,,ii #aadth ,,congress #ast ,session ,s4 #bdji ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,december #af1 #bjae,mr4 ,wyden introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend titles ,,xviii and ,,xix of the ,social ,security ,act to improve payments for hospital outpatient department services and complex rehabilitation technology and to improve program integrity1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,medicare and ,medicaid ,improvements and ,adjustments ,act of #bjae4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4,title ,i--,corrections to ,outpatient ,provision,sec4 #aja4 ,continuing ,medicare payment under ,,hopd prospective payment system for services furnished by off-campus outpatient departments of providers under development4,sec4 #ajb4 ,maintaining cancer hospital adjustment under ,medicare off-campus outpatient departments of a provider payment policy4,title ,,ii--,provisions ,protecting ,people with ,disabilities and ,chronic ,care ,needs,sec4 #bja4 ,non-application of ,medicare fee schedule adjustments for wheelchair accessories and seat and back cushions when furnished in connection with complex rehabilitative power wheelchairs4,sec4 #bjb4 ,treatment of infusion drugs furnished through durable medical equipment4,sec4 #bjc4 ,transitional payment rules for certain radiation therapy services under the ,medicare physician fee schedule4,sec4 #bjd4 ,fairness in ,medicaid supplemental needs trusts4,title ,,iii--,program ,integrity1 ,payment ,efficiency1 and ,additional ,medicare ,policies,sec4 #cja4 ,strengthening penalties for the illegal distribution of a ,medicare1 ,medicaid1 or ,,chip beneficiary identification or billing privileges4,sec4 #cjb4 ,civil monetary penalties for violations related to grants1 contracts1 and other agreements4,sec4 #cjc4 ,authorizing a blanket meaningful use significant hardship exception4,sec4 #cjd4 ,limiting ,federal ,medicaid reimbursement to ,states for durable medical equipment 7,,dme7 to ,medicare payment rates4,sec4 #cje4 ,treatment of patient encounters in ambulatory surgical centers in determining meaningful ,,ehr use4 ,i ,corrections to ,outpatient ,provision #aja4 ,continuing ,medicare payment under ,,hopd prospective payment system for services furnished by off-campus outpatient departments of providers under development ,section #ahcc7t7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77 is amended-- 7#a7 in paragraph 7#a77;,b77v71 by inserting 1 subject to subparagraph 7,e7 of such paragraph1 after #bjag1 by2 and 7#b7 in paragraph 7#ba7-- 7,a7 in subparagraph 7,c7 by striking that are described in paragraph 7#a77;,b77v7 shall be made and inserting to which paragraph 7#a77;,b77v7 applies shall be the amount determined2 7,b7 by redesignating subparagraph 7,e7 as subparagraph 7,f72 and 7,c7 by inserting after subparagraph 7,d7 the following new subparagraph3 7,e7 ,non-application with respect to departments under development 7i7 ,in general ,paragraph 7#a77;,b77v7 shall not apply to an off-campus outpatient department of a provider that is determined by the ,secretary to be under development as of the date of the enactment of the ,bipartisan ,budget ,act of #bjae4 7ii7 ,application ,for purposes of paragraph 7#a77;,b77v7 and this paragraph1 in determining whether an off-campus outpatient department of a provider was under development1 the ,secretary shall require that as of the date of the enactment of such ,act the department met-- 7,i7 at least one of the requirements described in clause 7iii72 and 7,,ii7 any additional requirements the ,secretary determines would indicate whether such off-campus outpatient department of a provider was under development as of such date4 7iii7 ,requirements described ,the following requirements are described in this clause3 7,i7 ,architectural plans were completed4 7,,ii7 ,zoning requirements were met or a request for approval of meeting such zoning requirements was submitted to appropriate agencies4 7,,iii7 ,necessary approvals from appropriate ,state agencies were applied for or received4 4 #ajb4 ,maintaining cancer hospital adjustment under ,medicare off-campus outpatient departments of a provider payment policy ,section #ahcc7t7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77 is amended-- 7#a7 in paragraph 7#a77;,b77v71 as amended by section #aja7a71 by striking subparagraph 7,e7 and inserting subparagraph 7,f72 and 7#b7 in paragraph 7#ba71 as added by section #fjc of the ,bipartisan ,budget ,act of #bjae and as amended by section #aja7b7-- 7,a7 by redesignating subparagraphs 7,d71 7,e71 and 7,f7 as subparagraphs 7,e71 7,f71 and 7,g71 respectively2 7,b7 by inserting after subparagraph 7,c7 the