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S. 1989 (114th): Primary Care Enhancement Act of 2015

The text of the bill below is as of Aug 5, 2015 (Introduced).


II

114th CONGRESS

1st Session

S. 1989

IN THE SENATE OF THE UNITED STATES

August 5, 2015

introduced the following bill; which was read twice and referred to the Committee on Finance

A BILL

To improve access to primary care services.

1.

Short title

This Act may be cited as the Primary Care Enhancement Act of 2015.

2.

Treatment of direct primary care service arrangements

(a)

In general

Section 223(c) of the Internal Revenue Code of 1986 is amended by adding at the end the following new paragraph:

(6)

Treatment of direct primary care service arrangements

An arrangement under which an individual is provided ongoing primary care services in exchange for a fixed periodic fee which is not billed to any third party on a fee for service basis—

(A)

shall not be treated as a health plan for purposes of paragraph (1)(A)(ii), and

(B)

shall not be treated as insurance for purposes of subsection (d)(2)(B).

.

(b)

Effective date

The amendment made by this section shall apply to taxable years beginning after the date of the enactment of this Act.

3.

Certain provider fees to be treated as medical care

(a)

In general

Subsection (d) of section 213 of the Internal Revenue Code of 1986 is amended by adding at the end the following new paragraph:

(12)

Periodic provider fees

The term medical care shall include periodic fees paid to a primary care physician for a defined set of medical services on an as-needed basis.

.

(b)

Effective date

The amendment made by this section shall apply to taxable years beginning after the date of the enactment of this Act.

4.

Medicare primary care medical home demonstration program

Section 1115A of title XI of the Social Security Act (42 U.S.C. 1315a) is amended—

(1)

in subsection (b)(2)(A), in the last sentence, by inserting , and shall include the model described in subsection (h) before the period at the end; and

(2)

by adding at the end the following new subsection:

(h)

Primary care medical home model

(1)

Model

(A)

In general

The model described in this subsection is a model under which qualified direct primary care medical home practices are reimbursed a periodic fee for furnishing services to an individual enrolled under part B of title XVIII.

(B)

Qualified direct primary care medical home practice

In this subsection, the term qualified direct primary care medical home practice means a qualified direct primary care medical home practice described in section 1301(a)(3) of the Patient Protection and Affordable Care Act (as amended by section 10104(a) of such Act).

(2)

Periodic fee

(A)

In general

Subject to the succeeding provisions of this paragraph, the Secretary shall establish the periodic fee to be paid to qualified direct primary care medical home practices participating in the model under this subsection for each individual enrolled in the practice.

(B)

Affordable primary care

In no case may a monthly equivalent of the periodic fee established by the Secretary under subparagraph (A) exceed an amount equal to twenty percent of the average per capita monthly amount that the Secretary estimates will be payable from the Federal Hospital Insurance Trust Fund under section 1817 and from the Federal Supplementary Medical Insurance Trust Fund for services and related administrative costs for an individual under parts A and B of title XVIII.

(C)

Adjustment to periodic fee

(i)

Performance benchmark

The Secretary shall establish a performance benchmark for a year using the ACO quality measures in the Medicare shared savings program under section 1899.

(ii)

Adjustment

Beginning with the second year the model under this subsection is conducted, in the case of a qualified direct primary care medical home practice participating in the model under this subsection—

(I)

that meets or exceeds the performance benchmark for the year under clause (i), the periodic fee paid to the practice for each individual enrolled in the practice shall be increased by 5 percent; and

(II)

that does not meet the performance benchmark for the year under clause (i), the periodic fee paid to the practice for each individual enrolled in the practice shall be reduced by 5 percent.

(3)

Termination if performance benchmark not net for 2 consecutive years

The Secretary shall terminate the participation of a qualified direct primary care medical home practice in the model under this subsection if the practice would otherwise be subject to the adjustment under paragraph (2)(C)(ii)(II) for 2 consecutive years.

(4)

Scope of services

Each qualified direct primary care medical home practice shall employ the following activities and functions associated with direct primary care medical homes:

(A)

Preventive care.

