,,ii #aaith ,,congress #b;d ,session ,s4 #dhhf ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,june #bd1 #bjbf,ms4 ,blunt ,rochester 7for herself1 ,mr4 ,wyden1 ,mr4 ,schumer1 ,mr4 ,merkley1 ,mr4 ,lujn1 ,mr4 ,markey1 ,ms4 ,warren1 ,mr4 ,reed1 ,ms4 ,duckworth1 ,mr4 ,welch1 ,mr4 ,booker1 ,mrs4 ,gillibrand1 ,mr4 ,padilla1 ,mr4 ,van ,hollen1 and ,mrs4 ,murray7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to protect against high out-of-pocket expenditures for ,medicare fee-for-service benefits1 and to amend titles ,,xviii and ,,xix of the ,social ,security ,act to enhance programs that protect low-income ,medicare beneficiaries4 #a4 ,short title ,this ,act may be cited as the ,medicare ,cost ,cap ,act of #bjbf4 #b4 ,protection against high out-of-pocket expenditures for ,medicare fee-for-service benefits 7a7 ,in general ,title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 is amended by adding at the end the following new section3 #ahii;,d4 ,protection against high out-of-pocket expenditures 7a7 ,in general ,notwithstanding any other provision of this title1 in the case of an applicable individual 7as defined in subsection 7c771 if the amount of the out-of-pocket cost-sharing 7as defined in subsection 7d77 incurred by such individual for a year 7beginning with #bjbh7 equals or exceeds the annual out-of-pocket limit under subsection 7b7 for that year1 the individual shall not be responsible for additional out-of-pocket cost-sharing incurred during that year4 7b7 ,annual out-of-,pocket limit 7#a7 ,in general ,the amount of the annual out-of-pocket limit under this subsection shall be-- 7,a7 for #bjbh1 #e1jjj2 or 7,b7 for a subsequent year1 the amount specified in this subsection for the preceding year increased by the annual percentage increase in average per capita aggregate expenditures under parts ,a and ,b1 as determined by the ,secretary for the #ab-month period ending in ,july of the previous year using such methods as the ,secretary shall specify4 7#b7 ,rounding ,if any amount determined under paragraph 7#a77;,b7 is not a multiple of #e1 such amount shall be rounded to the nearest multiple of #e4 7c7 ,applicable individual defined ,in this section1 the term applicable individual means an individual who is entitled to1 or enrolled for1 benefits under part ,a or enrolled in part ,b4 7d7 ,out-of-,pocket cost-,sharing defined 7#a7 ,in general ,subject to paragraphs 7#b7 and 7#c71 in this section1 the term out-of-pocket cost-sharing means1 with respect to an applicable individual1 the amount of the expenses incurred by the individual that are attributable to coinsurance1 deductible1 copayment1 or other cost-sharing otherwise applicable under part ,a or ,b4 7#b7 ,certain costs not included 7,a7 ,non-covered items and services ,expenses incurred for items and services which are not covered under part ,a or ,b shall not be considered incurred expenses for purposes of determining out-of-pocket cost-sharing under paragraph 7#a74 7,b7 ,items and services not furnished on an assignment-related basis ,if an item or service is furnished to an individual under this title and is not furnished on an assignment-related basis1 any additional expenses the individual incurs above the amount the individual would have incurred if the item or service was furnished on an assignment-related basis shall not be considered incurred expenses for purposes of determining out-of-pocket cost-sharing under paragraph 7#a74 7#c7 ,application ,for purposes of paragraph 7#a71 the ,secretary shall consider expenses to be incurred by the individual regardless of whether such costs are reimbursed through insurance or otherwise1 a group health plan1 or other third-party payment arrangement4 7e7 ,announcement ,not later than the first ,monday in ,april of each year 7beginning with #bjbg71 the ,secretary shall determine1 and shall announce 7in a manner intended to provide notice to interested parties71 the annual out-of-pocket limit under this section for the succeeding year4 7f7 ,implementation ,the ,secretary shall establish procedures to carry out this section1 including procedures-- 7#a7 to track the amount of out-of-pocket cost-sharing incurred by applicable individuals for items and services covered under this title during a year2 and 7#b7 provide notice to the applicable individual and providers of services and suppliers who furnish items and services to the applicable individual when the applicable individual has incurred expenses that exceed the annual out-of-pocket limit under subsection 7b7 for the year4 7g7 ,payment ,for provisions relating to payment for items and services furnished to an applicable individual once the annual out-of-pocket limit has been met1 see sections #ahac7;c7 and #ahcc7;ee74 4 7b7 ,conforming amendments 7#a7 ,part ,a ,section #ahac of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;e7 is amended by adding at the end the following new subsection3 7c7 7#a7 ,notwithstanding subsections 7a7 and 7b71 if the amount of the out-of-pocket cost-sharing for an applicable individual for a year 7beginning with #bjbh7 equals or exceeds the annual out-of-pocket limit under section #ahii;,d7b7 for that year1 payment under this part with respect to any additional incurred expenses for items or services furnished to the applicable individual in the calendar year shall be made as if any reduction in the amount payable for such items or services under subsection 7a7 due to any deductible or coinsurance that would 7but for the application of section #ahii;,d7 otherwise be applicable no longer applied4 7#b7 ,in this subsection1 the terms applicable individual and out-of-pocket cost sharing have the meaning given those terms in section #ahii;,d4 4 7#b7 ,part ,b 7,a7 ,payment ,section #ahcc of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7 is amended-- 7i7 by adding at the end the following new subsection3 7ee7 7#a7 ,notwithstanding subsections 7a7 and 7b71 if the amount of the out-of-pocket cost-sharing for an applicable individual for a year 7beginning with #bjbh7 equals or exceeds the annual out-of-pocket limit under section #ahii;,d7b7 for that year1 payment under this part with respect to any additional incurred expenses for items or services furnished to the applicable individual in the calendar year shall be made as if-- 7,a7 the deductible under subsection 7b7 no longer applied2 7,b7 the deduction described in the second sentence of subsection 7b7 7relating to blood7 no longer applied2 and 7,c7 #ajj percent and #j percent were substituted for #hj percent and #bj percent1 respectively1 each place either appears in subsection 7a71 in subsection 7i77#b71 in section #ahce7;b77#b71 and in subsections 7b77#b7 and 7b77#c7 of section #ahha4 7#b7 ,in this subsection1 the terms applicable individual and out-of-pocket cost sharing have the meaning given those terms in section #ahii;,d4 2 and 7ii7 in subsections 7c7 and 7g71 by striking 7a7 and 7b7 each place it appears and inserting 7a71 7b71 and 7ee74 7,b7 ,limitation on charges when annual limit reached ,section #ahff7;a77#b77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7a77#b77;,a77 is amended by adding at the end the following new sentence3 ,a provider of services may not impose a charge under the first sentence of this subparagraph for services for which payment is made to the provider pursuant to section #ahcc7;ee7 7relating to protection against high out-of-pocket expenses744 7,c7 ,beneficiary protections ,section #ahdb7;b77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieu7b77#c77 is amended-- 7i7 in subparagraph 7,l71 by striking the period at the end and inserting 2 and2 and 7ii7 by inserting after subparagraph 7,l7 the following new subparagraph3 7,m7 if it makes determinations or payments with respect to items and services furnished by a physician for which payment is made pursuant to section #ahcc7;ee7 but not on an assignment-related basis1 provide to the physician a notice that-- 7i7 states that the individual provided the service has reached the annual out-of-pocket limit under section #ahii;,d7b7 for the year1 and 7ii7 encourages the physician not to charge the individual amounts in excess of the reasonable charge recognized under this section and to accept payment on an assignment-related basis for physicians' services furnished the individual during the remainder of the year4 4 #c4 ,enhancements to programs that protect low-income ,medicare beneficiaries 7a7 ,elimination of resource standard for eligibility and enrollment determinations 7#a7 ,,lis ,section #ahfj;,d-#ad7;a77#c77;,a77iii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aad7;a77#c77;,a77iii77 is amended by striking meets and inserting with respect to a plan year beginning before ,january #a1 #bjbh1 meets4 7#b7 ,,msp ,section #aije7p77#a77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7p77#a77;,c77 is amended by striking whose resources and inserting prior to ,january #a1 #bjbh1 whose resources4 7b7 ,aligning eligibility criteria across ,,msp and ,,lis 7#a7 ,,lis ,section #ahfj;,d-#ad7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aad7;a77 is amended-- 7,a7 in paragraph 7#a71 in the matter preceding subparagraph 7,a71 by inserting or1 with respect to a plan year beginning on or after ,january #a1 #bjbh1 #bjj percent after #aej percent2 and 7,b7 in paragraph 7#c77;,a77ii71 by inserting 7or1 with respect to a plan year beginning on or after ,january #a1 #bjbh1 #bjj percent after #aej percent4 7#b7 ,,msp 7,a7 ,in general ,section #aije7p7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7p77 is amended-- 7i7 in paragraph 7#a77;,b71 by inserting 1 except that1 beginning with ,january #a1 #bjbh1 the methodology used in determining income eligibility under this subsection shall be no more restrictive than the methodology used by the ,social ,security ,administration in making income determinations under section #ahfj;,d-#ad7;a77#c77;,c7 after income program2 and 7ii7 in paragraph 7#b7-- 7,i7 in subparagraph 7,a7-- 7aa7 by striking shall be at least and inserting 8shall be-- 7i7 prior to ,january #a1 #bjbh1 at least 2 7bb7 in clause 7i71 as added by item 7aa71 by striking the period and inserting 2 and2 and 7cc7 by adding at the end the following new clause3 7ii7 on or after ,january #a1 #bjbh1 #bjj percent of the poverty line applicable to a family of the size involved4 2 and 7,,ii7 by adding at the end the following new subparagraph3 7,e7 ,with respect to eligibility for medical assistance on or after ,january #a1 #bjbh1 in this paragraph1 the definition of the term family of the size involved shall be no more restrictive than the definition of that term for purposes of section #ahfj;,d-#ad4 4 7,b7 ,conforming amendments ,title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 is amended-- 7i7 in section #aijb7;a77#aj77;,e7-- 7,i7 in clause 7iii71 by striking for making and inserting prior to ,january #a1 #bjbh1 for making2 and 7,,ii7 in clause 7iv71 by striking subject to and inserting prior to ,january #a1 #bjbh1 subject to2 and 7ii7 in section #aicc7;a71 by striking ,a ,state plan and inserting ,prior to ,january #a1 #bjbh1 a ,state plan4 7#c7 ,bidirectional eligibility deeming between ,,msp and ,,lis 7,a7 ,,lis ,section #ahfj;,d-#ad7;a77#c77;,b77v7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aad7;a77#c77;,b77v77 is amended to read as follows3 7v7 ,treatment of medicaid beneficiaries ,subject to subparagraph 7,f71 the ,secretary shall treat a part ,d eligible individual as a subsidy eligible individual described in paragraph 7#a7 if they are-- 7,i7 a full-benefit dual eligible individual 7as defined in section #aice7;c77#f772 7,,ii7 a recipient of supplemental security income benefits under title ,,xvi2 or 7,,iii7 determined for purposes of the ,state plan under title ,,xix to be eligible for medical assistance under section #aijb7;a77#aj77;,e77i74 4 7,b7 ,,msp ,section #aije7p7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7p77 is amended by adding at the end the following new paragraph3 7#g7 ,beginning ,january #a1 #bjbh1 a ,state shall provide that an individual described in paragraph 7#a77;,a7 who is a subsidy eligible individual described in section #ahfj;,d-#ad7;a77#c7 shall be treated as a qualified medicare beneficiary described in paragraph 7#a74 4 7,c7 ,treatment of leads data 7i7 ,transmittal ,section #aadd7;c77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;b-#ad7;c77#c77 is amended by striking which transmittal shall initiate an application of the individual for benefits under the ,medicare ,savings ,program with the ,state ,medicaid agency and inserting which the ,state ,medicaid agency shall treat as an application of the individual for benefits under the ,medicare ,savings ,program consistent with section #aice7;a77#d74 7ii7 ,consideration by ,states ,section #aice7;a77#d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#e7;a77#d77 is amended to read as follows3 7#d7 ,consideration of data transmitted by the ,social ,security administration for purposes of medicare savings program 7,a7 ,in general ,the ,state shall accept data transmitted under section #aadd7;c77#c7 and-- 7i7 in the case of an individual who is a subsidy eligible individual described in section #ahfj;,d-#ad7;a77#c71 promptly treat such individual as a qualified medicare beneficiary described in #aije7p77#a72 and 7ii7 in the case of any other individual who is likely to be a qualified medicare beneficiary1 as determined by the ,secretary1 act on such data in the same manner and in accordance with the same deadlines as if the data constituted an initiation of an application for benefits under the ,medicare ,savings ,program 7as defined for purposes of section #aadd7;c77#c77 that had been submitted directly by the applicant4 7,b7 ,date of application ,for purposes of subparagraph 7,a77ii71 the date of the individual's application for the low income subsidy program from which the data have been derived shall constitute the date of filing of such application for benefits under the ,medicare ,savings ,program4 4 7,d7 ,effective date ,the amendments made by this paragraph shall take effect on ,january #a1 #bjbh4