following new subparagraph3 7,d7 ,application of cancer hospital adjustment ,the ,secretary shall apply the adjustment under paragraph 7#ah7 to applicable items and services furnished on or after ,january #a1 #bjag1 by an off-campus outpatient department of a provider 7as defined in subparagraph 7,b77 of a hospital described in section #ahhf7;d77#a77;,b77v7-- 7i7 as if this paragraph 7other than this subparagraph7 and paragraph 7#a77;,b77v7 were not applicable to such applicable items and services and such applicable items and services were covered ,,opd services and paid under this subsection2 and 7ii7 without application of paragraphs 7#b77;,e7 and 7#i77;,b74 2 and 7,c7 in subparagraph 7,g77iii71 as redesignated by subparagraph 7,a7 of this paragraph1 by striking subparagraph 7,d7 and inserting subparagraph 7,e74 ,,ii ,provisions ,protecting ,people with ,disabilities and ,chronic ,care ,needs #bja4 ,non-application of ,medicare fee schedule adjustments for wheelchair accessories and seat and back cushions when furnished in connection with complex rehabilitative power wheelchairs 7a7 ,non-,application 7#a7 ,in general ,notwithstanding any other provision of law1 the ,secretary of ,health and ,human ,services shall not1 prior to ,january #a1 #bjag1 use information on the payment determined under the competitive acquisition programs under section #ahdg of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c77 to adjust the payment amount that would otherwise be recognized under section #ahcd7;a77#a77;,b77ii7 of such ,act 7#db ,u4,s4,c4 #aciem7a77#a77;,b77ii77 for wheelchair accessories 7including seating systems7 and seat and back cushions when furnished in connection with ,group #c complex rehabilitative power wheelchairs4 7#b7 ,implementation ,notwithstanding any other provision of law1 the ,secretary may implement this subsection by program instruction or otherwise4 7b7 ,,gao study and report 7#a7 ,study 7,a7 ,in general ,the ,comptroller ,general of the ,united ,states shall conduct a study on wheelchair accessories 7including seating systems7 and seat and back cushions furnished in connection with ,group #c complex rehabilitative power wheelchairs4 ,such study shall include an analysis of the following with respect to such wheelchair accessories and seat and back cushions in each of the groups described in clauses 7i7 through 7iii7 of subparagraph 7,b73 7i7 ,the item descriptions and associated ,,hcpcs codes for such wheelchair accessories and seat and back cushions4 7ii7 ,a breakdown of utilization and expenditures for such wheelchair accessories and seat and back cushions under title ,,xviii of the ,social ,security ,act4 7iii7 ,a comparison of the payment amount under the competitive acquisition program under section #ahdg of such ,act 7#db ,u4,s4,c4 #aciew-#c7 with the payment amount that would otherwise be recognized under section #ahcd of such ,act 7#db ,u4,s4,c4 #aciem71 including beneficiary cost sharing1 for such wheelchair accessories and seat and back cushions4 7iv7 ,the aggregate distribution of such wheelchair accessories and seat and back cushions furnished under such title ,,xviii within each of the groups described in subparagraph 7,b74 7v7 ,other areas determined appropriate by the ,comptroller ,general4 7,b7 ,groups described ,the following groups are described in this subparagraph3 7i7 ,wheelchair accessories and seat and back cushions furnished predominantly with ,group #c complex rehabilitative power wheelchairs4 7ii7 ,wheelchair accessories and seat and back cushions furnished predominantly with power wheelchairs that are not described in clause 7i74 7iii7 ,other wheelchair accessories and seat and back cushions furnished with either power wheelchairs described in clause 7i7 or 7ii74 7#b7 ,report ,not later than ,june #a1 #bjaf1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report containing the results of the study conducted under paragraph 7#a71 together with recommendations for such legislation and administrative actions as the ,comptroller ,general determines to be appropriate4 #bjb4 ,treatment of infusion drugs furnished through durable medical equipment ,section #ahdb7o77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieu7o77#a77 is amended-- 7#a7 in subparagraph 7,c71 by inserting 7and including a drug or biological described in subparagraph 7,d77i7 furnished during the #f-year period beginning on ,january #a1 #bjag7 after #bjje2 and 7#b7 in subparagraph 7,d7-- 7,a7 by striking infusion drugs and inserting infusion drugs or biologicals each place it appears2 and 7,b7 in clause 7i7-- 7i7 by striking #bjjd and inserting #bjjd 7other than during the #f-year period beginning on ,january #a1 #bjag72 