(B)

Wellness counseling.

(C)

Primary care.

(D)

Coordination of primary care with specialty and hospital care.

(E)

Availability of ongoing care appointments 7 days per week.

(F)

Secure e-mail and telephone consultation.

(G)

Availability of telephone access for ongoing care consultation on a 7-day-per-week, 24-hour-per-day basis.

(H)

Use of a primary care provider panel size that promotes the ability of participating providers to appropriately provide the scope of services described in this paragraph.

(5)

Priority

(A)

In general

In selecting qualified direct primary care medical home practices to participate under this subsection, the Secretary shall provide priority to practices that seek to enroll individuals who are dual eligible individuals.

(B)

Dual eligible individual

In subparagraph (A), the term dual eligible individual means an individual who is—

(i)

enrolled under part B of title XVIII; and

(ii)

described in subparagraph (A)(ii) of section 1935(c)(6) of the Social Security Act (42 U.S.C. 1396u–5(c)(6)), taking into account the application of subparagraph (B) of such section.

(6)

Not insurance

Care provided in a qualified direct primary care medical home practice participating in the model under this subsection shall not be considered an insurance product and shall not be subject to regulation as an insurance product or health maintenance organization by State insurance commissioners.

(7)

Reporting to Secretary

A qualified direct primary care medical home practice participating in the model under this subsection shall submit to the Secretary an annual report on—

(A)

the progress, of individuals enrolled in the practice with one or more chronic conditions, on the following:

(i)

Emergency room visits.

(ii)

Hospitalizations.

(iii)

Surgeries (including type of surgery).

(iv)

Specialist visits.

(v)

Use of advanced radiology (other than mammograms and DEXA scans); and

(B)

such other areas determined appropriate by the Secretary.

(8)

Provision of data to practices

The Secretary shall provide qualified direct primary care medical home practices participating in the model under this subsection with all necessary and relevant patient data, including any prior claims data, needed for clinical purposes and for the purpose of providing an evaluation of such the model under this subsection.

(9)

Providers currently opted out of Medicare

Notwithstanding section 1802(b), a physician or practitioner who has currently opted out of the Medicare program under such section may participate in a qualified direct primary care medical home practice participating in the model under this subsection and payment may be made under this title with respect to items and services furnished by such physician or practitioner under such model to Medicare beneficiaries with whom the physician or practitioner has in effect a private contract under such section.

(10)

Fraud

A physician or practitioner who has been excluded from participation in a Federal health care program (as defined in section 1128C(f)) shall not be permitted to participate in a qualified direct primary care medical home practice under the model under this subsection.

(11)

Duration

Subject to subsection (b)(3), the Secretary shall conduct the model under this subsection for a period of not less than 3 years.

(12)

Expansion

Notwithstanding subsection (c), if the Secretary determines, after the third year that the model under this subsection is conducted, that—

(A)

a qualified direct primary care medical home practice participating in the model under this subsection meets the requirements under paragraphs (1), (2), and (3) of such subsection, such practice shall continue permanently as long as it continues to meet such requirements and the other requirements of this subsection; and

(B)

a majority of qualified direct primary care medical home practice participating in the model under this subsection meet the requirements under paragraphs (1), (2), and (3) of such subsection, the Secretary shall expand the model on a nationwide basis.

.

5.

Use of direct primary care medical homes under the Medicare Advantage program

(a)

In general

Nothing in title XVIII of the Social Security Act or any other provision of law shall be construed to prohibit a Medicare Advantage organization offering a Medicare Advantage plan under part C of such title from—

(1)

contracting with a qualified direct primary care medical home practice to offer primary care services under such plan; or

(2)

including in such contract provisions for shared savings agreed upon between the Medicare Advantage organization and the the qualified direct primary care medical home practice.

(b)

Qualified direct primary care medical home practice

In this section, the term qualified direct primary care medical home practice means a qualified direct primary care medical home practice described in section 1301(a)(3) of the Patient Protection and Affordable Care Act (as amended by section 10104(a) of such Act).