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II
113th CONGRESS
1st Session
S. 1228
IN THE SENATE OF THE UNITED STATES
June 26, 2013
Mr. Wyden (for himself
and Mr. Portman) introduced the following
bill; which was read twice and referred to the
Committee on
Finance
A BILL
To establish a program to provide incentive payments to
participating Medicare beneficiaries who voluntarily establish and maintain
better health.
1.
Short
title
This Act may be cited as
the Medicare Better Health Rewards
Program Act of 2013.
2.
Medicare Better
Health Rewards Program
Part B
of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.) is amended
by adding at the end the following new section:
1849.
Medicare Better Health Rewards Program
(a)
In
general
The Secretary shall establish a Better Health Rewards
Program (in this section referred to as the Program) under which
incentives are provided to Medicare beneficiaries who voluntarily agree to
participate in the Program.
(b)
Enrollment
A
health professional participating in the Program shall provide their patients
who are Medicare beneficiaries with a description of and an opportunity to
enroll in the Program on a voluntary basis. If a Medicare beneficiary elects to
enroll in the Program, the health professional shall inform the Secretary of
the individual's enrollment through a process established by the Secretary,
which does not impose additional administrative requirements on the
participating health professional.
(c)
Establishment
of better health target standards
(1)
In
general
(A)
Establishment
The
Secretary shall establish standards for measuring better health targets and
points for achieving such standards for participating Medicare beneficiaries,
including such standards and points with respect to the following:
(i) Annual wellness
visit.
(ii) Tobacco
cessation.
(iii) Body Mass Index
(BMI).
(iv) Diabetes
screening test.
(v) Cardiovascular
disease screening.
(vi) Cholesterol
level screening.
(vii) Screening tests
and specified vaccinations.
(B)
Consultation
In
establishing standards and points for achieving such standards under this
subsection, the Secretary—
(i) shall consult
with 1 or more nationally recognized health care quality organizations, as
determined appropriate by the Secretary; and
(ii) may consult with
physicians and other professionals experienced with wellness programs.
(C)
Points
The
number of points awarded for a year for achieving standards with respect to
each of the targets described in clauses (i) through (vii) of subparagraph (A)
shall not exceed 5. Such points may be awarded on a sliding scale, based on
standards established under this subsection, as determined appropriate by the
Secretary.
(2)
Modification of
better health target standards and assigned points
(A)
In
general
The Secretary may modify standards for measuring better
health targets and, subject to paragraph (1)(C), points for achieving such
standards for participating Medicare beneficiaries under this
subsection.
(B)
Consultation
In
modifying standards and points for achieving such standards under this
paragraph, the Secretary—
(i) shall consult
with 1 or more nationally recognized health care quality organizations, as
determined appropriate by the Secretary; and
(ii) may consult with
physicians and other professionals experienced with wellness programs.
(d)
Conduct of
program
(1)
Duration
(A)
In
general
Subject to subparagraph (B), the Program shall be
conducted for not less than a 3-year period.
(B)
Expansion
The
Secretary shall expand the duration and scope of the Program, to the extent
determined appropriate by the Secretary, if—
(i) the Secretary
determines that such expansion is expected to—
(I) reduce spending
under this title without reducing the quality of care; or
(II) improve the
quality of care and reduce spending;
(ii) the Chief
Actuary of the Centers for Medicare & Medicaid Services certifies that such
expansion would reduce program spending under this title; and
(iii) the Secretary
determines that such expansion would not deny or limit the coverage or
provision of benefits under this title for individuals.
(2)
Collection and
use of baseline data
During the first year of the Program, a
health professional shall establish and report to the Secretary baseline
information for each participating Medicare beneficiary who is a patient of the
health professional as part of that beneficiary’s first year assessment under
paragraph (3)(A). The health professional shall use such data to aid in the
determination of whether and to what extent the participating Medicare
beneficiary is meeting the target standards under subsection (c) in each of
years 2 and 3 of the Program.
(3)
Required
assessments for participating Medicare beneficiaries
(A)
First
year
During year 1 of the Program, a health professional shall
furnish to each participating Medicare beneficiary that is a patient of the
health professional either an annual wellness visit or an initial preventive
physical examination.
(B)
Second and
third years
During each of years 2 and 3 of the Program, a health
professional shall furnish to each participating Medicare beneficiary that is a
patient of the health professional an annual wellness visit to determine
whether and to what extent the participating Medicare beneficiary has met the
target standards under subsection (c).