and 7ii7 by striking for such drug4 #bjc4 ,transitional payment rules for certain radiation therapy services under the ,medicare physician fee schedule 7a7 ,in general ,section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is amended-- 7#a7 in subsection 7b71 as amended by section #ejb of division ,o of the ,consolidated ,appropriations ,act1 #bjaf1 by adding at the end the following new paragraph3 7#aa7 ,special rule for certain radiation therapy services ,the code definitions1 the work relative value units under subsection 7c77#b77;,c77i71 and the direct inputs for the practice expense relative value units under subsection 7c77#b77;,c77ii7 for radiation treatment delivery and related imaging services 7identified in #bjaf by ,,hcpcs ,g-codes ,g#fjja through ,g#fjae7 for the fee schedule established under this subsection for services furnished in #bjag and #bjah shall be the same as such definitions1 units1 and inputs for such services for the fee schedule established for services furnished in #bjaf4 2 and 7#b7 in subsection 7c77#b77,k71 by adding at the end the following new clause3 7iv7 ,treatment of certain radiation therapy services ,radiation treatment delivery and related imaging services identified under subsection 7b77#aa7 shall not be considered as potentially misvalued services for purposes of this subparagraph and subparagraph 7,o7 for #bjag and #bjah4 4 7b7 ,report to ,congress on alternative payment model ,not later than #ah months after the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services shall submit to ,congress a report on the development of an episodic alternative payment model for payment under the ,medicare program under title ,,xviii of the ,social ,security ,act for radiation therapy services furnished in nonfacility settings4 #bjd4 ,fairness in ,medicaid supplemental needs trusts 7a7 ,in general ,section #aiag7;d77#d77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifp7d77#d77;,a77 is amended by inserting the individual1 after for the benefit of such individual by4 7b7 ,effective date ,the amendment made by subsection 7a7 shall apply to trusts established on or after the date of the enactment of this ,act4 ,,iii ,program ,integrity1 ,payment ,efficiency1 and ,additional ,medicare ,policies #cja4 ,strengthening penalties for the illegal distribution of a ,medicare1 ,medicaid1 or ,,chip beneficiary identification or billing privileges ,section #aabh;,b7b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;b7b77 is amended by adding at the end the following3 7#d7 ,whoever without lawful authority knowingly and willfully purchases1 sells or distributes1 or arranges for the purchase1 sale1 or distribution of a beneficiary identification number or unique health identifier for a health care provider under title ,,xviii1 title ,,xix1 or title ,,xxi shall be imprisoned for not more than #aj years or fined not more than #ejj1jjj 7#a1jjj1jjj in the case of a corporation71 or both4 4 #cjb4 ,civil monetary penalties for violations related to grants1 contracts1 and other agreements 7a7 ,in general ,section #aabh;,a of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;a7 is amended by adding at the end the following new subsection3 7o7 ,any person 7including an organization1 agency1 or other entity1 but excluding a program beneficiary1 as defined in subsection 7r77#d77 that1 with respect to a grant1 contract1 or other agreement for which the ,secretary of ,health and ,human ,services provides funding-- 7#a7 knowingly presents or causes to be presented a specified claim 7as defined in subsection 7r77#f77 under such grant1 contract1 or other agreement that the person knows or should know is false or fraudulent2 7#b7 knowingly makes1 uses1 or causes to be made or used any false statement1 omission1 or misrepresentation of a material fact in any application1 proposal1 bid1 progress report1 or other document that is required to be submitted in order to directly or indirectly receive or retain funds provided in whole or in part by such ,secretary pursuant to such grant1 contract1 or other agreement2 7#c7 knowingly makes1 uses1 or causes to be made or used1 a false record or statement material to a false or fraudulent specified claim under such grant1 contract1 or other agreement2 7#d7 knowingly makes1 uses1 or causes to be made or used1 a false record or statement material to an obligation to pay or transmit funds or property to such ,secretary with respect to such grant1 contract1 or other agreement1 or knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit funds or property to such ,secretary with respect to such grant1 contract1 or other agreement2 or 7#e7 fails to grant timely access1 upon