformation Act of 2014.

Subtitle B--Other Provisions (Sec. 521) Amends the Protecting Access to Medicare Act of 2014 to extend certain medical review activities involving the two-midnight rule. (The two-midnight rule allows Medicare coverage only of hospital stays where 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.)

(Sec. 522) Prohibits an entity from submitting a bid for a competitive acquisition area, during calendar 2017-2019, under a competitive DME and prosthetics, orthotics, and supplies (DMEPOS) acquisition program, unless it has obtained a bid surety bond of between $50,000 and $100,000 for each such area.

Requires the forfeit of any bid bond submitted for a competitive acquisition area if the bidding entity does not accept a contract offered for a product category when its composite bid was at or below the median composite bid rate for all bidding entities included in the calculation of the single payment amounts for the product category and the area. Requires the Secretary to collect on the forfeited bond.

Requires return of a bid bond within a specified 90-day period to a bidding entity that does not meet such bid forfeiture conditions.

Prohibits the Secretary from awarding a contract to any entity that does not meet state licensure requirements.

Requires a GAO study on the effect of this bid surety bond requirement on the participation of small suppliers in the Medicare DMEPOS competitive acquisition program.

(Sec. 523) Prohibits the Secretary from implementing the final rule requiring the transition of all 10-day and 90-day global surgical packages to 0-day global periods. (A global surgical package, also called global surgery, includes all necessary services normally furnished by a surgeon before, during, and after a procedure, a time-span constituting the global period.)

Directs the Secretary through rulemaking to develop and implement a process to gather, from a representative sample of physicians, information needed to value surgical services.

(Sec. 524) Extends through FY2015 the Secure Rural Schools and Community Self-Determination Act of 2000 and payments in lieu of taxes to the governments of states and counties containing tax-exempt federal land.

Prescribes a special rule for FY2014 payments.

Extends indefinitely requirements for the funding of special projects on federal land for which participating counties elect to expend a portion of such federal funds. Extends through FY2017 the authority to initiate such projects.

Extends indefinitely the authorization of appropriations under the Act.

(Sec. 525) Prohibits the entry of the budgetary effects of this Act on either PAYGO scorecard maintained under the Statutory Pay-As-You-Go Act of 2010 or section 201 of S. Con. Res. 21 (110th Congress).