(e)
Determination
of points and payment of incentives
(1)
Determination
of points
During each of years 2 and 3 of the Program, a health
professional shall—
(A) evaluate and
report to the Secretary whether each participating Medicare beneficiary that is
a patient of the health professional has achieved the target standards under
subsection (c); and
(B) determine the
total amount of points that each such participating Medicare beneficiary has
achieved for the year based on the points assigned for achieving such standards
under subsection (c).
(2)
Incentive
payment
(A)
In
general
The Secretary shall pay to each participating Medicare
beneficiary who achieves at least 20 points under paragraph (1)(B) for the year
an incentive payment. Such payment shall be equal to an amount determined
appropriate by the Secretary, but no case shall such amount exceed the
following:
PointsYear 2 Payment
AmountYear 3 or a Subsequent Year Payment Amount
20–24
points$100$200
25 or
more points$200$400.
(B)
Inflation
adjustment
The dollar amounts specified in this paragraph shall
be increased, beginning with 2017, from year to year based on the percentage
increase in the consumer price index for all urban consumers (all items; United
States city average), rounded to the nearest $1.
(3)
Final
determination of standards achievement made by participating health
professional
Under the Program, a participating health
professional shall make the final determination as to whether or not a
participating Medicare beneficiary has met the target standards under
subsection (c) and what screening tests and specified vaccinations, or other
services, are necessary for purposes of making such determination.
(f)
Spending
benchmarks
(1)
In
general
The Secretary shall collect relevant data, including data
on claims paid under this title for services furnished to participating
Medicare beneficiaries during the Program, for purposes of determining the
aggregate estimated savings achieved under this title for participating
Medicare beneficiaries during each of years 2 and 3 of the Program in
accordance with paragraph (2) (and for a subsequent year if the Program is
expanded under subsection (d)(1)(B)).
(2)
Determination
of aggregate estimated savings
(A)
In
general
The amount of the aggregate estimated savings under this
title for participating Medicare beneficiaries under paragraph (1), with
respect to a year, shall be equal to—
(i) the estimated
savings determined under subparagraph (B) for the year; minus
(ii) the aggregate
incentive payments made under the Program during the year.
(B)
Determination
of estimated savings
For purposes of subparagraph (A)(i), the
estimated savings determined under this subparagraph for a year shall be equal
to—
(i) the estimated
aggregate expenditures under this title (as projected under subparagraph (C))
for the year; minus
(ii) the actual
aggregate expenditures under this title (as determined by the Secretary and
taking into account any reduction in specific health risks of the participating
Medicare beneficiaries) for the year.
(C)
Projection of
estimated aggregate claims cost
(i)
Benchmark base
year
The Secretary shall establish a benchmark base year amount
of expenditures under this title for participating Medicare beneficiaries
during year 1 of the Program.
(ii)
Projection
The
Secretary shall use the benchmark base year amount established under clause (i)
to project the estimated aggregate expenditures for all participating Medicare
beneficiaries during each of years 2 and 3 of the Program as if the
beneficiaries were not participating in the Program. In making such projection,
the Secretary may include adjustments for health status or other specific risk
factors and geographic variation for the participating Medicare
beneficiaries.
(D)
Public report
of determination and other Program information
Not later than 90
days after determining the aggregate estimated savings (if any) under
subparagraph (A) with respect to a year, the Secretary shall make available to
the public a report containing a description of the amount of the savings
determined, including the methodology and any other calculations or
determinations involved in the determination of such amount. Such report shall
include—
(i) a
description of any reduction in specific health risks of participating Medicare
beneficiaries identified by the Secretary;
(ii) a description
of—
(I) standards for
measuring better health targets under subsection (c); and
(II) the points
available for achieving each such standard under that subsection; and
(iii) recommendations
for such legislation and administrative action as the Secretary determines
appropriate.
(3)
Monitoring of
Program costs
During the operation of the Program, the Chief
Actuary of the Centers for Medicare & Medicaid Services shall—
(A) monitor the
Program to determine whether or not the Program is reducing aggregate
expenditures under this title; and
(B) submit to the
Secretary an annual report on the results of such monitoring.
(4)
Required action
if aggregate incentive payments exceed savings
If the Secretary,
taking into account the reports under paragraph (3)(B), determines that the
aggregate expenditures under this title exceed the aggregate expenditures under
this title that would have been made if the Program had not been implemented,
the Secretary shall provide for changes to the provisions of the program in
order to eliminate such excess.
(g)
Waiver
authority
The Secretary may waive such requirements of titles XI
and XVIII as may be necessary to carry out the purposes of the Program
established under this section.
(h)
Definitions
In
this section:
(1)
Annual wellness
visit
The term annual wellness visit includes
personalized prevention plan services (as defined in section
1861(hhh)(1)).