reasonable request 7as defined by such ,secretary in regulations71 to the ,inspector ,general of the ,department1 for the purpose of audits1 investigations1 evaluations1 or other statutory functions of such ,inspector ,general in matters involving such grants1 contracts1 or other agreements1 shall be subject1 in addition to any other penalties that may be prescribed by law1 to a civil money penalty in cases under paragraph 7#a71 of not more than #aj1jjj for each specified claim2 in cases under paragraph 7#b71 not more than #ej1jjj for each false statement1 omission1 or misrepresentation of a material fact2 in cases under paragraph 7#c71 not more than #ej1jjj for each false record or statement2 in cases under paragraph 7#d71 not more than #ej1jjj for each false record or statement or #aj1jjj for each day that the person knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay2 or in cases under paragraph 7#e71 not more than #ae1jjj for each day of the failure described in such paragraph4 ,in addition1 in cases under paragraphs 7#a7 and 7#c71 such a person shall be subject to an assessment of not more than #c times the amount claimed in the specified claim described in such paragraph in lieu of damages sustained by the ,united ,states or a specified ,state agency because of such specified claim1 and in cases under paragraphs 7#b7 and 7#d71 such a person shall be subject to an assessment of not more than #c times the total amount of the funds described in paragraph 7#b7 or 7#d71 respectively 7or1 in the case of an obligation to transmit property to the ,secretary ,health and ,human ,services described in paragraph 7#d71 of the value of the property described in such paragraph7 in lieu of damages sustained by the ,united ,states or a specified ,state agency because of such case4 ,in addition1 the ,secretary of ,health and ,human ,services may make a determination in the same proceeding to exclude the person from participation in the ,federal health care programs 7as defined in section #aabh;,b7f77#a77 and to direct the appropriate ,state agency to exclude the person from participation in any ,state health care program4 7p7 ,the provisions of subsections 7c71 7d71 and 7g7 shall apply to a civil money penalty or assessment under subsection 7o7 in the same manner as such provisions apply to a penalty1 assessment1 or proceeding under subsection 7a74 7q7 ,with respect to a penalty or assessment under subsection 7o71 the ,inspector ,general of the ,department is authorized to receive1 and to retain for current use1 such amounts of such penalty or assessment as are necessary to provide reimbursement for the costs of conducting investigations and audits with respect to such subsection and for monitoring compliance plans with respect to such subsection when such penalty or assessment is ordered by a court1 voluntarily agreed to by the payor1 or otherwise4 ,funds received by such ,inspector ,general as reimbursement under the preceding sentence shall be deposited to the credit of the appropriations from which initially paid1 or to appropriations for similar purposes currently available at the time of deposit1 and shall remain available for obligation for #a year from the date of the deposit of such funds4 7r7 ,for purposes of this subsection and subsections 7o71 7p71 and 7q73 7#a7 ,the term ,department means the ,department of ,health and ,human ,services4 7#b7 ,the term material means having a natural tendency to influence1 or be capable of influencing1 the payment or receipt of money or property4 7#c7 ,the term other agreement includes a cooperative agreement1 scholarship1 fellowship1 loan1 subsidy1 payment for a specified use1 donation agreement1 award1 or sub-award 7regardless of whether one or more of the persons entering into the agreement is a contractor or sub-contractor74 7#d7 ,the term program beneficiary means1 in the case of a grant1 contract1 or other agreement designed to accomplish the objective of awarding or otherwise furnishing benefits or assistance to individuals and for which the ,secretary of ,health and ,human ,services provides funding1 an individual who applies for1 or who receives1 such benefits or assistance from such grant1 contract1 or other agreement4 ,such term does not include1 with respect to such grant1 contract1 or other agreement1 an officer1 employee1 or agent of a person or entity that receives such grant or that enters into such contract or other agreement4 7#e7 ,the term recipient includes a sub-recipient or subcontractor4 7#f7 ,the term specified claim means any application1 request1 or demand under a grant1 contract1 or other agreement for money or property1 whether or not the ,united ,states or a specified ,state agency has title to the money or property1 that is not a claim 7as defined in subsection 7i77#b77 and that-- 7,a7 is presented or caused to be presented to an officer1 employee1 or agent of the ,department or agency thereof1 or of any specified ,state agency2 or 7,b7 is made to a contractor1 grantee1 or any other recipient if the money or property is to be spent or used on the ,department's behalf or to advance a ,department program or interest1 and if the ,department-- 7i7 provides or has provided any portion of the money or property requested or demanded2 or 7ii7 will reimburse such contractor1 grantee or other recipient for any portion of the money or property which is requested or demanded4 7#g7 ,the term specified ,state agency means an agency of a ,state government established or designated to administer or supervise the administration of a grant1 contract1 or other agreement funded in whole or in part by the ,secretary of ,health and ,human ,services4 7s7 ,for purposes of subsection 7o71 the term obligation means an established duty1 whether or not fixed1 arising from an express or implied contractual1 grantor-grantee1 or licensor-licensee relationship1 for a fee-based or similar relationship1 from statute or regulation1 or from the retention of any overpayment4 4 7b7 ,conforming amendments ,section #aabh;,a of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;a7 is amended-- 7#a7 in subsection 7d7-- 7,a7 in paragraph 7#a71 by inserting or specified claims after claims2 and 7,b7 in paragraph 7#b71 by inserting or specified claims after claims2 7#b7 in subsection 7e71 by inserting or specified claim after claim2 and 7#c7 in subsection 7f7-- 7,a7 by inserting or specified claim 7as defined in subsection 7r77#f77 after district where the claim2 7,b7 by inserting 7or1 with respect to a person described in subsection 7o71 the person7 after claimant2 7,c7 by inserting that are not received by the ,inspector ,general of the ,department of ,health and ,human ,services under subsection 7q7 as reimbursement after amounts recovered2 and 7,d7 by inserting 7or1 in the case of a penalty or assessment under subsection 7o71 by a specified ,state agency 7as defined in subsection 7r77#g77 after or a ,state agency4 #cjc4 ,authorizing a blanket meaningful use significant hardship exception 7a7 ,physicians' services ,section #ahdh7;a77#g77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;a77#g77;,b77 is amended by inserting 7or through a blanket exception with respect to the payment adjustment for #bjag1 but only if a request for such exception is filed no later than ,june #cj1 #bjaf7 after on a case-by-case basis4 7b7 ,hospital services ,section #ahhf7;b77#c77;,b77ix77,,ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7b77#c77;,b77ix77,,ii77 is amended by inserting 7or through a blanket exception with respect to the payment adjustment for fiscal year #bjag1 but only if a request for such exception is filed no later than ,june #cj1 #bjaf7 after on a case-by-case basis4 7c7 ,implementation authority ,the ,secretary of ,health and ,human ,services may implement the amendments made by this section by interim final rule with comment period4 #cjd4 ,limiting ,federal ,medicaid reimbursement to ,states for durable medical equipment 7,,dme7 to ,medicare payment rates ,section #aijc7;i77#bg7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7i77#bg771 as added by section #ejc7;a77#a7 of division ,o of the ,consolidated ,appropriations ,act1 #bjaf1 is amended by striking ,january #a1 #bjai and inserting ,october #a1 #bjah4 #cje4 ,treatment of patient encounters in ambulatory surgical centers in determining meaningful ,,ehr use ,section #ahdh7o77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o77#b77 is amended by adding at the end the following new subparagraph3 7,e7 ,treatment of patient encounters at ambulatory surgical centers 7i7 ,in general ,subject to clause 7ii71 with respect to a payment adjustment applied under subsection 7a77#g77;,a71 for #bjag or a subsequent year1 any patient encounter of an eligible professional occurring at an ambulatory surgical center 7described in section #ahcc7;i77#a77;,a77 shall not be treated as a patient encounter in determining whether an eligible professional qualifies as a meaningful ,,ehr user4 ,notwithstanding any other provision of law1 the ,secretary may implement this clause by program instruction or otherwise4 7ii7 ,sunset ,clause 7i7 shall no longer apply as of the first payment year that begins more than #c years after the date the ,secretary determines1 through notice and comment rulemaking1 that certified ,,ehr technology is applicable to the ambulatory surgical center setting4 4