,i #aag? ,,congress #b;d ,session ,h4 ,r4 #ijai ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,septemb] #bh1 #bjbb,ms4 ,port] 7= h]self1 ,ms4 ,de,gette1 ,mr4 ,doggett1 ,ms4 ,s*ak[sky1 ,mr4 ,pocan1 ,mr4 ,grijalva1 ,mr4 ,takano1 ,ms4 ,ca/or ( ,florida1 ,ms4 ,de,lauro1 & ,ms4 ,jayapal7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,ways & ,means1 & 9 addition to ! ,committee on ,en]gy & ,comm]ce1 = a p]iod to be subsequ5tly det]m9$ by ! ,speak]1 9 ea* case = consid]ation ( su* provisions z fall )9 ! jurisdiction ( ! committee conc]n$ ,a ,,bill ,to am5d title ,,xviii ( ! ,social ,security ,act to require complete & accurate data set submissions f ,m$ic>e ,advantage organizations (f]+ ,m$ic>e ,advantage plans "u "p ,c ( ! ,m$ic>e program to improve transp>5cy1 & = o!r purposes4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,m$ic>e ,advantage ,consum] ,protection & ,transp>5cy ,act4 #b4 ,m$ic>e ,advantage ,supplem5tal b5efits data 7a7 ,9 g5]al ,section #aheb7;c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#abb7;c77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#c7 ,supplem5tal ,b5efits ,data 7,a7 ,submissions to ,secret>y ,= ea* plan ye> beg9n+ on or aft] ,janu>y #a ( ! second ye> beg9n+ on or aft] ! date ( enactm5t ( ?is p>agraph1 a ,m$ic>e ,advantage organization (f]+ supplem5tal b5efits describ$ 9 subsection 7a77#c7 "u a ,m$ic>e ,advantage plan %all submit 7or1 9 ! case ( su* an organization t contracts ) an entity 7su* z a ?ird p>ty contractor7 to provide supplem5tal b5efits 9 connection ) su* plan1 require "u su* contract = ! entity to submit71 n lat] ?an #f mon?s aft] ! end ( ! plan ye>1 to ! ,secret>y1 9 a cle>1 accurate1 & /&>diz$ =m 9 accordance ) subp>agraph 7,b7 complete & accurate 7z specifi$ by ! ,secret>y pursuant to subp>agraph 7,b77 in=mation1 at ! plan level & pres5t$ by cov]age1 s]vice1 or b5efit type 7z applicable71 on su* b5efits (f]$ "u su* plan dur+ ! plan ye>1 includ+ reg>d+ ! foll[+3 7i7 ,! type & nature ( ea* supplem5tal b5efit s (f]$ dur+ su* plan ye>4 7ii7 ,! numb] ( ,m$ic>e ,advantage eligible individuals enroll$ "u plan dur+ su* plan ye> ) cov]age t enables access to su* b5efits4 7iii7 ,! numb] ( ,m$ic>e ,advantage eligible individuals enroll$ "u ! plan dur+ su* plan ye> :o receiv$ a s]vice ) respect to ea* su* supplem5tal b5efit type s (f]$4 7iv7 ,! total plan & b5efici>y exp5ditures made = su* supplem5tal b5efits1 ) respect to su* plan ye>1 exclud+ pr(its1 adm9i/rative co/s1 & o!r ov]head exp5ses4 7v7 ,! total b5efici>y co/ %>+ = supplem5tal b5efits1 ) respect to su* plan ye>1 report$ 9 total b5efici>y exp5diture & z a p]c5tage ( total exp5diture4 7vi7 ,all enc\nt] data relat$ to claims = supplem5tal b5efits s (f]$1 ) respect to su* plan ye>4 7vii7 ,all paym5t data1 disaggregat$ by contribut+ pay]1 relat$ to claims = supplem5tal b5efits s (f]$1 ) respect to su* plan ye>4 7viii7 ,su* o!r in=mation z specifi$ by ! ,secret>y4 7,b7 ,regulations ,n lat] ?an ,july #a ( ! fir/ ye> beg9n+ on or aft] ! date ( ! enactm5t ( ?is p>agraph1 = purposes ( subp>agraph 7,a71 ! ,secret>y %all1 ?r\gh rulemak+-- 7i7 e/abli% proc$ures to /&>dize ! language us$ 9 describ+ supplem5tal b5efits 7includ+ categories ( su* b5efits7 & metrics2 7ii7 e/abli% proc$ures to /&>dize ! collection & evaluation ( data "u su* subp>agraph2 7iii7 analyze & publicly report1 9 common