(2)
Health
professional
The term health professional includes a
physician (as defined in section 1861(r)(1)) and a practitioner described in
clause (i) of section 1842(b)(18)(C).
(3)
Initial
preventive physical examination
The term initial preventive
physical examination has the meaning given that term in section
1861(ww)(1).
(4)
Medicare
beneficiary
The term Medicare beneficiary means an
individual enrolled in part B.
(5)
Participating
Medicare beneficiary
The term participating Medicare
beneficiary means a Medicare beneficiary who enrolls in the Program
under subsection (b).
(6)
Screening
tests
The term screening tests means any of the
following that are determined by a health professional to be appropriate for a
participating Medicare beneficiary:
(A) Colorectal cancer
screening tests (as defined in section 1861(pp)).
(B) Screening
mammography (as described in section 1861(jj)).
(C) Screening pap
smear and screening pelvic exam (as defined in section 1861(nn)).
(D) Screening for
glaucoma (as defined in section 1861(uu)).
(E) Bone mass
measurement (as defined in section 1861(rr)) for qualified individuals
described in paragraph (2)(A) of such section.
(F) HIV screening for
high-risk groups (as identified by the Secretary).
(7)
Specified
vaccinations
The term specified vaccinations means
the vaccinations described in section 1861(ww)(1) that are determined by a
health professional to be appropriate for a participating Medicare
beneficiary.
.
3.
Participation by
Medicare Advantage plans
Section 1859 of the Social Security Act (42
U.S.C. 1395w–28) is amended by adding at the end the following new
subsection:
(h)
Providing
incentives for voluntary participation in a Better Health Rewards
Program
(1)
In
general
Effective for plan years beginning on or after the date
of enactment of the Medicare Better Health
Rewards Program Act of 2013, a Medicare Advantage organization
may provide to individuals enrolled in an MA plan offered by the organization
incentive payments, including cash, cash-equivalent, or other types of
incentives, for voluntary participation in a Better Health Rewards Program (in
this subsection referred to as the Program) that rewards
individuals for meeting certain health targets established by the
Secretary.
(2)
Limitation
In
no case shall the monthly bid amount submitted by a Medicare Advantage
organization under section 1834(a)(6) (or the monthly premium charged by the
organization under section 1854(b)) with respect to an MA plan offered by the
organization take into account any incentive payments made to enrollees under
the Program.
(3)
Implementation
The
Program under this subsection shall be conducted in a similar manner to the
manner in which the program under section 1849 is conducted, in accordance with
standards established by the Secretary.
(4)
Notification
and provision of information
A Medicare Advantage organization
seeking to participate in the Program shall—
(A) notify the
Secretary of the organization's intent to participate in the Program;
and
(B) agree to provide
to the Secretary—
(i) information
regarding—
(I) which enrollees
participate in the Program;
(II) the scores of
those enrollees with respect to applicable health targets under the Program;
and
(III) the incentives
enrollees receive for meeting such health targets; and
(ii) any other
information specified by the Secretary for purposes of this subsection.
(5)
Waiver
authority
The Secretary may waive such requirements of titles XI
and XVIII as may be necessary to carry out the purposes of the Program
established under this
subsection.
.
4.
Participation of
section 1876 cost plans
Section 1876 of the Social Security Act (42
U.S.C. 1395mm) is amended by inserting at the end the following:
(l)
Providing
incentives for voluntary participation in a Better Health Rewards
Program
(1)
In
general
Effective for contract periods beginning on or after the
date of enactment of the Medicare Better
Health Rewards Program Act of 2013, an eligible organization may
provide to members enrolled under this section with the organization incentive
payments, including cash, cash-equivalent, or other types of incentives, for
voluntary participation in a Better Health Rewards Program (in this subsection
referred to as the Program) that rewards members for meeting
certain health targets established by the Secretary.
(2)
Limitation
In
no case shall the payment to an eligible organization under this section (or
the premium rate charged by the organization under this section) with respect
to members enrolled with the organization take into account any incentive
payments made to members under the Program.
(3)
Implementation
The
Program under this subsection shall be conducted in a similar manner to the
manner in which the program under section 1849 is conducted, in accordance with
standards established by the Secretary.
(4)
Notification
and provision of information
An eligible organization seeking to
participate in the Program shall—
(A) notify the
Secretary of the organization's intent to participate in the Program;
and
(B) agree to provide
to the Secretary—
(i) information
regarding—
(I) which members
participate in the Program;
(II) the scores of
those members with respect to applicable health targets under the Program;
and
(III) the incentives
members receive for meeting such health targets; and
(ii) any other
information specified by the Secretary for purposes of this subsection.