language1 ! /&>diz$ language to be us$ by plans 9 describ+ supplem5tal b5efits 7includ+ categories ( su* b5efits7 9 any mat]ials int5d$ = pot5tial consum]s1 includ+ m>ket+ mat]ials1 plan comp>ison tools "u section #ahea7;d71 & any o!r mat]ials ! ,secret>y deems appropriate2 7iv7 specify metrics & me?ods = det]m9+ :e!r in=mation submitt$ "u subp>agraph 7,a7 is complete & accurate1 includ+ by requir+ su* in=mation include at lea/ comp>isons ( supplem5tal b5efit in=mation betwe5 enc\nt] records submitt$ "u #aheb7;c77#c77;,a77vi71 aggregate data submitt$ "u #aheb7;c77#c77;,a77i-v71 sp5d+ data = types & categories ( supplem5tal b5efits submitt$ "u #aheg7;e77#d71 & supplem5tal b5efit in=mation submitt$ "u #ahed7;a77#f77;,a72 & 7v7 det]m9e categories or levels ( incomplet5ess = plans t d n submit complete enc\nt] data4 ,9 c>ry+ out clause 7iv71 a ,m$ic>e ,advantage plan %all be treat$ z n submitt+ complete enc\nt] data if ! ,secret>y det]m9es ! plan has submitt$ less ?an #ij p]c5t ( enc\nt] data1 includ+ ) respect to ! data s\rces id5tifi$ 9 clause 7ii74 4 7b7 ,p5alty = n submitt+ in=mation ,section #ahec7;a77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7;a77#a77 is am5d$-- 7#a7 9 subp>agraph 7,b7-- 7,a7 9 clause 7i71 by /rik+ subp>agraphs 7,f7 & 7,g7 & ins]t+ subp>agraphs 7,f71 7,g71 & 7,j72 7,b7 9 clause 7ii71 by /rik+ subp>agraphs 7,f7 & 7,g7 & ins]t+ subp>agraphs 7,f71 7,g71 & 7,j72 & 7,c7 9 clause 7iii71 by ins]t+ & 7if applicable7 "u subp>agraph 7,j7 aft] subp>agraph 7,c72 & 7#b7 by add+ at ! end ! foll[+ new subp>agraph3 7,j7 ,adju/m5t = n submitt+ supplem5tal b5efit in=mation ,9 ! case ( a ,m$ic>e ,advantage plan (f]$ by a ,m$ic>e ,advantage organization t1 ) respect to a plan ye> 7beg9n+ on or aft] ,janu>y #a ( ! second ye> beg9n+ on or aft] ! date ( ! enactm5t ( ?is subp>agraph71 has n submitt$ complete & accurate in=mation1 z requir$ "u section #aheb7;c77#c71 = ea* mon? dur+ su* plan ye> 7until su* mon?1 if any1 dur+ su* plan ye> dur+ :i* ! organization submits su* complete & accurate in=mation 7z det]m9$ 9 accordance ) ! metrics & me?ods specifi$ pursuant to section #aheb7;c77#c77;,b7771 ! mon?ly paym5t am\nt specifi$ 9 clauses 7i71 7ii71 & 7iii7 ( subp>agraph 7,b71 z applicable1 %all be r$uc$ by #e p]c5t ( ! am\nt t w\ld o!rwise apply4 4 #c4 ,m$ic>e ,advantage enc\nt] data acc\ntability 7a7 ,9 g5]al ,section #aheb7;c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#abb7;c771 z am5d$ by section #b1 is fur!r am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#d7 ,enc\nt] data acc\ntability 7,a7 ,submissions to ,secret>y ,= ea* plan ye> beg9n+ on or aft] ,janu>y #a ( ! second ye> beg9n+ on or aft] ! date ( ! enactm5t ( ?is p>agraph1 a ,m$ic>e ,advantage organization (f]+ a ,m$ic>e ,advantage plan %all1 9 accordance ) ! regulations promulgat$ pursuant to subp>agraph 7,b71 submit to ! ,secret>y1 n lat] ?an #f mon?s aft] ! end ( ! plan ye>1 complete & accurate 7z specifi$ by ! ,secret>y pursuant to su* regulations7 paym5t data1 disaggregat$ by plan & b5efici>y exp5diture1 & enc\nt] data = all enc\nt]s cov]$ ?r\gh b5efits "u ! orig9al fee-=-s]vice program def9$ "u subsection 7a77#a77;,b7 occurr+ dur+ ! plan ye> ) respect to ,m$ic>e ,advantage eligible individuals enroll$ "u su* plan dur+ su* plan ye>4 7,b7 ,regulations ,n lat] ?an ,july #a ( ! fir/ ye> beg9n+ on or aft] ! date ( ! enactm5t ( ?is p>agraph1 = purposes ( subp>agraph 7,a71 ! ,secret>y %all1 ?r\gh rulemak+-- 7i7 specify metrics & me?ods = det]m9+ :e!r in=mation submitt$ "u subp>agraph 7,a7 is complete & accurate1 :i* %all include1 z applicable1 at lea/ comp>isons betwe5-- 7,i7 enc\nt] records submitt$ "u ?is section2 7,,ii7 pati5t assessm5t =ms = home heal? 7us+ in=mation submitt$ ?r\gh ! ,outcome & ,assessm5t ,in=mation ,set in/rum5t or a successor in/rum5t71 skill$ nurs+ 7us+ in=mation submitt$ ?r\gh ! ,m9imum ,data ,set tool 7or a successor tool771 & inpati5t rehabilitation s]vices 7us+ in=mation submitt$ ?r\gh ! ,inpati5t ,rehabilitation ,facility ,pati5t ,assessm5t ,in/rum5t 7or a successor in/rum5t772 7,,iii7 mon?ly dialysis indicators us$ = risk adju/m5t2 7,,iv7 ,m$ic>e ,provid] & ,analysis ,review data2 7,v7 s]vice utilization data submitt$ "u section #ahed7;a77#f77;,a72 & 7,,vi7 any o!r data s\rce or me?od z specifi$ by ! ,secret>y2 & 7ii7 det]m9e categories or levels ( incomplet5ess = ,m$ic>e ,advantage plans t d n submit complete enc\nt] data4 ,9 c>ry+ out clause 7ii71 a ,m$ic>e ,advantage plan %all be treat$ z n submitt+ complete enc\nt] data if ! ,secret>y det]m9es ! plan has submitt$ less ?an #ij p]c5t ( enc\nt] data1 includ+ ) respect to ! data s\rces id5tifi$ 9 clause 7i74 7,c7 ,public report+ ,beg9n+ n lat] ?an ,july #a ( ! second ye> beg9n+ on or aft] ! date ( ! enactm5t ( ?is p>agraph1 ! ,secret>y %all publicly report ! data submitt$ pursuant to subp>agraph 7,a74 4 7b7 ,p5alty = n submitt+ in=mation ,section #ahec7;a77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7;a77#a771 z am5d$ by section #b1 is fur!r am5d$-- 7#a7 9 subp>agraph 7,b7-- 7,a7 9 clause 7i71 by /rik+ 7,g71 & 7,j7 & ins]t+ 7,g71 7,j71 & 7,k72 7,b7 9 clause 7ii71 by /rik+ 7,g71 & 7,j7 & ins]t+ 7,g71 7,j71 & 7,k72 & 7,c7 9 clause 7iii71 by /rik+ subp>agraph 7,j7 & ins]t+ subp>agraphs 7,j7 & 7,k72 & 7#b7 by add+ at ! end ! foll[+ new subp>agraph3 7,j7 ,adju/m5t = n submitt+ enc\nt] data 7i7 ,9 g5]al ,9 ! case ( a ,m$ic>e ,advantage plan (f]$ by a ,m$ic>e ,advantage organization t1 ) respect to a plan ye> 7beg9n+ on or aft] ,janu>y #a ( ! second ye> beg9n+ on or aft] ! date ( ! enactm5t ( ?is subp>agraph71 has n submitt$ any enc\nt] in=mation "u section #aheb7;c77#d71 = ea* mon? dur+ su* plan ye> 7until su* mon?1 if any1 dur+ su* plan ye> dur+ :i* ! organization submits su* in=mation71 ! mon?ly paym5t am\nt specifi$ 9 clauses 7i7 & 7ii7 ( subp>agraph 7,b7 %all be r$uc$ by #aj p]c5t ( ! am\nt t w\ld o!rwise apply4 7ii7 ,r$uction = incomplete data submitt$ ,9 ! case ( a ,m$ic>e ,advantage plan (f]$ by a ,m$ic>e ,advantage organization t1 ) respect to a plan ye> 7beg9n+ on or aft] ,janu>y #a ( ! second ye> beg9n+ on or aft] ! date ( ! enactm5t ( ?is subp>agraph71 has submitt$ enc\nt] in=mation1 z requir$ "u section #aheb7;c77#d71 b su* in=mation is n complete or is n accurate1 z requir$ "u su* section1 = ea* mon? dur+ su* plan ye> 7until su* mon?1 if any1 dur+ su* plan ye> dur+ :i* ! organization submits su* complete & accurate in=mation71 ! mon?ly paym5t am\nt specifi$ 9 clauses 7i71 7ii71 & 7iii7 ( subp>agraph 7,b71 z applicable1 %all be r$uc$ by a p]c5t specifi$ by ! ,secret>y 7n to exce$ #e p]c5t7 ( ! am\nt t w\ld o!rwise apply4 ,su* p]c5t specifi$ by ! ,secret>y %all be bas$ on ! p]c5tage ( in=mation miss+ 9 ! submission & det]m9$ pursuant to rulemak+4 7iii7 ,process ,9 apply+ ! r$uctions "u ?is subp>agraph1 ! ,secret>y-- 7,i7 %all provide public ju/ification = any p]c5t r$uction appli$ pursuant to clause 7ii71 includ+ data us$ to arrive at ! det]m9ation ( ! p]c5t s appli$2 7,,ii7 may au?orize an int]nal entity or contract ) an ext]nal entity to assi/ ) c>ry+ out subclause 7,i7 & det]m9+ any p]c5t r$uction to be appli$ "u clause 7ii72 & 7,,iii7 %all e/abli% a me*anism = ,m$ic>e ,advantage organizations to appeal det]m9ations "u ?is subp>agraph1 ) respect to su* organization4 7iv7 ,collection ( data ?r\gh ,m$ic>e ,adm9i/rative ,contractors ,! ,secret>y %all implem5t a me*anism requir+ direct submission ( provid] claims to ,m$ic>e ,adm9i/rative ,contractors-- 7,i7 = ,m$ic>e ,advantage plans t submit incomplete or inaccurate enc\nt] in=mation "u ?is subp>agraph = #b consecutive ye>s2 & 7,,ii7 9 ! case t ! ,secret>y f9ds t m ?an #e p]c5t ( ,m$ic>e ,advantage plans submitt$ incomplete or inaccurate in=mation = ?ree consecutive ye>s1 beg9n+ ) ! subsequ5t ye>1 = all ,m$ic>e ,advantage plans4 4 7c7 ,med,p,a,c report ,n lat] ?an #c ye>s aft] ! date on :i* in=mation is fir/ requir$ to be submitt$ pursuant to p>agraph 7#c7 ( section #aheb7;c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#abb7;c771 z add$ by section #b 7a71 & p>agraph 7#d7 ( su* section #aheb7;c71 z add$ by subsection 7a71 ! ,m$ic>e ,paym5t ,advisory ,commission %all submit to ,congress a report on su* in=mation t includes a descriptive analysis ( any in=mation report$ pursuant to su* p>agraph4 #d4 ,data on cov]age d5ials & prior au?orization requirem5ts 7a7 ,9 g5]al ,section #aheb7;c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;c771 z am5d$ by sections #b & #c1 is fur!r am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#e7 ,data on cov]age d5ials & prior au?orization requirem5ts 7,a7 ,9 g5]al ,= ea* plan ye> beg9n+ on or aft] ,janu>y #a ( ! second ye> beg9n+ on or aft] ! date ( ! enactm5t ( ?is p>agraph1 ) respect to applicable b5efits describ$ 9 subsection 7a77#a71 subsection 7a77#c71 & section #ahfj;,d-#b1 a ,m$ic>e ,advantage organization (f]+ a ,m$ic>e ,advantage plan %all1 9 addition to any applicable in=mation describ$ 9 a previ\s p>agraph1 submit1 n lat] ?an #f mon?s aft] ! end ( ! plan ye>1 to ! ,secret>y ! foll[+ data1 at ! plan level & pres5t$ by cov]age1 s]vice1 or b5efit type 7z applicable71 ) respect ,m$ic>e ,advantage eligible individuals enroll$ "u su* plan dur+ su* plan ye>3 7i7 ,! numb] ( claims d5i$1 pres5t$ by reason = ! d5ial4 7ii7 ,! numb] & type ( claims requir+ prior au?orization or prec]tification4 7iii7 ,! av]age p]iod betwe5 ! initial submission ( a claim = approval & ! deliv]y ( c>e4 7iv7 ,! numb] & p]c5tage ( cov]age d5ials appeal$ by s]vice type4 7v7 ,! numb] & p]c5tage ( prior au?orizations or prec]tifications appeal$4 7vi7 ,! numb] ( favorable decisions t ov]turn$ ! initial cov]age det]m9ation ^u appeal4 7vii7 ,! av]age p]iod betwe5 ! =mal initiation ( appeal proce$+s & f9al det]m9ation4 7viii7 ,total numb] & p]c5tage ( conv]sions ( inpati5t /ays to outpati5t & obs]vation /atus4 7ix7 ,in=mation on ea* prior au?orization or prec]tification episode1 includ+ ! ,m$ic>e ,advantage contract numb]1 b5efici>y ,m$ic>e ,,id1 national provid] id5tifi]1 provid] tax id5tification numb]1 ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em codes & modifi]s1 initial date ( receipt1 date ( initial decision1 action tak5 by ! plan1 d5ial code 7if applicable71 initial appeal date 7if applicable71 & f9al appeal decision date 7if applicable74 7x7 ,su* o!r in=mation z specifi$ by ! ,secret>y4 7,b7 ,d5ial codes & additional data elem5ts ,n lat] ?an ,janu>y #a ( ! second ye> beg9n+ on or aft] ! date ( ! enactm5t ( ?is p>agraph1 = purposes ( subp>agraph 7,a77ix71 ! ,secret>y %all e/abli%-- 7i7 d5ial code categories & def9itions & provide to ,m$ic>e ,advantage plans guidance on su* categories & def9itions2 & 7ii7 additional /&>diz$ data elem5ts1 z appropriate4 4 7b7 ,fur!r disclosures ,section #ahea7;d77#d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba7;d77#d77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,f7 ,cov]age d5ials & prior au?orizations ,in=mation submitt$ by ! plan "u section #aheb7;c77#e71 ) respect to su* ye>4 4 #e4 ,quality measures 7a7 ,9 g5]al ,section #aheb7;e77#c77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;e77#c77;,a77 is am5d$-- 7#a7 9 clause 7i71 by /rik+ & subject to subp>agraph 7,b7 & ins]t+ & subject to clause 7v7 & subp>agraph 7,b72 & 7#b7 by add+ at ! end ! foll[+ new clause3 7v7 ,plan level data ,= ea* plan ye> beg9n+ on or aft] ,janu>y #a ( ! second ye> beg9n+ on or aft] ! date ( ! enactm5t ( ?is clause1 subject to section #ahec7o77#f71 data submitt$ "u ?is subp>agraph %all be at ! plan level 9 addition to ! contract level4 4 7b7 ,application to ,/> rat+ sy/em ,section #ahec7o77#d77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7o77#d77;,a77 is am5d$ by add+ at ! end ! foll[+ new s5t5ce3 ,= ea* plan ye> beg9n+ on or aft] ,janu>y #a ( ! second ye> beg9n+ on or aft] ! date ( ! enactm5t ( ! ,m$ic>e ,advantage ,consum] ,protection & ,transp>5cy ,act1 subject to p>agraph 7#f71 ! ,secret>y %all require report+ ( data "u section #aheb7;e7 =1 & apply "u ?is subsection1 quality measures at ! plan level 9 addition to at ! contract level44 #f4 ,provid] network in=mation 7a7 ,9 g5]al ,section #ahea7;d77#e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba7;d77#e77 is am5d$ by add+ at ! end ! foll[+3 ,= ea* plan ye> beg9n+ on or aft] ,janu>y #a ( ! second ye> beg9n+ on or aft] ! date ( ! enactm5t ( ! ,m$ic>e ,advantage ,consum] ,protection & ,transp>5cy ,act1 ! ,secret>y %all ensure su* ,int]net site includes complete & accurate in=mation 7to be updat$ at lea/ qu>t]ly7 on provid]s ( s]vices & suppli]s p>ticipat+ 9 ! networks ( ,m$ic>e ,advantage plans & a portal t enables plans to update in=mation on su* site on ! provid]s ( s]vices & suppli]s p>ticipat+ 9 ! networks ( su* plans1 includ+ any *anges 9 su* networks & :e!r su* provid]s & suppli]s are accept+ new pati5ts44 7b7 ,disclosure by plans ,section #ahea7;d77#d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba7;d77#d771 z am5d$ by section #d7;b71 is fur!r am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,g7 ,provid] network in=mation ,= ea* plan ye> beg9n+ on or aft] ,janu>y #a ( ! second ye> beg9n+ on or aft] ! date ( ! enactm5t ( ?is subp>agraph1 accurate in=mation t is submitt$ 9 a ma*9e readable =mat & t id5tifies all provid]s ( s]vices & suppli]s p>ticipat+ 9 ! network ( ! plan1 includ+ all *anges to su* network t occur dur+ ! plan ye>1 & :e!r su* provid]s & suppli]s are accept+ new pati5ts4 4