(5)
Waiver
authority
The Secretary may waive such requirements of titles XI
and XVIII as may be necessary to carry out the purposes of the Program
established under this
subsection.
.
5.
Participation of
programs of all-inclusive care for the elderly (PACE)
(a)
Medicare
Section 1894 of the Social Security Act (42
U.S.C. 1395eee) is amended by inserting at the end the following:
(j)
Providing
incentives for voluntary participation in a Better Health Rewards
Program
(1)
In
general
Effective for PACE program agreements entered into on or
after the date of enactment of the Medicare
Better Health Rewards Program Act of 2013, a PACE provider may
provide to PACE program eligible individuals enrolled under this section with
the PACE provider incentive payments, including cash, cash-equivalent, or other
types of incentives, for voluntary participation in a Better Health Rewards
Program (in this subsection referred to as the Program) that
rewards enrollees for meeting certain health targets established by the
Secretary.
(2)
Limitation
In
no case shall the payment to a PACE provider under this section (or any premium
charged by the provider under this section) with respect to PACE program
eligible individuals enrolled with the PACE provider take into account any
incentive payments made to individuals under the Program.
(3)
Implementation
The
Program under this subsection shall be conducted in a similar manner to the
manner in which the program under section 1849 is conducted, in accordance with
standards established by the Secretary.
(4)
Notification
and provision of information
A PACE provider seeking to
participate in the Program shall—
(A) notify the
Secretary of the PACE provider's intent to participate in the Program;
and
(B) agree to provide
to the Secretary—
(i) information
regarding—
(I) which PACE
program eligible individuals enrolled with the PACE provider participate in the
Program;
(II) the scores of
those individuals with respect to applicable health targets under the Program;
and
(III) the incentives
individuals receive for meeting such health targets; and
(ii) any other
information specified by the Secretary for purposes of this subsection.
(5)
Waiver
authority
The Secretary may waive such requirements of titles XI,
XVIII, and XIX as may be necessary to carry out the purposes of the Program
established under this
subsection.
.
(b)
Medicaid
Section
1934 of the Social Security Act (42 U.S.C. 1396u–4) is amended by adding at the
end the following new subsection:
(k)
Providing
incentives for voluntary participation in a Better Health Rewards
Program
(1)
In
general
Effective for PACE program agreements entered into on or
after the date of enactment of the Medicare
Better Health Rewards Program Act of 2013, a PACE provider may
provide to PACE program eligible individuals enrolled under this section with
the PACE provider incentive payments, including cash, cash-equivalent, or other
types of incentives, for voluntary participation in a Better Health Rewards
Program (in this subsection referred to as the Program) that
rewards enrollees for meeting certain health targets established by the
Secretary.
(2)
Limitation
In
no case shall the payment to a PACE provider under this section (or any premium
charged by the provider under this section) with respect to PACE program
eligible individuals enrolled with the PACE provider take into account any
incentive payments made to individuals under the Program.
(3)
Implementation
The
Program under this subsection shall be conducted in a similar manner to the
manner in which the program under section 1849 is conducted, in accordance with
standards established by the Secretary.
(4)
Notification
and provision of information
A PACE provider seeking to
participate in the Program shall—
(A) notify the
Secretary of the PACE provider's intent to participate in the Program;
and
(B) agree to provide
to the Secretary—
(i) information
regarding—
(I) which PACE
program eligible individuals enrolled with the PACE provider participate in the
Program;
(II) the scores of
those individuals with respect to applicable health targets under the Program;
and
(III) the incentives
individuals receive for meeting such health targets; and
(ii) any other
information specified by the Secretary for purposes of this subsection.
(5)
Waiver
authority
The Secretary may waive such requirements of titles XI,
XVIII, and XIX as may be necessary to carry out the purposes of the Program
established under this
subsection.
.
6.
Exclusion of
incentive payments
(a)
In
general
Part III of subchapter B of chapter 1 of the Internal
Revenue Code of 1986 is amended by inserting after section 139D the following
new section:
139E.
Medicare
Better Health Rewards payments
Gross income shall not include any payment
made under the following programs:
(1) The Medicare Better Health Rewards Program
established under section 1849 of the Social Security Act.
(2) A Better Health
Rewards Program established pursuant to section 1859(h), 1876(l), 1894(j), or
1934(k) of the Social Security
Act.
.
(b)
Clerical
amendment
The table of sections for part III of subchapter B of
chapter 1 of such Code is amended by inserting after the item relating to
section 139D the following new item:
Sec. 139E. Medicare Better Health Rewards
payments.
.